How to Minimize the Pain of Local Anesthetic Injection for Wide Awake Surgery

State-of-the-art review: The advantage and use of Wide Awake Local Anaesthesia No Tourniquet (WALANT) for nerve decompression surgery

PURPOSE

Wide Awake Local Anesthesia No Tourniquet (WALANT) has gained significant attention since its introduction in 2005. Over 343 publications since 2013 highlight its increasing use in nerve decompression surgeries. WALANT is known for its safety benefits, cost-effectivenes and improved patient experience compared to traditional sedation and tourniquet-based methods. This review examines the advantages of WALANT in nerve decompression surgery, emphasizing its growing adoption and benefits.

METHODS

A comprehensive review of the WALANT technique is provided, focusing on injection strategies, including buffered lidocaine with epinephrine, proper needle placement and generous volume of tumescent anesthesia. Specific injection protocols and surgical approaches are discussed for various nerve decompression procedures such as carpal tunnel, lacertus, cubital tunnel, radial tunnel and lateral intermuscular septum releases.

RESULTS

WALANT eliminates sedation-related risks such as nausea, aspiration pneumonia and thromboembolism, making it suitable for high-risk patients (ASA 4). It reduces healthcare costs by decreasing the need for post-anesthesia care units and operating in minor procedure rooms. The technique fosters greater surgeon-patient interaction, reduces hospital stays and avoids preoperative fasting and testing. WALANT has demonstrated positive outcomes across multiple nerve decompression procedures.

CONCLUSION

WALANT provides a transformative approach in nerve decompression surgery, offering enhanced safety, cost-effectiveness and improved patient-centered care. It significantly contributes to positive surgical outcomes, making it a valuable technique for both patients and healthcare providers.

Surgeons Can Decrease the Pain of WALANT Local Anesthesia Injection if They Ask for Patient Feedback

Introduction: Some patients who are having WALANT (Wide Awake Local Anesthesia No Tourniquet) carpal tunnel surgery are afraid of the pain of local anesthesia injection. Many surgeons do not yet focus on minimally painful injection techniques to avoid unnecessary painful patient experiences. This study measured the number of local anesthetic injection pain events in feedback from patients to the injecting surgeon to decrease the pain of his injections. Methods: A single surgeon asked 250 consecutive carpal tunnel surgery patients to tell him each time they felt a pain event during his local anesthetic injection process for WALANT carpal tunnel surgery. The pain events were counted and provided an objective pain number to score the surgeon's injection skill over the 35 months of the study. Results: The surgeo's injection pain score improved dramatically over the time of the study. In his last 50 patients, he scored a hole-in-one 37 times, where none of his first 50 patients gave him such a high score. A hole-in-one happens when the only pain the patient feels is the small sting of the first 27 gauge needle insertion. Conclusions: Surgeons who inject local anesthesia for carpal tunnel surgery can ask patients to tell them each time they feel a pain event after the sting of the first needle insertion is numbed. Counting the number of pain events provides a score for each injection process. This score from immediate patient feedback can help the surgeons decrease the pain of their injections.

Patients Tracking Pain Episodes Show Wide-awake Local Anesthesia Without Tourniquet Can Be Nearly Painless

Background

Minimally painful tumescent local anesthesia ensures patients feel only the first needle insertion, with no further pain. This technique includes real-time patient feedback, where they report each pain event during injection.

Methods

This prospective study involved 154 consecutive patients undergoing wide-awake local anesthesia no tourniquet surgery at 3 hand surgery centers (January-April 2024). Patients objectively scored pain events during injection and rated pain intensity (0-10 Likert scale), intraoperative pain, anxiety, and overall experience.

Results

During local anesthesia injection, 61 (40%) patients reported no pain, 92 (59.7%) reported 1 pain event, and 1 (0.7%) patient reported 2 events. Among the 93 patients who felt pain, 90 reported only mild discomfort (1-2 of 10), whereas 3 reported moderate pain (3-5 of 10). Anxiety levels during anesthesia and surgery were 3 of 10 or less for 147 (95.5%) patients.

