LAUSR

changes were observed in any of the patients. The percentage of 2% patients who reported epinephrine reactions is surprising. In our center about 10,000 outpatient and inpatient procedures are performed per year, mainly using 3D-histology as a variant of Mohs surgery. For this purpose, we use a standardized solution of ropivacaine, lidocaine, and epinephrine, which is diluted to various concentrations between 0.05% and 0.21%. Patients are monitored with a pulse oximeter for both local anesthesia and during the procedure. Side effects are routinely monitored, but there have been less than 10 epinephrine reactions in the last 5 years, characterized by an immediate pulse increase, nausea, or agitation. In fact, we often observe pronounced nervousness and anxiety in patients presenting with very similar clinical symptoms. The authors raise this point in the discussion too, but the title and the aim of the study suggest that a clear epinephrine response has been demonstrated and recorded in 2% of the patients. Because none of the patients showed an objectifiable reaction regarding vital parameters (pulse increase, blood pressure increase, etc), it seems necessary to critically discuss the causal relationship between epinephrine and these reactions. Furthermore, the data collection of side effects in this study was based on a self-reporting system, as described by the authors. In times of increasingly critical voices regarding mixture-based local anesthetics, categorical statements should be avoided.