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Janes L, Sepehripour S, Lalonde D. Clinically Important Pharmacologic Considerations for Wide-Awake Local Anesthesia No Tourniquet Hand Surgery. Plast Reconstr Surg 2024; 154:391e-402e. [PMID: 37220403 DOI: 10.1097/prs.0000000000010706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
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.
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Affiliation(s)
- Lindsay Janes
- From the Department of Orthopaedic Surgery, University of Pennsylvania
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Lalonde DH, Gruber MM, Ahmad AA, Langer MF, Sepehripour S. New Frontiers in Wide-Awake Surgery. Plast Reconstr Surg 2024; 153:1212e-1223e. [PMID: 38810165 DOI: 10.1097/prs.0000000000011414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
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.
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Affiliation(s)
| | | | | | - Martin F Langer
- the Clinic for Trauma, Hand, and Reconstructive Surgery, University Clinic Muenster
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Degreef I, Lalonde DH. WALANT surgery of the hand: state of the art. EFORT Open Rev 2024; 9:349-356. [PMID: 38726975 PMCID: PMC11099575 DOI: 10.1530/eor-24-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
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.
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Affiliation(s)
- Ilse Degreef
- Department of Orthopaedic, Hand Unit, Leuven University Hospitals, Gasthuisberg, Herestraat, Leuven, Belgium
| | - Donald H Lalonde
- Division of Plastic Surgery, Dalhousie University, Saint John, New Brunswick, Canada
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Lawand J, Hantouly A, Bouri F, Muneer M, Farooq A, Hagert E. Complications and side effects of Wide-Awake Local Anaesthesia No Tourniquet (WALANT) in upper limb surgery: a systematic review and meta-analysis. INTERNATIONAL ORTHOPAEDICS 2024; 48:1257-1269. [PMID: 38367058 PMCID: PMC11001684 DOI: 10.1007/s00264-024-06104-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/21/2024] [Indexed: 02/19/2024]
Abstract
PURPOSE Wide-Awake Local Anaesthesia No Tourniquet (WALANT), a groundbreaking anaesthetic technique resurging in practice, warrants a comprehensive safety analysis for informed adoption. Our study aimed to identify complications/side effects of WALANT upper limb procedures through a systematic review and meta-analysis. METHODS This PROSPERO-registered study was performed with strict adherence to PRISMA guidelines. Embase, OVIDMedline, Cochrane, Web of Science, and Scopus databases were searched until February 2023. Inclusion criteria involved English articles, reporting complications/side effects in primary WALANT upper limb surgeries. Outcomes included all complications and side effects, data on the anaesthetic mixture, publication year/location, study type, and procedures performed. The meta-analysis employed the Freeman-Tukey Double Arcsine Transformation, computed I2 statistics, and utilized common or random effects models for pooled analysis. RESULTS 2002 studies were identified; 79 studies met the inclusion criteria representing 15,595 WALANT patients. A total of 301 patients had complications, and the meta-analysis using a random effects model provided a complication rate of 1.7% (95% CI: 0.93-2.7%). The most reported complications were superficial infection (41%, n = 123/300), other/specified (12%, n = 37/300), and recurrent disease (6.7%, n = 20/300). A decade-by-decade analysis revealed no statistically significant difference in complication rates spanning the last three decades (p = 0.42). Adding sodium bicarbonate to the anaesthetic solution significantly reduced postoperative complications (p = 0.025). CONCLUSION WALANT has a low overall complication rate of 1.7%, with no significant temporal variation and a significant reduction in complications when sodium bicarbonate is added to the anaesthetic solution. Our findings support the safety of WALANT in upper limb procedures. REGISTRATION PROSPERO: CRD42023404018.
