Guidelines for Wide-Awake Local Anesthesia Surgery with No Tourniquet in the Office Setting Using Field Preparation Sterility

SUMMARY

Wide-awake local anesthesia surgery with no tourniquet, or WALANT, has become popular in surgery, especially among hand surgeons. With the increasing number of surgeons performing office-based procedures, this article provides guidelines that may be used in the office setting to help transition more traditional hospital operating room-based procedures to the office setting. This article outlines the benefits of performing office-based wide-awake local anesthesia surgery with no tourniquet and provides a step-by-step guide to performing procedures that can be easily incorporated into any hand surgeon's practice successfully and safely.

Digital ischemia after lidocaine with epinephrine injection in a patient with primary Raynaud's phenomena

Lidocaine with epinephrine is ubiquitous in hand procedures. Although existing literature supports the overall safety of this, significant physiologic changes accompanying epinephrine can disproportionately affect vascularly compromised patients, such as in Raynaud's phenomenon. The literature is reviewed and a case presented regarding the dangers of epinephrine injection in this population.

A randomized controlled trial of three different local anesthetic methods for minor hand surgery

Purpose: Hemostasis and local anesthetic injection are essential for minor hand surgeries under local anesthesia (LA). Wide awake local anesthesia no tourniquet (WALANT) became popular for achieving hemostasis without a tourniquet. However, a recent study reported that injection is more painful than tourniquet use in minor hand surgery. Therefore, this study aimed to compare three LA methods that differ according to injection and hemostasis, namely, the combination of a tourniquet and buffered lidocaine solution (CTB), WALANT, and conventional LA. Methods: This randomized prospective single-center study included 169 patients who underwent minor hand surgery between 2017 and 2020. We randomly allocated the patients to each group and recorded the pain and anxiety score during the surgery, as well as satisfaction after the surgery. Results: Pure lidocaine injection was significantly more painful than buffered lidocaine and WALANT solution injection (p < 0.001). Local anesthesia injection was significantly more painful than tourniquet use in all groups (p < 0.001). The intraoperative anxiety score was significantly lower in the CTB group than in the conventional LA and WALANT groups (p < 0.001). The satisfaction score was significantly higher in the CTB and WALANT groups than in the conventional LA group (p < 0.001). Conclusion: CTB for minor hand surgery under LA is associated with less injection pain and patient anxiety. The tourniquet is tolerable without much pain and waiting time. Thus, CTB in minor hand surgery is a good alternative to WALANT and conventional LA.

Use of local anesthetics with an epinephrine additive on fingers and penis - dogma and reality

Epinephrine supplements in local anesthetics are regularly used for surgery in areas with terminal vessels. According to the pharmaceutical guidelines, the use of epinephrine as an additive to local anesthetics is contraindicated for these areas. This review provides an overview of the current scientific data as well as new clinical developments in various fields. It also reviews the current legal situation. A literature research was carried out to survey the current status of relevant data. Written inquiries to several German institutions (Institute for Quality and Efficiency in Health Care, National Association of Statutory Health Insurance Physicians, Center for Clinical Studies Tübingen, Federal Institute for Drugs and Medical Devices) were made to determine the legal situation. No evidence was found in the literature for a causal relationship between the use of epinephrine as a vasoconstrictor and necrosis of the finger or penis. Studies and reviews show that the use of local anesthetics with epinephrine on the fingers or penis is a safe procedure with many clinical and economic advantages. In routine clinical practice, the WALANT method (Wide Awake Local Anesthesia No Tourniquet) as well as the increasing incidence of skin tumors in acral areas has led to a tendency towards increasing use. However, its use is still legally contraindicated, and the pharmaceutical companies show no interest in supporting a drug study. Further clinical trials - regardless of the strength of the evidence - would not change the current legal contraindication.

A Review of 1073 Cases of Wide-Awake-Local-Anaesthesia-No-Tourniquet (WALANT) in Finger and Hand Surgeries in an Urban Hospital in Malaysia

