- Email: [email protected]
Tourniquet Use for Short Hand Surgery Procedures Done Under Local Anesthesia Without Epinephrine
SCIENTIFIC ARTICLE
Tourniquet Use for Short Hand Surgery Procedures Done Under Local Anesthesia Without Epinephrine Brandon S. Shulman, MD,* Michael Rettig, MD,* S. Steven Yang, MD,* Anthony Sapienza, MD,* Joseph Bosco, MD,* Nader Paksima, DO, MPH* Purpose Wide-awake local anesthesia no tourniquet (WALANT) is an increasingly popular surgical technique. However, owing to surgeon preference, patient factors, or hospital guidelines, it may not be feasible to inject patients with solutions containing epinephrine the recommended 25 minutes prior to incision. The purpose of this study was to assess pain and patient experience after short hand surgeries done under local anesthesia using a tourniquet rather than epinephrine for hemostasis. Methods Ninety-six consecutive patients undergoing short hand procedures using only local anesthesia and a tourniquet (LA-T) were assessed before and after surgery. A high arm pneumatic tourniquet was used in 73 patients and a forearm pneumatic tourniquet was used in 23. All patients received a local, unbuffered plain lidocaine injection. No patients received sedation. Pain related to local anesthesia, pneumatic tourniquet, and the procedure was assessed using a visual analog scale (VAS). Patient experience was assessed using a studyspecific questionnaire based on previous WALANT studies. Tourniquet times were recorded. Results Mean pain related to anesthetic injection was rated 3.9 out of 10. Mean tourniquet related pain was 2.9 out of 10 for high arm pneumatic tourniquets and 2.3 out of 10 for forearm pneumatic tourniquets. Patients rated their experience with LA-T favorably and 95 of 96 patients (99%) reported that they would choose LA-T again for an equivalent procedure. Mean tourniquet time was 9.6 minutes and only 1 patient had a tourniquet inflated for more than 20 minutes. Tourniquet times less than 10 minutes were associated with less pain than tourniquet times greater than 10 minutes (P < .05); however, both groups reported the tourniquet to be on average less painful than the local anesthetic injection. Conclusion Short wide-awake procedures using a tourniquet are feasible and well accepted. Local anesthetic injection was reported to be more painful than pneumatic tourniquet use. Tourniquets for short wide-awake procedures can be used in settings in which preprocedure epinephrine injections are logistically difficult or based on surgeon preference. (J Hand Surg Am. 2019;-(-):1.e1-e6. Copyright Ó 2019 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Hand surgery, local anesthesia, tourniquet, wide awake, WALANT.
From the *Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY.
Corresponding author: Nader Paksima, DO, MPH, NYU Langone Medical Center, 530 1st Ave., Suite 8U, New York, NY 10016; e-mail: [email protected].
Received for publication September 9, 2018; accepted in revised form October 30, 2019.
0363-5023/19/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2019.10.035
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Ó 2019 ASSH
r
Published by Elsevier, Inc. All rights reserved.
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WIDE-AWAKE SURGERY WITH TOURNIQUET
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IDE-AWAKE HAND SURGERY IS an increasingly popular surgical technique in which only local injections and no sedatives are used for pain control.1e3 In comparison with traditional anesthesia, wide-awake hand surgery lowers patient burden and cost by obviating the need for traditional anesthesia, intravenous access, postsurgical hospital beds, patient chaperones, and fasting before surgery.1,2,4 The wide-awake local anesthesia no tourniquet (WALANT) technique uses epinephrine instead of a tourniquet to achieve a bloodless field and has been well described as a safe and effective anesthesia technique for hand surgeries.3e8 Traditional thinking has been that tourniquets are poorly tolerated by awake patients, and thus, tourniquet use necessitates general anesthesia.1,2,9 In fact, the lack of tourniquet use and elimination of tourniquetassociated discomfort is commonly described as a main benefit of using the WALANT technique.1,2,10 However, WALANT has some drawbacks. Epinephrine must be injected 25 to 30 minutes prior to incision in order to achieve the maximum hemostasis effect,9 which is not feasible in all surgical settings. Patients can become tremulous from the use of epinephrine and experience blanching long after the conclusion of the procedure, which can be disconcerting.4 Despite a strong safety record and the ability to reverse epinephrine-associated vasoconstriction with phentolamine, there have also been case reports of digital necrosis.5,11 Owing to regulations at our institution prohibiting preprocedure injections of epinephrine, we began performing short, wide-awake hand procedures using a tourniquet for hemostasis. The purpose of this study was to assess pain and patient experience after short hand surgeries done under local anesthesia using a tourniquet rather than epinephrine for hemostasis (LA-T). Our goal was to determine whether LA-T was well tolerated for common hand procedures.
