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Department of Anesthesia, Akita University School of Medicine, Akita, Japan
Address correspondence and reprint requests to Makoto Tanaka, MD, Department of Anesthesia, Akita University School of Medicine, Hondo 1-1-1, Akita-shi, Akita-ken 010-8543, Japan. Address e-mail to mtanaka{at}med.akita-u.ac.jp
This study was designed to determine the efficacy of heart rate (HR), systolic blood pressure (SBP), and changes in T-wave morphology in detecting intravascular injection of 15 µg of epinephrine (test dose) in sevoflurane-anesthetized adults. In addition, the testing threshold using the T-wave amplitude was derived. Ninety-six healthy patients were randomized to receive end-tidal sevoflurane 0.5%, 1%, or 2% and nitrous oxide 67% in oxygen (n = 32 for each sevoflurane concentration). Each group of patients was further randomized to receive 3 mL of 1.5% lidocaine plus 15 µg of epinephrine IV or 3 mL of saline IV (n = 16 each). HR, SBP, and T-wave amplitude were continuously monitored for 5 min after the IV injection of the study drug. None receiving IV saline and 15, 15, and 14 patients receiving the IV test dose developed HR increases 
10 bpm during 0.5%, 1%, and 2% sevoflurane, respectively. No patient receiving saline and all patients receiving the test dose developed SBP increases 15 mm Hg. T-wave amplitude decreased by >0.1 mV and by >25% in all patients receiving the IV test dose, and its magnitude was similar regardless of the sevoflurane concentrations. When 0.1-mV and 25% decreases in T-wave amplitude were considered as testing thresholds, 100% sensitivities and specificities were obtained. We conclude that a peak SBP increase 15 mm Hg and a decrease in T-wave amplitude 0.1 mV and 25% are more reliable than a HR increase 10 bpm for detecting intravascular injection of epinephrine-containing test dose during sevoflurane anesthesia.
Implications: To determine whether an epidural catheter resides in a blood vessel, a standard test dose containing a local anesthetic and 15 µg of epinephrine is used. We found that, in sevoflurane-anesthetized adult patients, a systolic blood pressure increase 15 mm Hg and a decrease in T-wave amplitude 0.1 mV and 25% in lead II, but not a heart rate increase 10 bpm, are reliable indicators for detecting intravascular injection.
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