Conclusions

Real-time patient feedback improved surgeons' ability to administer tumescent local anesthesia with minimal pain. As a result, most patients experienced no pain or only 1 minor event during local anesthesia injection for wide-awake local anesthesia no tourniquet surgery.

Topical Anesthesia in Cutaneous Head and Neck Surgery: A Randomized Controlled Trial

OBJECTIVE

Cutaneous head and neck surgery can safely and effectively be performed using local anesthetic (LA). However, optimizing pain management during LA administration is paramount for patient comfort and procedural efficacy. The primary objective of this study was to investigate the comparative effectiveness of EMLA cream and ethyl chloride (EC) spray in mitigating pain associated with LA administration in cutaneous head and neck surgery.

STUDY DESIGN

Randomized controlled trial.

SETTING

University-affiliated tertiary head and neck oncology center.

METHODS

Sample size calculation was performed followed by computer randomization into the following groups: EMLA, EMLA placebo (aqueous cream), EC, and a control group (no topical agent). Demographics, pain, and procedural experience scores were recorded perioperatively. Statistical analysis was performed to analyse differences between groups utilizing the Mann-Whitney U test, Kruskall-Wallis test, Chi-square test, and Spearman's Rho.

RESULTS

121 cutaneous lesions with a median patient age of 76 were analyzed. There were no statistically significant differences in pain scores (median [IQR]) between patients receiving EMLA (4 [3.75]), EMLA placebo (4.8 [3.6]), EC (5.8 [2.8]), and no treatment (5 [4.1], P = .19). Procedural experience scores were clinically similar (P = .02). Risk factors associated with elevated nociceptive sensitivity were surgical site (scalp, P = .01), malignant lesions (P < .01) and lesion surface area (rs = 0.22, P = .01).

CONCLUSION

EMLA and EC did not mitigate LA-associated pain in patients undergoing cutaneous head and neck surgery and as such practitioners should reconsider their use of these in this regard. Patients' operative experience remains excellent regardless of topical anesthetic use.

LEVEL OF EVIDENCE

Ib.

Words to Avoid During Wide-awake Local Anesthesia No Tourniquet Surgery to Enhance Patient Experience

In the evolving landscape of ambulatory surgery, wide-awake local anesthesia no tourniquet (WALANT) surgery has emerged as a preferred approach due to its efficacy, cost-effectiveness, and patient satisfaction. This paradigm shift places the patient at the center of intraoperative communication, requiring a significant change in the dialogue within the operating room (OR). Traditional conversations, which often exclude the unconscious patient, must evolve to accommodate and prioritize the psychological comfort of the conscious patient. This article examines the impact of language, tone, and conversation content on the patient experience during WALANT. We propose a communication framework that emphasizes empathy, reassurance, and patient inclusion to reduce anxiety and increase patient compliance. By analyzing common OR dialogues and their potential impact on awake patients, we identify specific phrases and words that may exacerbate patient stress or discomfort. Alternatives are suggested to foster a more positive and inclusive environment. Our recommendations are based on extensive clinical experience and supported by relevant literature, highlighting the critical role of mindful communication in improving clinical outcomes and patient satisfaction in WALANT.

Safe and Effective Augmentation Mastopexy with Tumescent Local Anesthesia: A Decade of Experience

