Effect of Topic Epinephrine on Opioid Consumption in Ear Surgery

Research Article

Austin J Anesthesia and Analgesia. 2022; 10(1): 1106.

Effect of Topic Epinephrine on Opioid Consumption in Ear Surgery

Prusak M¹*, Liu DT², Emich P¹, König SL¹ and Windpassinger M¹

¹Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria

²Department of Otorhinolaryngology, Medical University of Vienna, Vienna, Austria

*Corresponding author: Michal Prusak, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University Vienna, Vienna, Austria; Spitalgasse 23, 1090 Vienna, Austria

Received: April 01, 2022; Accepted: April 28, 2022; Published: May 05, 2022


Background and Objectives: Topically applied epinephrine is used routinely in ear surgery to stop bleeding in the operating field. The data on its effect on postoperative pain perception has been missing so far.

Materials and Methods: We carried out a single center retrospective cohort study of patients undergoing ear surgery over a period of 12 months. Epinephrine given intraoperatively was compared to piritramide dose given postoperatively. Patients receiving no piritramide intraoperatively were additionally compared to postoperative VAS score.

Results: There was no difference in piritramid dose required for pain therapy as well as in VAS score in 230 patients included in the analysis.

Conclusions: Epinephrine used in ear surgery has no effect on pain perception and thus may not be taken in consideration in postoperative pain management.

Keywords: Epinephrine; Piritramide; Ear surgery; Pain


VAS: Visual Analogue Scale; Epi: Epinephrine; LA: Local Anaesthesia


Epinephrine added to local anesthetic in a low concentration (usually 1:50.000, 1:100.000 or 1:200.000) is able to prolong the duration of analgetic effect of the local anesthetic by vasoconstriction, thus lowering blood flow and slowing down the drug elimination [1,2]. Even these very low concentrations can impair inner ear perfusion though not causing any relevant clinical complications [3,4]. Besides that epinephrine can be applied superficially on the bleeding tissue in a high concentration (1:1.000) to diminish or stop bleeding in situations when surgical hemostatic methods fail or are technically not feasible, such es endoscopic or microscopic ear surgery [5-8]. It is believed that this may have an effect on local circulation as well as on pain perception, this phenomenon has not been investigated yet.

The overall percepted pain level is determined by a sum of various mechanisms. In case of excessive vasoconstriction tissue damage due to ischemia may occur and add on the surgical damage with consecutive pain increase. Activation of β2-and β3-adrenergic receptors of peripheral nociceptive cells is known to favor nociception, too [9-12]. Although epinephrine is a mediator of sympathetic automonic nervous system and thus a stress response including deminished perception of acute pain, any systemic effects on central nervous system in case of resorption are unprobable as there are no adrenergic receptors (in contrast to noradrenergic receptors) on the central nerve cells [13]. Despite of that there is still an evidence of interference with pain threshold level in animal models [14,15].

Materials and Methods

Study participants

We analyzed all adult patients who underwent ear surgery at the Department of Ear-Nose-Throat Medicine at Medical University of Vienna between 1st July 2019 and 30th June 2020 in general anesthesia and treated postoperatively in recovery room. The study protocol was approved by the local Ethics Committee of the Medical University of Vienna.


The data were collected manually from operating protocols and IntelliSpace Critical Care and Anesthesia information system (Philips Healthcare, Amsterdam, Netherlands). Recorded data included age, gender, type of the surgery (divided in four categories of middle ear surgery which includes mastoidectomy, tympanoplasty, ossiculoplasty and myringoplasty; cochlear implant surgery; tumor surgery; other surgery), duration of the surgery, amount of lidocaine 0.5% injection with epinephrine in ratio 1:200.000, dose of piritramide given in the operating room and in the recovery room, and pain intensity measured by 11-point numeric rating scale (NRS; 0 = no pain; 10 = the worst pain) on arrival to the recovery room and before leaving the recovery room.

Statistical analysis

We performed statistical analysis using IBM SPSS Statistics 27.0 (IBM Corporation, Armonk, NY, USA). Age, gender, type and duration of the surgery were assessed by the descriptive statistics. The difference in piritramide consumption in patients with and without epinephrine was compared by unpaired t-test. As there was a high proportion of patients receiving local anesthesia at the beginning of the surgery too, we created two categories within both groups resulting in four subgroups (non-Epi, non-LA; non-Epi, LA; Epi, non-LA; Epi, LA); the difference in these four subgroups was calculated with one-way ANOVA test. VAS score was calculated in the same way for the defined groups and subgroups, but only in those patients who received no piritramide at the end of the surgery.


On total, ear surgery was performed in 252 patients in our center over the period of 12 months. In 16 patients the surgery was performed without general anesthesia and these patients were not treated in recovery room postoperatively. 5 patients were admitted to the intensive care unit because of ongoing mechanical ventilation and/or need for prolonged observation. In 1 patient the recovery room protocol was missing.

230 patients were included, among whom 127 (55%) were women and 103 (45%) were men with an average age of 51 years (SD 18 years). The most common type of surgery was middle ear surgery counting 119 cases (52%), followed by cochlear implant surgery with 69 cases (30%). Duration of the surgery was 138 minutes on average (SD 65 minutes). 37 patients (16%) did not receive any local anesthesia (non- LA) and in remaining 193 patients (84%) local anesthesia was applied at the beginning of the surgery (LA). In these patients the amount of lidocaine 0.5% injection with epinephrine in ratio 1:200.000 was 4.0 ml on average (SD 1.6ml). 132 patients (57%) did not receive any epinephrine (non-Epi), whereas 98 patients (43%) required application of epinephrine (Epi) in a concentration of 1:1.000.

At the end of the surgery - still in the operating room - 129 patients (56%) were given no piritramide and 101 patients (44%) received piritramide in average dose of 4.42mg (SD 1.58mg). The patients receiving no piritramide targeted VAS score 0.84 (SD 1.45, min 0, max 6) on arrival to the recovery room compared to VAS score of 1.23 (SD 1.72, min 0, max 6) in those patients who were given piritramide in the operating room.

During the stay in the recovery room the patients given no piritramide in the operating room received 2.64mg (SD 3.37, min 0, max 15) piritramide and those who were already given piritramide in the operating room required 3.41mg (SD 3.65, min 0, max 13.5) of additional piritramide. The average VAS score when leaving the recovery room was 0.37 (SD 0.67, min 0, max 3) and 0.44 (SD 0.66, min 0, max 3) in patients receiving no piritramide and some piritramide at the end of the surgery respectively. The attributes of the four subgroups are shown in Table 1 for all patients and in Table 2 for the patients who received no piritramide before attending the recovery room.

Citation: Prusak M, Liu DT, Emich P, König SL and Windpassinger M. Effect of Topic Epinephrine on Opioid Consumption in Ear Surgery. Austin J Anesthesia and Analgesia. 2022; 10(1): 1106.