TABLE 1.
Demographics
High Arm Tourniquet
Forearm Tourniquet
P
n
73
23
Age, y (mean)
60
55
.15
% Women
56
65
.45
Tourniquet time, min (mean)
9.8
9.0
.58
Tourniquet pain (mean)
2.9
2.3
.34
at the discretion of the treating surgeon. All patients received anesthesia from a local unbuffered plain 1% lidocaine injection administered by the surgeon in the operating room. All injections were given at room temperature using a 25-gauge needle.2,5,12,13 Lidocaine was chosen given the short duration of the procedures, lidocaine’s excellent safety record, and the possibility of additional anesthetics such as bupivacaine producing a touch and pressure numbing effect outlasting its pain control.13 No patient received sedation and no anesthesiologist was present for any case. All surgeries were performed by 1 of 4 fellowship-trained orthopedic hand surgeons (M.R., S.S.Y., A.S., N.P.) at the same surgery center. Patients were administered a survey (Appendix A; available on the Journal’s Web site at www. jhandsurg.org) adapted from previous WALANT studies3,10,14 assessing their anxiety, pain, and experience following their procedure in the postoperative care unit. Inclusion criteria were patients undergoing the following procedures: open carpal tunnel release, trigger finger release, first dorsal compartment release, removal of hardware, or mass excision. An LA-T was offered to every patient who met the inclusion criteria. The decision to undergo LA-T versus surgery with traditional anesthesia was made by the patient. Exclusion criteria were patients who did not speak English as well as patients with the following medical comorbidities who were not deemed safe for operations at our surgery center: resting angina, congestive heart failure, an implanted defibrillator, need for supplemental oxygen, or a brain tumor. Demographic and surgical information, including tourniquet time and location of the tourniquet, was collected on all patients (Table 1). Anxiety related to the administration of local anesthesia and the procedure itself was collected using single-question 0 to 10 scales, with 0 being no anxiety and 10 being maximally anxious. Pain during
MATERIALS AND METHODS A prospective cohort of 96 patients who underwent LA-T at our institution from September 2016 to April 2018 was studied. This was a sample of convenience. From June 2017 to September 2017, no data were collected owing to a personnel change on our research team. In 73 patients, hemostasis was achieved using a high arm pneumatic tourniquet and in 23 patients from a forearm pneumatic tourniquet. Tourniquets were inflated to 100 mg Hg above the systolic blood pressure. The decision to use a high arm versus a forearm pneumatic tourniquet was made J Hand Surg Am.
Differences by Tourniquet Group
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the administration of local anesthesia, during the procedure, and related to the tourniquet were collected using visual analog scale (VAS) scores on a 0 to 10 scale, with 0 being no pain and 10 being the worst pain. All patients were asked whether they would choose LA-T again for a similar procedure and whether they would recommend LA-T to a friend or family member. Mean anxiety and pain scores were analyzed as ordinal values. Mann-Whitney U tests were used to determine the relationship between tourniquet-related pain and tourniquet time (> or < 10 minutes). Mann-Whitney U tests were used to evaluate differences in treatment and outcomes between patients treated with high arm tourniquets and patients treated with forearm tourniquets. The institutional review board of our institution approved this study. Significance level was set at P less than .05. This manuscript adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines; the study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki.
Preoperative Preoperative Anxiety Anxiety (Procedure) (Local Anesthesia)
F
FIGURE 1: Survey results. All questions are based on a 0 to 10 VAS or Likert scale; reported results are based on the mean value for the full cohort.