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Affiliation(s)
- Jad Lawand
- Medical Branch, University of Texas, 301 University Blvd, Galveston, TX, 77555, USA
| | - Ashraf Hantouly
- Department of Orthopedic Surgery, Hamad Medical Cooperation, Doha, Qatar
| | - Fadi Bouri
- Department of Orthopedic Surgery, Hamad Medical Cooperation, Doha, Qatar
| | - Mohammad Muneer
- Department of Plastic Surgery, Hamad Medical Corporation, Doha, Qatar
| | | | - Elisabet Hagert
- Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar.
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden.
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Brutus JP, Chang MC, Ahmad AA, Apard T. Description of WALANT technique in open bone and ligament wrist surgery. HAND SURGERY & REHABILITATION 2024; 43:101610. [PMID: 38393765 DOI: 10.1016/j.hansur.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 02/25/2024]
Abstract
The gold-standard for bone, ligament and joint surgery in the wrist is locoregional anesthesia in most countries. Wide-Awake Local Anesthesia No Tourniquet (WALANT) is commonly used for simple soft-tissue hand surgery procedures such as carpal tunnel or trigger finger release, and can now also be safely used in procedures such as proximal row carpectomy, scapholunate ligament repair or partial wrist fusion, to name but a few. This article describes the use of WALANT for complex surgery in the wrist. WALANT surgery offers many known benefits, such as enhanced patient safety and comfort, simplified perioperative process and avoidance of anesthesia-related risks, and also allows the surgeon to perform intraoperative testing of the repaired structures. Thus, the surgeon can tailor the rehabilitation program and shorten recovery time. We describe detailed guidelines for performing WALANT procedures safely and effectively, making it a favorable option for complex surgeries in the wrist.
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Affiliation(s)
| | - Min Cheol Chang
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Namku, Taegu, Republic of Korea.
| | | | - Thomas Apard
- Ultrasound-Guided Hand Surgery Center, Paris, Versailles, France
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Nijs K, Ruette J, Van de Velde M, Stessel B. Regional anaesthesia for ambulatory surgery. Best Pract Res Clin Anaesthesiol 2023; 37:397-408. [PMID: 37938085 DOI: 10.1016/j.bpa.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/05/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
Regional anaesthesia (RA) has an important and ever-expanding role in ambulatory surgery. Specific practices vary depending on the preferences and resources of the anaesthesia team and hospital setting. It is used for various purposes, including as primary anaesthetic technique for surgery but also as postoperative analgesic modality. The limited duration of action of currently available local anaesthetics limits their application in postoperative pain control and enhanced recovery. The search for the holy grail of regional anaesthetics continues. Current evidence suggests that a peripheral nerve block performed with long-acting local anaesthetics in combination with intravenous or perineural dexamethasone gives the longest and most optimal sensory block. In this review, we outline some possible blocks for ambulatory surgery and additives to perform RA. Moreover, we give an update on local anaesthesia drugs and adjuvants, paediatric RA in ambulatory care and discuss the impact of RA by COVID-19.
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Affiliation(s)
- Kristof Nijs
- Department of Anaesthesiology and Pain Medicine, Jessa Hospital, Hasselt, Belgium; UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium; KULeuven, Department of Cardiovascular Sciences, Leuven, Belgium; Department of Anaesthesiology and Pain Medicine, University Hospitals Leuven, Leuven, Belgium.