Background The Wide-Awake-Local-Anaesthesia-No-Tourniquet (WALANT) technique achieves an almost bloodless field for clear visualization during surgeries. WALANT utilizes lidocaine and epinephrine for anesthesia and hemostasis, respectively, without the usage of sedation and tourniquet. This avoids the potential side effects of tourniquet-related pain and sedation-related complications. However, acceptance is still low due to concerns regarding the safety of epinephrine injection in the finger. There is a persistent belief that epinephrine can cause digital ischemia. Purpose To evaluate retrospectively possible complications of hand surgeries performed using the WALANT technique. Methods All finger and hand procedures performed under the WALANT technique from June 2016 to May 2021 in an urban tertiary hospital were studied retrospectively. Results There were a total of 1073 cases, of which 694 were females and 379 were males. The mean age was 55 years. Finger surgeries (e.g., trigger finger release, excision of finger lesions, removal of implants) consisted of 707 cases; and the rest (366 cases) were hand surgeries (e.g., carpal tunnel release, excision of hand lesions, removal of implants). In all cases reviewed, there were no instances of circulatory compromise. There were also no circumstances where usage of reversal with phentolamine is recorded. Conclusion We believe that performing finger and hand surgeries using the WALANT technique is safe and beneficial. The usage of WALANT in hand surgeries avoids tourniquet pain. However, WALANT should be used with caution in those with vascular insufficiency or disease.

Acute Peripheral and/or Cutaneous Ischemic Syndrome: What Rheumatologists Should Know

ABSTRACT

In daily practice, the frequent appearance of limb and/or skin necrosis, which we term "acute peripheral and/or cutaneous ischemic syndrome" (APCIS), can be a manifestation of numerous underlying diseases, or it can sometimes be a clinical phenomenon whose etiology is undefined even after a wide investigation. The mechanisms for the development of APCIS include vessel wall abnormalities (atherosclerosis, vasculitis, and calciphylaxis), embolic processes (infectious endocarditis, atrial myxoma, and cholesterol emboli), local thrombotic injuries (genetic or acquired thrombophilias and heparin- and warfarin-induced ischemia), dysproteinemias (cryoglobulinemia and cryofibrinogenemia), or venous limb gangrene. Here, we report 5 illustrative cases of APCIS with different pathogenetic mechanisms, thereby highlighting some clinical conditions that cause APCIS that may be of special interest for rheumatologists, such as antiphospholipid syndrome, primary and secondary vasculitis, and cryoproteinemias. Furthermore, we describe a large spectrum of other causes of APCIS beyond the scope of rheumatology. Because there are no validated guidelines for APCIS, we tentatively propose an initial diagnostic workup and a therapeutic approach based on full-dose anticoagulation and immunosuppressive therapy.

A randomized controlled trial of trigger finger release under digital anesthesia with (WALANT) and without adrenaline

BACKGROUND

Trigger finger release utilizing wide-awake local anesthesia no tourniquet (WALANT) usage in extremity surgery is not widely used in our setting due to the possibility of necrosis. Usage of a tourniquet is generally acceptable for providing surgical field hemostasis. We evaluate hemostasis score, surgical field visibility, onset and duration of anesthesia, pain score, and the duration of surgery and potential side effects of WALANT.

METHODS

Eighty-six patients scheduled for trigger finger release between July 2016 and December 2017 were randomized into a control group (1% lignocaine and 8.4% sodium bicarbonate with arm tourniquet; given 10 min prior to procedure) and an intervention group (1% lignocaine, 1:100,000 of adrenaline and 8.4% sodium bicarbonate; given 30 min prior to procedure), with a total of 4 ml of solution injected around the A1 pulley. The onset of anesthesia and pain score upon injection of the first 1 ml were recorded. After the procedure, the surgeon rated for the hemostasis score (1-10: 1 as no bleeding and 10 being profuse bleeding). Duration of surgery and return of sensation were recorded.

RESULTS

Hemostasis score was grouped into visibility score as 1-3: good, 4-6: moderate, and 7-10: poor. The intervention group (with adrenaline) had a 74% of good surgical field visibility compared to 44% from the controlled group (without adrenaline; p < 0.05). Duration of anesthesia was longer in the intervention group (with adrenaline), with a 2.77-h difference.

CONCLUSION

WALANT provides excellent surgical field visibility and is safe and on par with conventional methods but without the usage of a tourniquet and its associated discomfort.

488 hand surgeries with local anesthesia with epinephrine, without a tourniquet, without sedation, and without an anesthesiologist

Objectives

Evaluate the incidence of digital infarction and tissue necrosis using local anesthesia with 1% lidocaine and 1:100,000 epinephrine in wrist, hand, and fingers surgeries, without a tourniquet, without sedation, and without an anesthesiologist.

Methods

Patients with wrist, hand, and fingers disorders prospectively underwent surgery under local anesthesia with 1% lidocaine and 1:100,000 epinephrine. The primary outcomes evaluated were the presence of digital infarction and tissue loss due to necrosis. As secondary outcomes, the need for the use of sedatives, tourniquet, anesthesiologist assistance, or surgery suspension were evaluated.

Results

Fifty-three wrists, 307 hands, and 128 fingers were anesthetized with lidocaine and epinephrine without any complications related to epinephrine. There was no patient that presented with any of the primary or secondary outcomes.