DISCUSSION Our results confirmed our hypothesis that LA-T for simple hand surgeries of less than 20 minutes is feasible and well tolerated. Previous studies of WALANT outcomes have demonstrated similar patient experiences. Teo et al3 reported that 86% of patients would prefer to have WALANT for a similar surgery, and 88% of patients would definitely or probably recommend WALANT to a friend. Davidson et al14 reported that 93% of patients who underwent an open carpal tunnel release via WALANT would chose WALANT again for a similar surgery. Numerous previous studies have commented on tourniquet tolerance in awake subjects. Hutchinson and McClinton in 199315 reported that, at 300 mm Hg, high arm tourniquet tolerance averaged 29 minutes and forearm tolerance averaged 42 minutes. Lim et al16 compared high arm tourniquet pressures of 200 mm Hg and 250 mm Hg in the upper extremity and found that all subjects tolerated tourniquets for 20 minutes regardless of pressure, but did note lower tourniquet pressures were associated with less pain. Multiple other studies have reported that the majority of patients can tolerate high arm tourniquets inflated to 100 mm Hg above the systolic blood pressure for approximately 20 minutes.17e20 Our findings support the existing literature because all patients tolerated their tourniquet for the length of their short procedures. Furthermore, although tourniquet times of less than 10 minutes were associated with lower tourniquetrelated pain scores, patients with tourniquet times of greater than10 minutes still reported comparatively less pain from the tourniquet than from the local lidocaine injection based on score comparison. This leads us to believe that tourniquet inflation for less than 20 minutes is nearly universally well tolerated. The notion that there is secondary
RESULTS Results of VAS and experience scores are displayed in Figure 1. Ninety-five of 96 patients (99%) reported that they would choose LA-T for an equivalent procedure in the future. Ninety-five of 96 patients (99%) reported that they would recommend LA-T to a friend. Mean pain related to anesthetic injection was rated 3.9 of 10. Overall, there were no differences in tourniquet time or tourniquet-related pain between patients with pneumatic high arm tourniquets and patients with pneumatic forearm tourniquets (Table 1). Mean tourniquet time was 9.6 minutes and only 1 patient had a tourniquet inflated for more than 20 minutes. Tourniquet times of less than 10 minutes were associated with less tourniquet-related pain than tourniquet times 10 minutes or greater (P < .05); however, both groups reported the tourniquet to be, on average, less painful than the local anesthetic injection (1.7 tourniquet pain vs 4.5 injection pain and 3.2 tourniquet pain vs 4.3 injection pain, respectively). No tourniquets were let down prematurely owing to tourniquet-related pain. No complications, defined as nontransient loss of strength, nontransient diminished sensation, or continued pain on clinical examination were encountered. In addition to a postoperative examination in the surgery center, patients were reexamined between 2 and 6 weeks following their surgery. J Hand Surg Am.
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reperfusion pain that begins a few minutes after deflation, as described by Prodhomme et al,18 was not found to be clinically relevant in our study. All surveys were administered in the postoperative care unit approximately 10 to 30 minutes after tourniquet deflation, at which point we expected both inflation- and reperfusion-related pain to be captured. Furthermore, patients reported that pain related to the tourniquet was, on average, less painful than local injection with unbuffered plain lidocaine. We likely could have decreased the pain caused by our local injections by using buffered solutions, 27gauge instead of 25-guage needles, and warming the anesthetic prior to injection.2,12,21 It should be noted that injection-related pain scores of 0 to 2 have been reported using these practices in addition to proper injection technique.22 Lees et al23 reported that exsanguinating the upper extremity prior to tourniquet inflation led to significantly less tourniquet-related pain than elevation alone. White et al24 reported that giving patients 50% oxygen 3 minutes prior to and throughout tourniquet inflation led to decreased pain compared with placebo. We routinely exsanguinated limbs using an Esmarch bandage prior to tourniquet inflation, but did not use supplemental oxygen. Relatively little data have been published regarding LA-T. Braithwaite et al in 19936 compared a variation of WALANT (different administration technique than described by Lalonde and Wang13) with LA-T on contralateral limbs of patients undergoing bilateral carpal tunnel release. They reported less pain in the modified WALANT group, but shorter surgery times in the LA-T.6 There were no differences in postoperative pain.6 Gunasagaran et al25 recently compared WALANT with LA-T in Malaysian patients and reported that WALANT was associated with less pain, but longer preoperative preparation times. However, they did not comment on the position or pressure of their tourniquets and did not assess patient experience. Miller et al,26 Kamath et al,27 Ruxasagulwong et al,28 and Davidson et al14 all compared WALANT with tourniquet use under light sedation and found relatively equal rates of patient satisfaction. Although notable for suggesting that patients are relatively happy regardless of anesthesia plan, these 4 studies did not address tourniquet use in fully awake patients. Although we did not directly compare WALANT with LA-T in our study, we believe that, given our results, LA-T is, at minimum, a viable alternative to WALANT. J Hand Surg Am.
