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- Author or Editor: Allison S. Arp x
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There is a long-standing stigma associated with the use of epinephrine in digital nerve blocks (DNBs) over the concern of digital necrosis. We conducted a systematic review to assess the duration of anesthesia, onset of anesthesia, and complications of lidocaine with epinephrine compared with plain lidocaine for DNBs in adults. We searched Medline via Ovid, Cochrane Library, and ClinicalTrials.gov on January 28, 2020. We included randomized controlled trials that examined lidocaine with epinephrine 1:80,000 to 1:1,000,000 (1–12.5 µg/mL) and plain lidocaine for DNBs of fingers or toes in adults. We completed a blinded review of all unique articles, followed by full-text reviews, data extraction, and quality assessment of all eligible trials. Risk of bias was assessed to inform qualitative data analysis. We identified seven studies with a combined 363 adults and 442 DNBs that met the inclusion criteria. All five studies that reported duration of anesthesia established longer duration in the epinephrine-supplemented lidocaine group, with significant increases in three. Two of the three studies that reported the onset of anesthesia demonstrated significant differences. The two studies that reported complications did not have a single case of digital necrosis. In adults, the use of lidocaine with epinephrine 1:80,000 to 1:1,000,000 (1–12.5 µg/mL) for DNB yields a longer duration of anesthetic effect and seems to be as safe as plain lidocaine in healthy adults. Several studies had some concern for bias, and additional studies are warranted.
Cognitive Bias in Postoperative Opioid-Prescribing Practice
A Novel Effect
Background: Given that excess opioid prescriptions contribute to the US opioid epidemic and there are few national opioid-prescribing guidelines for the management of acute pain, it is pertinent to determine whether prescribers can sufficiently assess their own prescribing practice. We investigated podiatric surgeons’ ability to evaluate whether their own opioid-prescribing practice is less than, near, or above that of an “average” prescriber.
Methods: We administered a scenario-based, voluntary, anonymous, online questionnaire consisting of five surgery-based scenarios commonly performed by podiatric surgeons. Respondents were asked the quantity of opioids they would prescribe at the time of surgery. Respondents were also asked to rate their prescribing practice compared with the average (median) podiatric surgeon. We compared self-reported behavior to self-reported perception (“I prescribe less than average,” “I prescribed about average,” and “I prescribe more than average”). Analysis of variance was used for univariate analysis among the three groups. We used linear regression to adjust for confounders. Data restriction was used to account for restrictive state laws.
Results: One hundred fifteen podiatric surgeons completed the survey in April 2020. Less than half of the time, respondents accurately identified their own category. Consequently, there were no statistically significant differences among podiatric surgeons who reported that they “prescribe less,” “prescribe about average,” and “prescribe more.” Paradoxically, there was a flip in scenario 5: respondents who reported they “prescribe more” actually prescribed the least and respondents who believed they “prescribe less” actually prescribed the most.
Conclusions: Cognitive bias, in the form of a novel effect, occurs in postoperative opioid-prescribing practice; in the absence of procedure-specific guidelines or an objective standard, podiatric surgeons, more often than not, were unaware of how their own opioid-prescribing practice measured up to that of other podiatric surgeons.
