How to Create an Exceptional Hand Surgery Patient Experience with WALANT

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.

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.

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.

Patient satisfaction using wide-awake local anaesthesia no tourniquet (WALANT) in adults undergoing elective hand surgery: A systematic review and meta-analysis

BACKGROUND

Wide-awake local anaesthesia no tourniquet (WALANT) is increasing in popularity within hand surgery. However, evidence is unclear on patient satisfaction rates when WALANT is compared against more traditional anaesthetic techniques where pneumatic tourniquets are used. The present study aimed to evaluate the satisfaction rates of patient with the WALANT technique.

METHODS

A literature search was performed using the PubMed, Embase and Cochrane databases for observational studies and randomised controlled trials (RCTs) from 2003 up to June 2023. The review was carried out among adults undergoing elective hand surgery. The mean difference in operation time and standardised mean difference (SMD) for patient satisfaction and post-operative pain (<24 h) were computed using the random effects model. The quality of studies was evaluated using RoB-2 for RCTs and risk of bias in non-randomised studies ROBINS-I for observational studies. Data were collated and a meta-analysis was performed.

RESULTS

Five RCTs and 15 observational studies were included in our analysis, comprising a total cohort of 1800 patients. Among them, 899 patients received WALANT (50.0%). Among the RCTs, patient satisfaction was found to be higher in patients receiving WALANT (SMD 1.01, 95% CI 0.11-1.92, p = 0.03, I² = 93%). Post-operative pain was found to be non-significant using WALANT (95% CI -3.72-0.03, p = 0.10, I² = 99%), as was operative time difference (95% CI -0.42-0.40, p = 0.96, I² = 0%).

CONCLUSION

The use of WALANT in elective hand surgery potentially results in higher satisfaction rates compared with anaesthesia with tourniquets. Post-operative pain and operation time were also found to be non-inferior in WALANT, but more robust studies are needed to verify these findings.

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.

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.