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do Rosario Saraiva M, Vázquez OS, Ortiz-Huerta JH, Santamaría-Vázquez M. The wide-awake local anesthesia no tourniquet (WALANT) technique in thumb injuries: a systematic review. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02579-8. [PMID: 38967789 DOI: 10.1007/s00068-024-02579-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 06/10/2024] [Indexed: 07/06/2024]
Abstract
Human hands have a complex anatomical structure. The thumb, being an integral part of the hand, has an essential function in gripping. In this sense, thumb fractures account for 4% of all hand fractures (it may occur in association with fractures of the trapezium). The majority of hand fractures should be treated non-surgically and surgeons must avoid unnecessary surgery. Historically, hand surgery has used a combination of local/regional/general anaesthesia and a tourniquet. This study aims to carry out a systematic review to determine whether the WALANT technique is an advantageous alternative to conventional anaesthesia for surgical procedures on thumb injuries, in terms of patient function and pain. METHOD We conducted a search in the following databases: Pubmed/Medline, EBSCOhost, Web of Science, Scopus, ScienceDirect and Google Scholar, using the equation "WALANT" OR "Wide Awake Local Anesthesia No Tourniquet" AND "thumb pathology". RESULTS In five of the 584 articles included, two studied trapeziometacarpal osteoarthritis, one De Quervain's disease and the remaining two flexor injuries. WALANT showed good results in active movements, but with similar levels of pain between anaesthetics. Patients were more anxious during general anaesthesia, plus the fact that they were fasting and suspending medication. CONCLUSION WALANT is a convenient and favourable option in several studies. It has been demonstrated the benefits in terms of return to function and pain.
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Affiliation(s)
- Maria do Rosario Saraiva
- School of Health Sciences of Polytechnic of Leiria, Campus 2 - Morro Do Lena, Alto Do Vieiro - Apartado 4137, 2411-901, Leiria, Portugal
- Department of Rehabilitation, Local Health Unit - Guarda Hospital, Guarda, Portugal
| | - Olalla Saiz Vázquez
- Health Sciences Department, Universidad de Burgos, Paseo Comendadores s/n, Burgos, 09001, España.
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Nijs K, Hertogen P‘, Buelens S, Coppens M, Teunkens A, Jalil H, Van de Velde M, Al Tmimi L, Stessel B. Axillary Brachial Plexus Block Compared with Other Regional Anesthesia Techniques in Distal Upper Limb Surgery: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:3185. [PMID: 38892896 PMCID: PMC11173314 DOI: 10.3390/jcm13113185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/21/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Several regional anesthesia (RA) techniques have been described for distal upper limb surgery. However, the best approach in terms of RA block success rate and safety is not well recognized. Objective: To assess and compare the surgical anesthesia and efficacy of axillary brachial plexus block with other RA techniques for hand and wrist surgery. The attainment of adequate surgical anesthesia 30 min after block placement was considered a primary outcome measure. Additionally, successful block outcomes were required without the use of supplemental local anesthetic injection, systemic opioid analgesia, or the need to convert to general anesthesia. Methods: We performed a systematic search in the following databases: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and CENTRAL. RCTs comparing axillary blocks with other brachial plexus block techniques, distal peripheral forearm nerve block, intravenous RA, and the wide-awake local anesthesia no tourniquet (WALANT) technique were included. Results: In total, 3070 records were reviewed, of which 28 met the inclusion criteria. The meta-analysis of adequate surgical anesthesia showed no significant difference between ultrasound-guided axillary block and supraclavicular block (RR: 0.94 [0.89, 1.00]; p = 0.06; I2 = 60.00%), but a statistically significant difference between ultrasound-guided axillary block and infraclavicular block (RR: 0.92 [0.88, 0.97]; p < 0.01; I2 = 53.00%). Ultrasound-guided infraclavicular blocks were performed faster than ultrasound-guided axillary blocks (SMD: 0.74 [0.30, 1.17]; p < 0.001; I2 = 85.00%). No differences in performance time between ultrasound-guided axillary and supraclavicular blocks were demonstrated. Additionally, adequate surgical anesthesia onset time was not significantly different between ultrasound-guided block approaches: ultrasound-guided axillary blocks versus ultrasound-guided supraclavicular blocks (SMD: 0.52 [-0.14, 1.17]; p = 0.12; I2 = 86.00%); ultrasound-guided axillary blocks versus ultrasound-guided infraclavicular blocks (SMD: 0.21 [-0.49, 0.91]; p = 0.55; I2 = 92.00%). Conclusions: The RA choice should be individualized depending on the patient, procedure, and operator-specific parameters. Compared to ultrasound-guided supraclavicular and infraclavicular block, ultrasound-guided axillary block may be preferred for patients with significant concerns of block-related side effects/complications. High heterogeneity between studies shows the need for more robust RCTs.
