Epinephrine one-per-mil tumescent solution in hand surgery: Review of experimental and clinical studies

Hand Surg Rehabil. 2021 Oct;40(5):554-559. doi: 10.1016/j.hansur.2021.04.013. Epub 2021 May 14.


One-per-mil epinephrine solution (1:1,000,000) injected as a tumescent has been used in several hand and upper-limb surgery cases as a substitute for tourniquet. However, reviews of its effectiveness are still lacking. A comprehensive review was conducted based on PubMed, Scopus, Science Direct, Cochrane Library, and Semantic Scholar database search of relevant studies using the keyword "one-per-mil." Studies not using the exact one-per-mil tumescent solution formula were excluded. The review of clinical studies was conducted according to PRISMA guidelines. Epinephrine and the hydrostatic vasocompressive effect created bloodless operative fields, with 100% experimental flap survival after ischemic insult. The technique was effective in creating bloodless operative fields in 36.3% of varied hand and upper-limb surgery cases and in fully awake surgery. Current studies show that one-per-mil tumescent solution is safe and effective, enabling use of tourniquet to be avoided.

Keywords: Anesthésie locale; Blessures à la main; Epinephrine; Epinéphrine; Hand injury; Lidocaine; Lidocaïne; Local anesthesia; Vigilance; Wakefulness.

Publication types

  • Review

MeSH terms

  • Anesthesia, Local / methods
  • Anesthetics, Local
  • Brain Neoplasms*
  • Epinephrine
  • Hand* / surgery
  • Humans
  • Lidocaine
  • Wakefulness


  • Anesthetics, Local
  • Lidocaine
  • Epinephrine