Background: Tumescent local anesthesia (TLA) is widely used in esthetic surgery due to its ability to reduce complications, eliminate the need for general anesthesia, provide effective pain control, and shorten hospitalization times. Methods: This study evaluates the use of TLA in 80 patients who underwent augmentation mastopexy between 2010 and 2022. A tumescent solution containing 500 mg lidocaine, 672 mg sodium bicarbonate, and 1 mg epinephrine in 1000 mL of saline was infiltrated, with an average of 300 mL per breast. The surgical technique involved creating a subpectoral pocket for textured round implants (250-400 cc), followed by careful hemostasis. Results: No patients required conversion to general anesthesia, and there were no signs of toxicity or major complications. Minor complications included wound dehiscence (6.2%), hematoma (2.5%), and capsular contracture (2.5%). Pain management satisfaction at 3 months post-surgery was rated as "outstanding" by 12.5% of patients, "excellent" by 67.5%, and "good" by 20%. The longest follow-up was 6 years, with no implant ruptures except one (1.2%). Conclusions: While the study did not include a control group or statistical analysis, the findings suggest that TLA is a safe and effective alternative to general anesthesia for augmentation mastopexy, providing excellent pain control and a low rate of complications.

Wide-Awake Local Anesthesia No Tourniquet in hand surgery: A systematic review and meta-analysis

WALANT (Wide Awake Local Anesthesia No Tourniquet) has been widely implemented in hand surgery. We conducted a systematic review from 1979 to 2022, led by a team of anesthesiologist. Only randomized studies comparing WALANT to other types of regional anesthesia were included. The outcomes studied were pain, duration of the procedure, intraoperative bleeding, complications, and patient satisfaction. Twelve articles were included in the analysis. We found a reduction of 2.77 on the VAS (95% CI -3.79; -1.75, I² 93%) for intraoperative pain in the WALANT group. There was no significant difference (MD 0.79, 95% CI 95% -0.11; 1.69, I² 73%) for duration of surgery. Patient satisfaction was consistently high in the WALANT group. Intraoperative bleeding was minimal and not clinically relevant. Compared to other types of regional anesthesia in hand surgery, the WALANT technique decreases pain for the patients without increasing the length of surgery.

A Method of Tumescent Anesthesia Based on Facial and Cervical Nerve Block for Face and Neck Liposuction

OBJECTIVE

Liposuction of the face and neck is a common treatment for fat deposition. If conventional methods are used for tumescent anesthesia, patients will experience pain, affecting their surgery experience. Using general anesthesia for liposuction of the face and neck can increase the cost to the patient and cause various adverse effects.

METHODS

The authors selected appropriate parts of the patient's neck, angle of the mandible, and face as needle entry points, and performed nerve block in different directions. Afterward, we performed facial liposuction on these patients and evaluated their level of pain.

RESULTS

This study included a total of 20 female participants who underwent facial liposuction after a nerve block. The Visual Analog Scale score of the 20 participants was 0.55 (±0.60). There were no significant adverse reactions during the treatment process, and all patients expressed satisfaction with this treatment.

CONCLUSIONS

In this article, the authors present a method of tumescent anesthesia based on facial and cervical nerve block that significantly reduces the pain associated with facial and neck liposuction, eliminating the need for general anesthesia and enhancing the patient's comfort during the procedure.

Clinically Important Pharmacologic Considerations for Wide-Awake Local Anesthesia No Tourniquet Hand Surgery

SUMMARY

Understanding the clinically important pharmacokinetics (what the body does to the drug) and pharmacodynamics (what the drug does to the body) of medications used in surgery will help surgeons use them more safely and effectively. The goal of this article is to provide an overview of these considerations for the 2 medications used in wide-awake local anesthesia with no tourniquet upper extremity surgery (ie, lidocaine and epinephrine) to establish a better understanding of lidocaine and epinephrine in tumescent local anesthesia, as well as adverse reactions and how to manage them.

New Frontiers in Wide-Awake Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Explain the most important benefits of wide-awake surgery to patients. 2. Tumesce large parts of the body with minimal pain local anesthesia injection technique to eliminate the need for sedation for many operations. 3. Apply tourniquet-free surgery to upper and lower limb operations to avoid the sedation required to tolerate tourniquet pain. 4. Move many procedures out of the main operating room to minor procedure rooms with no increase in infection rates to decrease unnecessary cost and solid waste in surgery.