| | - Joke Ruette
- Department of Anaesthesiology and Pain Medicine, Jessa Hospital, Hasselt, Belgium; Department of Anaesthesiology and Pain Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Marc Van de Velde
- KULeuven, Department of Cardiovascular Sciences, Leuven, Belgium; Department of Anaesthesiology and Pain Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Björn Stessel
- Department of Anaesthesiology and Pain Medicine, Jessa Hospital, Hasselt, Belgium; UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium
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Shaw AV, Holmes D, Jansen V, Fowler C, Wormald JCR, Wade RG, Taha R, Reay E, Gardiner MD. RSTN COVID Hand: Hand trauma in the United Kingdom and Europe during the COVID-19 pandemic. J Plast Reconstr Aesthet Surg 2023; 84:258-265. [PMID: 37354711 PMCID: PMC10148718 DOI: 10.1016/j.bjps.2023.04.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 06/26/2023]
Abstract
The COVID-19 pandemic rapidly impacted the delivery of hand surgery services throughout the UK and Europe; from triage to treatment. Our aim was to assess the impact on management of common hand trauma injuries to inform future service delivery and research. The Reconstructive Surgery Trials Network led a service evaluation during the first wave of COVID-19 in 2020. Data was collected on hand injury management during the COVID-19 pandemic and was compared to the management clinicians would have delivered prior. Across 35 hand surgery units, 2540 patients with hand trauma were included. There was an increase of between 3% and 7% in non-operative management of injuries, apart from flexor tendon injuries where management remained unchanged. Cases triaged by a consultant doubled, with a 22% increase in the see-and-treat model. There was a move to operating in low-resource settings; a 13% increase in the use of minor operating theatres and 10% in clinic rooms. Use of WALANT, absorbable sutures, and remote follow-up also increased by 16%, 24%, and between 11% and 25%, respectively. The reported 30-day complication rate was 3.2%, with a surgical site infection rate of 1.8%. The pandemic led to rapid change in many aspects of hand trauma care. It was the impetus for increased out-of-theatre operating, use of local anaesthetic, and more non-operative management of injuries, without an increase in complication rate. Further research needs to assess the clinical and cost-effectiveness of these changes to ensure that COVID-19 is a catalyst for a modern, evidence-based, and environmentally sustainable delivery of hand trauma services.
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Affiliation(s)
- Abigail V Shaw
- Department of Plastic Surgery, Portsmouth Hospitals University NHS Trust, Cosham, Portsmouth PO6 3LY, UK.
| | - David Holmes
- Department of Orthopaedic Surgery, Leighton Hospital, Mid Cheshire Hospital NHS Foundation Trust, Middlewich Road, Crewe CW1 4QJ, UK
| | - Victoria Jansen
- Pulvertaft Hand Centre, University Hospitals of Derby and Burton NHS Foundation Trust, Uttoxeter Road, Derby DE22 3NE, UK
| | - Christy Fowler
- Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK
| | - Justin C R Wormald
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Windmill Road, Oxford OX3 7LD, UK
| | - Ryckie G Wade
- Leeds Institute for Medical Research, University of Leeds, Leeds LS2 9JT, UK
| | - Rowa Taha
- Centre for Evidence Based Hand Surgery, University of Nottingham, Queens Medical Centre Campus, NG7 2UH, UK
| | - Emma Reay
- Department of Hand Surgery, James Cook University Hospital, South Tees NHS Foundation Trust, Marton Road, Middlesborough TS4 3BW, UK
| | - Matthew D Gardiner
- Department of Plastic Surgery, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Wexham Street, Slough SL2 4HL, UK; Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Roosevelt Drive, Oxford OX3 7FY, UK
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Admani A, Sherman I, Jani P, Mwamuye A, Sepehripour S, Lalonde D. Below-knee Amputation with Minimally Painful Injection of Tumescent Local Anesthesia. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5164. [PMID: 37496983 PMCID: PMC10368383 DOI: 10.1097/gox.0000000000005164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/20/2023] [Indexed: 07/28/2023]
Abstract
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.
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Affiliation(s)
- Asif Admani
- From the Coast General Teaching and Referral Hospital, Department of Surgery, Mombasa, Kenya
| | - Imraan Sherman
- From the Coast General Teaching and Referral Hospital, Department of Surgery, Mombasa, Kenya
| | - Pankaj Jani
- Department of Surgery, University of Nairobi, Nairobi, Kenya
| | - Arnold Mwamuye
- From the Coast General Teaching and Referral Hospital, Department of Surgery, Mombasa, Kenya
| | - Sarvnaz Sepehripour
- Birmingham Women’s and Children’s National Health Service Foundation Trust, Birmingham, England
| | - Donald Lalonde
- Division of Plastic Surgery, Dalhousie University, Saint John, New Brunswick, Canada
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