Conclusions

Wrist, hand, and fingers surgeries can be safely performed with local anesthesia with 1% lidocaine and 1:100,000 epinephrine, without sedation, without a tourniquet, and without an anesthesiologist.

Conceptual origins, current practice, and views of wide awake hand surgery

This article reviews historical background, essential practice principles, and the new emerging area of wide awake hand surgery. It outlines the reasons that wide awake, local anaesthesia, no tourniquet surgery has emerged so quickly in the last 10 years over the world. I explain the origin of the concepts and some of the challenges of getting the technique accepted; in particular, the debunking of the myth of epinephrine danger in the finger. I review the most recent developments in several operations in this rapidly changing field of the tourniquet-free approach. Finally, this review includes speculations on the future of this technique.

Digital Necrosis After Lidocaine and Epinephrine Injection in the Flexor Tendon Sheath Without Phentolamine Rescue

The literature generally supports the safety of epinephrine injection in the digits, but recent case reports describe ischemic adverse events associated with the use of lidocaine and epinephrine in which phentolamine rescue was not performed. We present a case of finger necrosis and subsequent amputation in a patient after 1% lidocaine with 1:100,000 epinephrine was injected in the fat and flexor sheaths in the palm for a 3-finger trigger release. Phentolamine rescue was not performed. All surgeons who use epinephrine in the finger should be prepared to reverse vasoconstriction with phentolamine rescue if there is persistently inadequate perfusion of the fingertip.

Drug-induced Raynaud's phenomenon: beyond β-adrenoceptor blockers

AIM

Drug-induced Raynaud's phenomenon (RP) has long been associated with the use of different drugs, including cancer chemotherapy or β-adrenoceptor blockers. However, sources report extremely variable prevalence and the level of evidence for each class is heterogeneous. Moreover, new signals are emerging from case reports and small series. Our objective was therefore to review available evidence about this adverse drug effect and to propose a mechanistic approach of drug-induced RP.

METHODS

A systematic review of English and French language articles was performed through Medline (1946-2015) and Embase (1974-2015). Further relevant papers were identified from the reference lists of retrieved articles.

RESULTS

We identified 12 classes of drugs responsible for RP, with a variety of underlying mechanisms such as increased sympathetic activation, endothelial dysfunction, neurotoxicity or decreased red blood cell deformability. Cisplatin and bleomycin were associated with the highest risk, followed by β-adrenoceptor blockers. Recent data suggest a possible involvement of tyrosine kinase inhibitors (TKI), through an unknown mechanism.

CONCLUSION

Drug-induced RP is a probably underestimated adverse drug event, with limited available evidence regarding its prevalence. Although rare, serious complications like critical digital ischaemia have been reported. When these treatments are started in patients with a history of RP, careful monitoring must be made and, if possible, alternative therapies that do not alter peripheral blood flow should be considered.

Partial fingertip necrosis following a digital surgical procedure in a patient with primary Raynaud's phenomenon

Raynaud's phenomenon is a common clinical disorder consisting of recurrent, long-lasting and episodic vasospasm of the fingers and toes often associated with exposure to cold. In this article, we present a case of partial fingertip necrosis following digital surgical procedure in a patient with primary Raynaud's phenomenon.

[Necrosis in fingers and toes following local anaesthesia with adrenaline--an urban legend?]

BACKGROUND

It is often maintained that a local anaesthetic (usually lidocaine) with adrenaline must not be used in fingers and toes because it may cause necrosis due to vascular spasm in end arteries. This review article is an attempt to find evidence to support this warning.

METHOD

Relevant literature was found by means of searches in PubMed limited downwards to 1946 and in EMBASE from 1980 to 2012, and in reference lists.

RESULTS

Five review articles on finger necrosis following local anaesthesia concluded that lidocaine with adrenaline does not entail a risk of ischaemic injury. One article found 48 reported cases of finger necrosis in the period 1880 to 2000. Most were from the first half of the 1900s, and none involved lidocaine. Gangrene of part of the finger tip has subsequently been described in one patient with Raynaud's syndrome. No cases of necrosis have been described in a large number of reported accidents in which EpiPen injections contained the same quantity of adrenaline as is found in 60 ml lidocaine with adrenaline. Over a quarter of a million reports have been made of operations on feet, hands, fingers and toes anaesthetised with lidocaine with adrenaline without resulting necrosis.

INTERPRETATION

There are no grounds for the warning against using lidocaine with adrenaline in fingers and toes. This anaesthetic offers considerable practical advantages. Care should be taken with infected fingers or fingers with poor circulation.