title: The efficacy of hemodynamic and T wave criteria for detecting intravascular injection of epinephrine test doses in anesthetized adults: a dose-response study.
abstract: Recent studies have shown that an epidural test dose containing 15 microg of epinephrine has a sensitivity and specificity of 100% for detecting intravascular injection based on the systolic blood pressure (SBP) (positive if > or =15-mm Hg increase) and the T wave criteria (positive if > or =0.1 mV and 25% decrease in amplitude), whereas the modified heart rate (HR) criterion (positive if > or =10-bpm increase) produced uncertain results in sevoflurane-anesthetized adults. Because a fractional dose of the test dose may be injected intravascularly in actual clinical situations, we designed this study to determine, in a dose-related manner, the efficacy and minimum effective dose of epinephrine based on those hemodynamic and the T wave criteria. Eighty healthy adult patients were randomly assigned to one of four groups according to a simulated IV test dose under 2% end-tidal sevoflurane and nitrous oxide 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 microg of epinephrine (1); and the epinephrine-10 and -5 groups received 2 and 1 mL of the test dose of the identical components, respectively. HR, SBP, and lead II of the electrocardiograph were recorded continuously for 5 min after the IV injection of the study drug. Sensitivities and specificities of 100% were obtained based on the HR and the SBP criteria only if 15 microg of epinephrine was injected IV, whereas sensitivities and specificities of 100% were obtained based on both T wave criteria after 15 and 10 microg of epinephrine was injected IV. Two blinded observers were able to detect all T wave changes in patients who received 15, 10, and 5 microg of epinephrine IV, resulting in 100% efficacy (P: < 0.05 versus HR and SBP criteria). We conclude that minimum effective epinephrine doses for detecting accidental intravascular injection are 15 microg on the HR and the SBP criteria, and 10 microg on both T wave criteria, and that observing T wave changes may detect even smaller (5 microg) doses of epinephrine injected IV in adult patients anesthetized with sevoflurane and nitrous oxide.
  
  
  CONCLUSIONS
  To determine whether an epidural catheter is in a blood vessel, an epidural test dose containing 15 microg of epinephrine is used. We found that a decrease in T wave amplitude appears to be more sensitive than heart rate and systolic blood pressure change for detecting accidental intravascular injection of a small dose of epinephrine-containing test dose in sevoflurane-anesthetized patients.
authors.affiliation: Department of Anesthesia, Akita University School of Medicine, Akita-ken, Japan. mtanaka@med.akita-u.ac.jp
authors.forename: M
authors.initials: M
authors.lastname: Tanaka
authors.forename: T
authors.initials: T
authors.lastname: Goyagi
authors.forename: T
authors.initials: T
authors.lastname: Kimura
authors.forename: T
authors.initials: T
authors.lastname: Nishikawa
mesh_terms: D000328:Adult; D000767:Anesthesia, Epidural / Q000009:adverse effects; D000768:Anesthesia, General; D018685:Anesthetics, Inhalation; D001794:Blood Pressure / Q000187:drug effects*; D004305:Dose-Response Relationship, Drug; D004562:Electrocardiography / Q000187:drug effects*; D004837:Epinephrine / Q000008:administration & dosage; D005260:Female; D006339:Heart Rate / Q000187:drug effects*; D006801:Humans; D007275:Injections, Intravenous; D008297:Male; D019300:Medical Errors; D008738:Methyl Ethers; D009609:Nitrous Oxide; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D000077149:Sevoflurane
chemical_list: D018685:Anesthetics, Inhalation; D008738:Methyl Ethers; D000077149:Sevoflurane; D009609:Nitrous Oxide; D004837:Epinephrine