438 and ANALGESIA.
ANESTHESIA . . Curre& Researches
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OF THE PROBLEMS associated
0 NE
with regional block, in general, and
peridural block, in particular, has been
the latent period from the time of injec-
tion of the local anesthetic drug to the
time that adequate surgical anesthesia
is obtained.' This study investigates the
clinical impression that the addition of
epinephrine to a local anesthetic delays
the onset of anesthesia.
Since its introduction by Lofgren and
Lundquist in 1943, lidocaine has sus-
tained remarkable popularity as a local
anesthetic drug. It is stable, may be
stored almost indefinitely, and may be
heated vigorously in the presence of
strong alkalis and acids. It has wide
clinical application and adaptability ; it
diffuses rapidly, has low toxicity, and
produces profound anesthesia.2
*Section of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut.
The clinical literature is sparse, how-
ever, regarding the onset of action of
lidocaine, with o r without epinephrine.
None of the claims seem to be substan-
tiated statistically, nor are the means
of testing stated. Crawford and asso-
ciates state that the time interval be-
tween the administration of the anes-
thetic and the onset of peridural anes-
thesia with lidocaine is 5 to 8 minutes
and that the addition of epinephrine de-
lays the onset slightly but prolongs the
duration of anesthesia 30 to 50 per cent.]
Blundell and associates reported that
the onset of anesthesia by 2 per cent
lidocaine without epinephrine takes 3 to
5 minutes.3 Moore found that the com-
bination of 2 per cent lidocaine, 50 mg.
of tetracaine and 1:160,000 epinephrine
required 15 to 20 minutes to become ef-
VOLUME38, NUMBER6 - NOVEMBER-DECEMBER,
1959 439

fective.* Foldes and co-workers record- METHODS

ed t h a t lidocaine without epinephrine
takes effect in 7 to 10 minutes;5 how-
ever, Stringer stated that 2 per cent
lidocaine takes effect in 10 minutes.6
Cox reported the rapidity of onset with
lidocaine to be twice as fast as pro-
caine,' and Bromage found that the on-
set of effect from 2 per cent lidocaine
without epinephrine was from 6 to 10
minutes after injection and that anes-
thesia with 1.4 per cent lidocaine with
1 :100,000 to 1 :150,000 epinephrine with
7.5 per cent polyvinylpyrrolidone took 10
to 25 minutes to become developed fully.*
Southworth and Dabbs found that the
latent period of 1 per cent lidocaine in-
jected in the caudal canal was 5 to 8
minutes t o the time of onset of anal
a n e ~ t h e s i a . ~Haglund and Conroy re-
corded the onset of caudal analgesia us-
ing lidocaine without epinephrine to be
1to 5 minutes but did not state the con-
centration of the drug.]"
One hundred bottles of 2 per cent
lidocaine, half containing 1 :100,000 epi-
nephrine, were prepared with random
numbers by a third person. Neither pa-
tients nor investigators knew which bot-
tles contained epinephrine, and the third
person did not know the results until the
termination of the investigation.
Lumbar peridural puncture by inter-
mittent needle advancement and the
syringe pressure technique, using a 17-
gauge Huber point needle and a 2-ml.
syringe, was done with the patient in
the lateral recumbent position.
When the peridural space was reach-
ed, and the needle was advanced 2 mm.
further to facilitate passage of a fine
plastic catheter approximately 4 em. in
a cephalad direction, then the Huber
point needle was withdrawn. The cath-
eter was taped in place and the patient