SUMMARY

Three disruptive innovations are changing the landscape of surgery: (1) minimally painful injection of large-volume, low-concentration tumescent local anesthesia eliminates the need for sedation for many procedures over the entire body; (2) epinephrine vasoconstriction in tumescent local anesthesia is a good alternative to the tourniquet and proximal nerve blocks in extremity surgery (sedation for tourniquet pain is no longer required for many procedures); and (3) evidence-based sterility and the elimination of sedation enable many larger procedures to move out of the main operating room into minor procedure rooms with no increase in infection rates. This continuing medical education article explores some of the new frontiers in which these changes affect surgery all over the body.

WALANT surgery of the hand: state of the art

Wide-awake local anesthesia no tourniquet is named the WALANT technique. WALANT has had a major positive impact on cost, convenience, ecology, patient satisfaction, access to surgical care, and outcomes in hand surgery in the last 20 years. Safe and efficient application of the technique is based on two principles. The first principle is the tumescent injection of a large volume low concentration 0.25-1% lidocaine, with 1:100 000-1:400 000 epinephrine. The second principle of WALANT is that the proper injection should be almost painless, with the patient only feeling the first needle poke of a tiny 30G needle. This wide awake patient approach reduces pain, neuropraxia, and systemic side effects of sedation with preservation of motor control, thereby aiding balanced reconstruction in hand surgery.

Minimal Pain Tumescent Local Anesthesia Injection for Wide Awake Modified Radical Mastectomy

The advent of minimal pain tumescent local anesthesia injection has improved patient safety by eliminating the need for sedation for many wide awake operations, especially in patients with significant medical comorbidities. Modified radical mastectomy (MRM) for breast cancer is commonly performed under general anesthesia as it requires the dissection of the entire breast and an ipsilateral axillary lymph node dissection (ALND). General anesthesia has been shown to have a high risk in patients with severe medical comorbidities. We present a case of a 78-year-old male patient who was diagnosed with invasive ductal breast carcinoma, cardiac failure, and other metabolic abnormalities. Taking his comorbidities into account, we performed a wide awake MRM and ALND after tumescent minimal pain local anesthesia injection. The patient experienced the successful procedure safely with minimal discomfort.

Oral Sedation Anesthesia Protocol for In-Office Oculoplastic Surgery

PURPOSE

To present an oral anesthesia protocol for in-office oculoplastic surgery and to compare safety outcomes and patient and physician experiences to ambulatory surgery center (ASC)-based surgery with intravenous sedation or general anesthesia.

METHODS

A prospective study was performed on consecutive patients undergoing surgery at an oculofacial plastic surgery practice. Surgery was performed in an in-office setting using our standardized oral sedation protocol or at an ASC with intravenous sedation or general anesthesia. Preoperative and postoperative surveys were conducted by patients and physicians to compare surgical experience, safety, and efficacy of our oral sedation protocol for in-office surgery in the ASC setting.

RESULTS

Two hundred and fifty-three patients (167 in-office and 86 at ASC) underwent surgery between March and November 2022. There was no significant difference in how patients or physicians rated their experience between the 2 locations. A significantly higher proportion of ASC patients would have rather had surgery in-office (34.9% vs. 19.2%; p = 0.006). A significantly higher number of physicians in the office setting would have rather performed surgery at the ASC than the reverse (12.7% vs. 2.3%, respectfully; p = 0.007). There were no safety complications reported in either setting.

CONCLUSIONS

Within our patient cohort, the presented oral sedation protocol provided safe and effective anesthesia for in-office oculoplastic surgery that is comparable to an ASC.

Tips, Tricks, and Pearls for a Superior Patient and Surgeon Experience for Wide-awake Dupuytren Surgery

Fasciectomy for Dupuytren disease is a common procedure traditionally performed with a tourniquet under general or regional anesthesia. Since the year 2001, the wide-awake local anesthesia no tourniquet (WALANT) approach has been applied successfully to Dupuytren surgery, with current excellent surgeon and patient satisfaction. However, using WALANT for Dupuytren surgery may be intimidating for hand surgeons who want to begin using this method. The purpose of this article is to offer a series of tips and tricks the authors have learned after having performed hundreds of WALANT fasciectomies, to make this technique easier for surgeons and a more pleasurable experience for patients.