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Affiliation(s)
- Kristof Nijs
- Department of Anesthesiology and Pain Medicine, Jessa Hospital, 3500 Hasselt, Belgium
- Faculty of Medicine and Life Sciences, University of Hasselt, 3590 Diepenbeek, Belgium
- Department of Cardiovascular Sciences, University of Leuven, 3000 Leuven, Belgium
| | - Pieter ‘s Hertogen
- Department of Anesthesiology and Pain Medicine, Jessa Hospital, 3500 Hasselt, Belgium
- Department of Cardiovascular Sciences, University of Leuven, 3000 Leuven, Belgium
- Department of Anesthesiology and Pain Medicine, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Simon Buelens
- Department of Anesthesiology and Pain Medicine, Jessa Hospital, 3500 Hasselt, Belgium
- Department of Cardiovascular Sciences, University of Leuven, 3000 Leuven, Belgium
- Department of Anesthesiology and Pain Medicine, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Marc Coppens
- Department of Anesthesiology and Perioperative Medicine, University Hospital Ghent, 9000 Ghent, Belgium
- Department of Basic and Applied Medical Sciences, University Ghent, 9000 Ghent, Belgium
| | - An Teunkens
- Department of Cardiovascular Sciences, University of Leuven, 3000 Leuven, Belgium
- Department of Anesthesiology and Pain Medicine, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Hassanin Jalil
- Department of Anesthesiology and Pain Medicine, Jessa Hospital, 3500 Hasselt, Belgium
| | - Marc Van de Velde
- Department of Cardiovascular Sciences, University of Leuven, 3000 Leuven, Belgium
- Department of Anesthesiology and Pain Medicine, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Layth Al Tmimi
- Department of Cardiovascular Sciences, University of Leuven, 3000 Leuven, Belgium
- Department of Anesthesiology and Pain Medicine, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Björn Stessel
- Department of Anesthesiology and Pain Medicine, Jessa Hospital, 3500 Hasselt, Belgium
- Faculty of Medicine and Life Sciences, University of Hasselt, 3590 Diepenbeek, Belgium
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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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Kanapathy M, Faderani R, Bray J, Dehbi HM, Panca M, Vindrola-Padros C, Prasad A, Burr N, Williams NR, Al-Ajam Y, Bhat W, Wong J, Mosahebi A, Nikkhah D. WAFER trial: a study protocol for a feasibility randomised controlled trial comparing wide-awake local anaesthesia no tourniquet (WALANT) to general and regional anaesthesia with tourniquet for flexor tendon repair. BMJ Open 2023; 13:e075440. [PMID: 37640464 PMCID: PMC10462963 DOI: 10.1136/bmjopen-2023-075440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/26/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION Flexor tendons are traditionally repaired under either general anaesthesia (GA) or regional anaesthesia (RA), allowing for the use of an arm tourniquet to minimise blood loss and establish a bloodless surgical field. However, the use of tourniquets exposes the patient to certain risks, including skin, muscle and nerve injuries. A recent advancement in anaesthesia delivery involves the use of a wide-awake approach where no sedation nor tourniquets are used (wide-awake local anaesthesia no tourniquet (WALANT)). WALANT uses local anaesthetic with epinephrine to provide pain relief and vasoconstriction, reducing operative bleeding. Several studies revealed potential benefits for WALANT compared with GA or RA. However, there remains a paucity of high-quality evidence to support the use of WALANT. As a result of this uncertainty, the clinical practice varies considerably. We aim to evaluate the feasibility of WALANT as an alternative to GA and RA in patients undergoing surgical repair of flexor tendon injuries. This involves addressing factors such as clinician and patient support for a trial, clinical equipoise, trial recruitment and dropout and the most relevant outcomes measures for a future definitive trial. METHODS AND ANALYSIS WAFER is a