About the Authors

Dr. Sayig Dr. Hehre

* JOHN M. SAYIG,M.D., presently a resident in anesthesiology at Yale

New Haven Medical Center, New Haven, Connecticut, was born in
Istanbul, Turkey. He received his medical degree from Istanbul Univer-
sity School of Medicine, and served a one-year internship and one-year
residency in internal medicine a t St. Mary's Memorial Hospital, Knox-
ville, Tennessee. Music, dancing and chess are his special interests.
Dr. Sayig is married and has one daughter.
* FREDERICK W. HEHRE, M.D., attended Columbia University and
Columbia College of Physicians and Surgeons. From 1953 to 1955 he
served in the U. S. Army. Dr. Hehre is Associate Director of the Depart-
ment of Anesthesia at Grace-New Haven Community Hospital and
Assistant Professor of Anesthesiology, Yale University School of
Medicine.
440
and ANALGESIA
ANESTHESIA
turned to a supine position. A 2-ml. test
dose was injected through the catheter
to rule out accidental subarachnoid
puncture. Approximately 1t o 2 minutes
later a definitive dose of 12 to 15 ml. of
the unknown lidocaine solution was in-
jected and the time at the end of injec-
tion recorded. Five minutes after injec-
tion, the patient was tested for level of
anesthesia by pinprick, When the pain-
ful sensation diminished, the patient was
tested with an Allis clamp. As soon as
the patient no longer evinced discomfort
when the clamp was locked on several
skin segments, the end point was reach-
ed and the time recorded.
The patients were chosen at random
from the surgical schedules. The ma-
jority received secobarbital, 0.1 gm., and
atropine 0.0004 gm., intramuscularly as
preanesthetic medication. The obstetric
patients generally had no medication.
However, some had received meperidine,
0.05 gm., intramuscularly 1 hour prior to
the block, but these were in the minor-
ity.
RESULTS
The average time of onset of anes-
thesia for 2 per cent lidocaine without
epinephrine was 8.9 minutes, plus or
minus a standard deviation of 3.3 min-
utes. The average time of onset of action
of 2 per cent lidocaine with 1:100,000
epinephrine was 10.0 minutes, plus or
minus a standard deviation of 2.9 min-
utes. The results are not statistically
significant.
COMMENT
The results indicate that the presence
of 1:100,000 epinephrine does not influ-
ence significantly the onset of action of
2 per cent lidocaine in the peridural
space in man. Apparently factors relat-
ing to the patient are of greater impor-
tance. Among these may be (1) degree
of depression of the individual from the
preanesthetic medication and (2) the
individual subjective response to the
method of testing (although all patients
seemed to co-operate well and all blocks
were adequate f o r subsequent surgical
or obstetric procedures). The latter
bears no relation to this study.
..
. Current Researches
SUMMARY
One hundred patients were anesthe-
tized by lumbar peridural block with 2
per cent lidocaine which in half the cases
contained 1:100,000 epinephrine. A dou-
ble-blind technique was utilized to de-
termine whether or not the presence of
epinephrine in the lidocaine delayed the
onset of anesthesia. The average time
of onset for 2 per cent lidocaine without
epinephrine was 8.9 2 3.3 minutes. The
average time of onset for 2 per cent lido-
caine with 1:100,000 epinephrine was
10.0 * 2.9 minutes. The results are not
statistically significant.
REFERENCES
1. Crawford, 0. B., Brasher, C. and Buck-
ingham, W. W.: Peridural Anesthesia f o r
Thoracic Surgery. Anesthesiology 18 :241
(March-April) 1957.
2. Crawford, 0. B.: Comparative Qualities
of Three New Anesthetic Drugs: Xylocaine,
Cyclaine and Pravocaine. Anesthesiology
14:278 (May) 1953.
3. Blundell, A. E., Bodell, B., Andorko,
J. E., Sweeney, J. C., Jr. and Ansbro, F. P.:
Clinical Evaluation of Drugs Used in Obtain-
ing Lumbar Epidural Anesthesia. Anesthesi-
ology 16:386 (May) 1955.
4. Moore, D. C.: Lumbar Epidural Block:
Anesthetic of Choice for Caesarean Section.
West. J. Surg. 61:459 (August) 1953.
5. Foldes, F. F., Colavincenzo, J. W. and
Birch, J. H.: Epidural Anesthesia: A Reap-
praisal. Anesth. & Analg. 35 :33 (January-
February) 1956.
6. Stringer, R. M.: Epidural Anesthesia
with Xylocaine@. Anesth. & Analg. 33:195
(May-June) 1954.
7. Cox, P. A.: Lidocaine, a New Local
Anesthetic. U. S. Armed Forces M. J. 3:1561
(October) 1952.
8. Bromage, P. R.: Spinal Epidural Anal-
gesia. Edinburgh & London, E. & S. Living-
stone, Ltd., 1954.
9. Southworth, J. L. and Dabbs, C. H.:
Xylocaine, a Superior Agent for Conduction
Anesthesia. Anesth. & Analg. 32:159 (May-
June) 1953.
10. Haglund, G. and Conroy, W. A.: Xylo-
caine for Regional Analgesia. Illinois M. J.
99:3 (March) 1951.