Comparison of pain relief in soft tissue tumor excision: anesthetic injection using an automatic digital injector versus conventional injection

BACKGROUND

The pain caused by local anesthetic injection can lead to patient anxiety prior to surgery, potentially necessitating sedation or general anesthesia during the excision procedure. In this study, we aim to compare the pain relief efficacy and safety of using a digital automatic anesthetic injector for local anesthesia.

METHODS

Thirty-three patients undergoing excision of a benign soft tissue tumor under local anesthesia were prospectively enrolled from September 2021 to February 2022. A single-blind, randomized controlled study was conducted. Patients were divided into two groups by randomization: the experimental group with digital automatic anesthetic injector method (I-JECT group) and the control group with conventional injection method. Before surgery, the Amsterdam preoperative anxiety information scale was used to measure the patients' anxiety. After local anesthetic was administered, the Numeric Pain Rating Scale was used to measure the pain. The amount of anesthetic used was divided by the surface area of the lesion was recorded.

RESULTS

Seventeen were assigned to the conventional group and 16 to the I-JECT group. The mean Numeric Pain Rating Scale was 1.75 in the I-JECT group and 3.82 in conventional group. The injection pain was lower in the I-JECT group (p< 0.01). The mean Amsterdam preoperative anxiety information scale was 11.00 in the I-JECT group and 9.65 in conventional group. Patient's anxiety did not correlate to injection pain regardless of the method of injection (p= 0.47). The amount of local anesthetic used per 1 cm 2 of tumor surface area was 0.74 mL/cm2 in the I-JECT group and 2.31 mL/cm2 in the conventional group. The normalization amount of local anesthetic was less in the I-JECT group (p< 0.01). There was no difference in the incidence of complications.

CONCLUSION

The use of a digital automatic anesthetic injector has shown to reduce pain and the amount of local anesthetics without complication.

A novel nerve block technique for nail surgery

In pediatric patients, nail unit anesthesia is frequently required for procedures including matrixectomy or nail avulsion. However, nail unit anesthesia is very painful and requires a significant amount of time to take complete effect, causing a great deal of distress for most pediatric patients. By targeting the palmar and dorsal digital nerves in the distal part of the fingers, our method enables fast, simple, and less painful anesthesia.

Wide-Awake Local Anesthetic No Tourniquet Surgery of the Foot and Ankle

Wide awake local anesthetic no tourniquet (WALANT) surgery of the foot and ankle has the potential to offer safe and effective surgeon-based anesthesia for a significant number of surgeries about the foot and ankle. This has been documented with significant and growing body of literature. WALANT could offer significant advantages with respect to patient experience, per case cost of procedures as well as for improving access for patients to operative resources in a setting of scarcity or restricted access.

Regional Anesthesia in Upper-Limb Surgery

BACKGROUND

Local and regional anesthesia is associated with numerous clinical and institutional advantages relative to general anesthesia. As anesthesiologists and surgeons increasingly integrate local and regional anesthesia into their clinical practice, an understanding of the principles, evolution, and trends underpinning modern anesthetic techniques continues to be relevant.

METHODS

A review of the literature in databases Medline, PubMed, and EMBASE identified recent developments, ongoing trends, and historical milestones in upper-limb regional anesthesia.

RESULTS

Advances in regional anesthetic techniques in the last century have led to reduced postoperative pain, improved safety, and improved outcomes in upper-limb surgery. The development of ultrasound-guided techniques, as well as pharmacological advances in local anesthetic drugs and adjuncts, has further advanced the role of regional anesthesia. Wide-awake local anesthesia with no tourniquet has allowed certain procedures to be performed on select patients in outpatient and low-resource settings.