multicentre, single-blinded, parallel group, randomised controlled trial (RCT) to assess the feasibility of WALANT versus RA and GA. The target population is patients with acute traumatic flexor tendon injuries, across 3 major hand surgery units in England involving a total of 60 participants. Outcome assessors will be blinded. The primary outcome will be the ability to recruit patients into the trial, while secondary outcomes include difference in functional outcome, patient-reported outcome measures, health-related quality of life, cost-effectiveness and complication rates. ETHICS AND DISSEMINATION Ethical approval was obtained from the London-City and East Research Ethics Committee (22/PR/1197). Findings will be disseminated through peer-reviewed publication, conferences, patient information websites and social media networks. TRIAL REGISTRATION NUMBER ISRCTN identifier: 15052559.
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Affiliation(s)
- Muholan Kanapathy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
| | - Ryan Faderani
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
- Faculty of Medical Sciences, University College London, London, UK
| | - Juliette Bray
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
| | - Hakim-Moulay Dehbi
- University College London Institute of Clinical Trials and Methodology, London, UK
| | - Monica Panca
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | | | - Anjana Prasad
- Department of Anaesthesia, Royal Free NHS Foundation Trust Hospital, London, UK
| | - Nicola Burr
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
| | - Norman R Williams
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Yazan Al-Ajam
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
| | - Waseem Bhat
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jason Wong
- Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
| | - Afshin Mosahebi
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
| | - Dariush Nikkhah
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK
- Faculty of Medical Sciences, University College London, London, UK
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Nijs K, Van Rossum M, Ory JP, Pierson M, De Wachter G, Callebaut I, Jalil H, Vandenbrande J, Vandebergh V, Van de Velde M, Stessel B. Ultrasound-guided axillary brachial plexus block versus distal peripheral forearm nerve block for hand and wrist surgery: a randomised controlled trial. Br J Anaesth 2023:S0007-0912(23)00143-5. [PMID: 37080867 DOI: 10.1016/j.bja.2023.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 04/22/2023] Open
Affiliation(s)
- Kristof Nijs
- Department of Anaesthesiology and Pain Medicine, Jessa Hospital, Hasselt, Belgium; Faculty of Medicine and Life Sciences, Universiteit Hasselt, Diepenbeek, Belgium; Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium; Department of Anaesthesiology and Pain Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Maxime Van Rossum
- Department of Anaesthesiology and Pain Medicine, Jessa Hospital, Hasselt, Belgium; Department of Anaesthesiology and Pain Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Jean-Paul Ory
- Department of Anaesthesiology and Pain Medicine, Jessa Hospital, Hasselt, Belgium
| | - Maud Pierson
- Department of Anaesthesiology and Pain Medicine, Jessa Hospital, Hasselt, Belgium
| | | | - Ina Callebaut
- Department of Anaesthesiology and Pain Medicine, Jessa Hospital, Hasselt, Belgium; Faculty of Medicine and Life Sciences, Universiteit Hasselt, Diepenbeek, Belgium
| | - Hassanin Jalil
- Department of Anaesthesiology and Pain Medicine, Jessa Hospital, Hasselt, Belgium
| | - Jeroen Vandenbrande
- Department of Anaesthesiology and Pain Medicine, Jessa Hospital, Hasselt, Belgium
| | - Vincent Vandebergh
- Department of Anaesthesiology and Pain Medicine, Jessa Hospital, Hasselt, Belgium
| | - Marc Van de Velde
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, 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; Faculty of Medicine and Life Sciences, Universiteit Hasselt, Diepenbeek, Belgium.
