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REGIONAL ANESTHESIA

The Efficacy of Hemodynamic and T-Wave Criteria for Detecting Intravascular Injection of Epinephrine Test Dose in Propofol-Anesthetized Adults

Shinji Takahashi, MD^*, Makoto Tanaka, MD, and Hidenori Toyooka, MD^*

*Department of Anesthesiology, Institute of Clinical Medicine, University of Tsukuba, Tsukuba; and 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-city 010-8543, Japan. Address e-mail to mtanaka{at}med.akita-u.ac.jp

A recent study demonstrated 100% effectiveness of hemodynamic criteria during propofol anesthesia, when a full dose of an epinephrine (15 µg)-containing test dose was injected intravascularly. We designed this dose-response study to determine minimal effective epinephrine doses and efficacies of hemodynamic and T-wave criteria for detecting intravascular injection of the epinephrine test dose in propofol-anesthetized adults. Eighty healthy adult patients were randomly assigned to one of four groups according to a simulated IV test dose using propofol (133 µg · kg^-1 · min^-1) and nitrous oxide (FIO₂ = 0.33) anesthesia after endotracheal intubation (n = 20 each). The Saline group received 3 mL of normal saline IV; the Epinephrine-15 group received 3 mL of 1.5% lidocaine containing 15 µg epinephrine; and the Epinephrine-10 and -5 groups received 2 and 1 mL of the test dose of the identical components, respectively. Heart rate (HR), systolic blood pressure (SBP), and lead II of the electrocardiogram were recorded continuously for 5 min after the IV injection of the study drug via a peripheral vein. Sensitivities and specificities of 100% were obtained based on the modified HR (positive if 10 bpm increase) and the T-wave (positive if 25% in amplitude) criteria if 5 µg of epinephrine was injected IV. Based on the SBP criterion (positive if 15 mm Hg increase), however, 100% sensitivity and specificity were associated only with 10 µg of epinephrine doses. These results suggest that the minimal effective epinephrine doses for detecting unintentional intravascular injection are 5 µg based on the HR and T-wave criteria, and 10 µg based on the SBP criterion in adult patients anesthetized with propofol and nitrous oxide.

IMPLICATIONS: Accidental migration of an epidural catheter into a blood vessel is often detected by hemodynamic changes after injecting an epidural test dose containing epinephrine. Our results suggest that 5 µg of epinephrine is not adequate to reliably produce hemodynamic and T-wave alterations in adult patients during propofol anesthesia.

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