CONCLUSIONS

This review provides an overview of local and regional anesthesia in the upper-limb from its historical origins to its contemporary applications in upper-limb surgery, particularly during the COVID-19 pandemic.

Below-knee Amputation with Minimally Painful Injection of Tumescent Local Anesthesia

We successfully performed minimally painful injection of tumescent local anesthesia to eliminate the need for the tourniquet and sedation for a below-knee amputation in a frail patient with multiple medical comorbidities in Mombasa, Kenya. Minimal pain injection of WALANT (wide awake local anesthesia no tourniquet) pure local anesthesia can be a good alternative for lower limb amputation in frail patients when safe sedation services are unavailable or unaffordable in many countries.

Tips to Successful Flexor Tendon Repair and Reconstruction with WALANT

WALANT has generated many changes that have improved flexor tendon repair and reconstruction in the last 10 years. Seeing awake unsedated educable patients move repaired reconstructed tendons during the surgery has changed how we do surgery and therapy in many ways for the better. This article offers many tips on how to get better results in using these new techniques with the help of WALANT.

How to Create an Exceptional Hand Surgery Patient Experience with WALANT

This article provides practical tips that surgeons can use to improve their patient experience with wide awake local anesthesia no tourniquet hand surgery. The difference between patient satisfaction and patient experience is explained. Delivering a superior patient experience leads to better outcomes for patients, less postoperative complications, and a better quality of life and practice for the surgeon. Practical tips are presented, broken down into the preoperative, operative, and postoperative phases. Surgeons who commit to improving their patient experience will enjoy superior outcomes, patient loyalty, more fulfillment, and a rejuvenated sense of purpose.

Comparison of pain and extent of anesthesia in digital blocks for isolated finger lacerations: A randomized controlled trial

OBJECTIVES:

Digital injuries are among the most common presentations to the emergency department. In order to sufficiently examine and manage these injuries, adequate, prompt, and predictable anesthesia is essential. In this trial, we aim to primarily compare the degree of pain and anesthesia onset time between the two-injection dorsal block technique (TD) and the single-injection volar subcutaneous block (SV) technique. Further, we describe the temporal and anatomical effects of both techniques for an accurate delineation of the anesthetized regions.

METHODS:

This is a single-center prospective randomized controlled trial involving patients presenting with isolated wounds to the fingers requiring primary repair under local anesthesia. Patients were randomized to either the SV or TD blocks. The primary outcome was procedure-related pain (Numerical Rating Scale). Further, we assessed the extent of anesthesia along with the anesthesia onset time.

RESULTS:

A total of 100 patients were included in the final analysis, 50 on each arm of the study. The median pain score during injection was significantly higher in patients who received TD block than patients who received SV block (median [interquartile range] = 4 [2.25, 5.00] vs. 3.00 [2.00, 4.00], respectively, P = 0.006). However, anesthesia onset time was not statistically different among the groups (P = 0.39). The extent of anesthesia was more predictable in the dorsal block compared to the volar block.

CONCLUSION:

The single-injection volar subcutaneous blocks are less painful with a similar anesthesia onset time. Injuries presenting in the proximal dorsal region may benefit from the two-injection dorsal blocks, given the anatomical differences and timely anesthesia of the region.

Ten Questions About Wide Awake Local Anaesthesia No Tourniquet (WALANT) Surgery

The aim of this review article is to provide many important tips and tricks for surgeons to start Wide Awake Local Anaesthesia No Tourniquet (WALANT) hand surgery in their practice. The massive cost reduction of this disruptive new approach will enable them to increase access to hand surgery for their patients who cannot afford unnecessary sedation or unnecessary sterility of the expensive main operating room environment. Evidence-based sterility will permit surgeons to move a lot of their surgery out of the main operating room to minor procedure rooms without a significant increase in infection rates. Important pointers on how to inject minimally painful local anaesthesia will have patients thinking the surgeon injector is a bit of a magician. WALANT enables surgeons to improve the outcomes of many hand surgery procedures. Level of Evidence: Level V (Therapeutic).