Don Lalonde, MD, MSc, FRCSC,     Surgery, Dalhousie University, Hilyard Place, Suite C204, 600 Main Street, Saint John, New Brunswick E2K 1J5, Canada. Email: drdonlalonde@nb.aibn.com

The minimally invasive tumescent local anesthesia technique used in wide-awake hand surgery is having an impact in hand surgery practice. Patients spend less time and money and get to speak to their surgeon and receive education during the surgery itself. Improvements in operations such as flexor tendon repair have happened, because surgeons can see movement during the case and make adjustments before the skin is closed. Surgeons can perform more cases in the same amount of time with fewer personnel. The cost of the surgery is decreased, as all expenses surrounding the provision of sedation are removed.

Keywords

Wide-awake

Epinephrine finger

WALANT

Tourniquet-free

Sedation-free

Key points

Videos of how to inject carpal tunnel with minimal pain for wide awake surgery; Field sterility for surgery; surgery; intraoperative patient advice; bandage; and typical patient impression after surgery accompany this article at http://www.hand.theclinics.com/

Introduction/Nature of the problem

One of the most significant recent advances in hand surgery has been the movement away from tourniquet surgery, which often requires sedation or general anesthesia. The advent of epinephrine safety in the finger has led many to use this mode of hemostasis. This is providing a patient experience similar to a visit to the dentist; the patient comes in, rolls up his sleeve, gets the local anesthesia, has the hand surgery and goes home without preoperative testing or postoperative recovery time in the hospital or surgery center.

What is minimally invasive anesthesia for wide-awake hand surgery?

In wide-awake hand surgery, the only medications given to the patient are subcutaneous lidocaine and epinephrine. This mixture is infiltrated wherever surgical dissection, K wire insertion, or manipulation of fractured bones will occur. The concept behind this technique is that the local anesthetic results in an extravascular Bier block but only where it is needed. The other term that is frequently used to describe this approach is tumescent local anesthesia.

There are several advantages to this minimally invasive technique. If the local anesthesia is administered properly,1 all that the patient feels is the first needle poke of a 27-gauge needle in the hand for most hand operations. The lack of any sedation means there is no need for preoperative testing, intravenous insertion, intraoperative monitoring, or the postoperative anesthetic care unit. The procedures can be performed without sedation, because epinephrine is used for hemostasis, which obviates the need of a painful tourniquet. Once exposed to this concept, the patients love it.2 The patient experience of hand surgery using this technique becomes more on par with a visit to the dentist.

Indications/Contraindications

The author and colleagues believe that nearly every patient should be offered the wide-awake option. Most people who do not want sedation at the dentist are likely to prefer the wide-awake approach, because it is more convenient than going through the time-consuming process associated with sedation: preoperative testing, intravenous insertion, and postsedation recovery period. Patients with pre-existing medical problems such as renal dialysis, morbid obesity, and severe lung problems should be considered for this approach, as it is safer than the sedation/general anesthesia route.

Of course, some patients really are better served having sedation, and it should be given to them. Patients with high anxiety or severe post-traumatic stress disorder may not tolerate a wide-awake procedure. Also take care in offering this technique to non-native English speakers and those with cognitive impairments. Finally, not all surgeons enjoy interactive discussion with patients that can occur during operative procedures. This technique is not for those surgeons.

Epinephrine-induced cardiac ischemia is a possible but extremely rare event; even with high doses (1:1000 epinephrine).3 The author and colleagues have not had this complication with over 2000 cases. However, if there is concern with epinephrine use because of cardiac disease, lowering the dose of epinephrine to 1:400,000 is an option the author and colleagues occasionally employ. Some have even found epinephrine 1:1,000,000 effective for hemostasis.4

Technique

How to inject minimal pain local anesthesia for wide-awake hand surgery

There are 2 ways to inject local anesthesia; the traditional method of rapid injection with a 25-gauge needle, or the less painful “blow slow before you go” technique, which hurts patients...