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Regional anaesthesia: what surgical procedures, what blocks and availability of a “block room”? Curr Opin Anaesthesiol 2022; 35:698-709. [PMID: 36302208 DOI: 10.1097/aco.0000000000001187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
PURPOSE OF REVIEW With an expected rise in day care procedures with enhanced recovery programs, the use of specific regional anaesthesia can be useful. In this review, we will provide insight in the used regional block and medication so far known and its applicability in a day care setting. RECENT FINDINGS Regional anaesthesia has been improved with the aid of ultrasound-guided placement. However, it is not commonly used in the outpatient setting. Old, short acting local anaesthetics have found a second life and may be especially beneficial in the ambulatory setting replacing more long-acting local anaesthetics such as bupivacaine.To improve efficiency, a dedicated block room may facilitate the performance of regional anaesthesia. However, cost-efficacy for improved operating time, patient care and hospital efficiency has to be established. SUMMARY Regional anaesthesia has proven to be beneficial in ambulatory setting. Several short acting local anaesthetics are favourable over bupivacaine in the day care surgery. And if available, there are reports of the benefit of an additional block room used in a parallel (monitored) care of patients.
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Abstract
PURPOSE OF REVIEW Ambulatory surgery is increasingly performed in medically complex patients. This dynamic environment requires new approaches to ensure cost-effective, efficient, and ultimately safe preoperative evaluation of the patient. This review investigates recent advances in the assessment of ambulatory patients, with a special focus on patient screening, digital communication, and multidisciplinary team evaluation. RECENT FINDINGS Identifying suitable candidates for ambulatory surgery relies on a variety of medical, surgical, and institutional factors. Identification of high-risk patients and optimization of their treatment can be achieved through multidisciplinary protocols specific to the local institution and in line with current guidelines. Virtual assessment may be sufficient for most patients and provide an efficient evaluation strategy and high patient satisfaction. Prescreening can be supported by preoperative nursing teams. SUMMARY The increasing complexity of treatment provided in day surgery offers a unique opportunity to highlight the importance of anesthesiology staff as perioperative caregivers. Preoperative evaluation serves as a central junction to integrate a variety of surgical, medical, and institutional factors to provide safe, satisfactory, and efficient care for patients. Implementing technological innovation to streamline and facilitate this process is paramount.
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Single sterile silicon ring technique for utilization of upper limb intravenous regional anesthesia: A prospective study of patients with operated distal radius fractures. Injury 2021; 52:3611-3615. [PMID: 34420690 DOI: 10.1016/j.injury.2021.08.011] [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] [Received: 03/17/2021] [Revised: 07/17/2021] [Accepted: 08/05/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Intravenous regional anesthesia is a well-established method of anesthesia in upper extremity surgery. In this study, we present a modification of the technique using a silicon ring tourniquet in 30 patients undergoing internal fixation for distal radius fractures. METHODS A sterile silicone ring wrapped within a stockinette sleeve was applied, and a local anesthetic solution (3 mg/kg lidocaine 0,5%) was injected intravenously. After anesthesia onset, the ring was rolled distally to provide immediate pain and discomfort relief. RESULTS The silicone ring achieved adequate exsanguination in all patients. Mean pain VAS score was 2.7 ± 0.9 intraoperatively and 4.3 ± 1.3 during the first hour postoperatively. The onset and termination times of sensory block were 5.8 ± 2.1 and 102 ± 7.8 min, and of motor block 13.8 ± 2.8 and 54.2 ± 4.6 min, accordingly. All patients were satisfied from the procedure. CONCLUSION Sterile silicone ring tourniquet application is a simple, safe and effective analgesic and anesthetic technique for the operative treatment of distal radius fractures.
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