The main limitation of this study was our inability to use a validated outcomes measure. Because we needed to assess intraoperative outcomes of awake patients and most validated instruments assess postoperative outcomes of sedated patients, we found that the available validated outcomes instruments did not address our hypothesis. We based our survey on the surveys used by Davison et al,14 Teo et al,3 and Rhee et al10 to assess WALANT procedures, although changes had to be made to incorporate tourniquetrelated pain and better specify the use of a VAS (Appendix A; available on the Journal’s Web site at www.jhandsurg.org). Another major limitation of this study is its inherent selection bias because only patients who elected to have LA-T were included in the study and most had no point of comparison with surgery with sedation. Patients who elected for traditional anesthesia may have had higher anxiety and pain scores and a worse experience had they only been offered a wide-awake procedure but preferred to be sedated. We were further unable to directly compare outcomes of our protocol with the WALANT protocol because our institution prohibits preprocedure injections. However, our intention is not to diminish the benefits of WALANT, but to bring to light that, in appropriate patients, LA-T is feasible and well tolerated. This study shows that performing LA-T is a well-tolerated technique for short hand surgical procedures. The LA-T obviates the need for extra postoperative monitoring and consideration of epinephrine reversal. It also has the advantage of having a nearly identical workflow and operative setup to traditional hand surgery cases. Local anesthesia using a tourniquet is a useful option for many patients undergoing short procedures. ACKNOWLEDGMENTS The authors thank Adam Jacobs, BA, for data collection and Lorraine Hutzler, BA, for research coordination. Research Conducted at the Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY 10003. REFERENCES 1. Lalonde DH. Conceptual origins, current practice, and views of wide awake hand surgery. J Hand Surg Eur. 2017;42(9):886e895. 2. Lalonde D, Eaton C, Amadio P, Jupiter J. Wide-awake hand and wrist surgery: a new horizon in outpatient surgery. Instr Course Lect. 2015;64:249e259. 3. Teo I, Lam W, Muthayya P, Steele K, Alexander S, Miller G. Patients’ perspective of wide-awake hand surgery—100 consecutive cases. J Hand Surg Eur. 2013;38(9):992e999.
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18. Prodhomme G, Mouraux D, Dugailly PM, Chantelot C, Fontaine C, Schuind F. Tolerance of upper extremity pneumatic tourniquets and their effect on grip strength. J Hand Surg Eur. 2008;33(3):266e271. 19. Tanpowpong T, Kitidumrongsook P, Patradul A. The deleterious effects of exsanguination with a tight bandage on tourniquet tolerance in the upper arm. J Hand Surg Eur. 2012;37(9):839e841. 20. Yousif NJ, Grunert BK, Forte RA, Matloub HS, Sanger JR. A comparison of upper arm and forearm tourniquet tolerance. J Hand Surg Br. 1993;18(5):639e641. 21. Hogan ME, vanderVaart S, Perampaladas K, Machado M, Einarson TR, Taddio A. Systematic review and meta-analysis of the effect of warming local anesthetics on injection pain. Ann Emerg Med. 2011;58(1):86e98.e1. 22. Farhangkhoee H, Lalonde J, Lalonde DH. Teaching medical students and residents how to inject local anesthesia almost painlessly. Can J Plast Surg. 2012;20(3):169e172. 23. Lees DA, Penny JB, Baker P. A single blind randomised controlled trial of the impact on patient-reported pain of arm elevation versus exsanguination prior to tourniquet inflation. Bone Joint J. 2016;98B(4):519e525. 24. White N, Dobbs TD, Murphy GR, Khan K, Batt JP, Cogswell LK. Oxygen reduces tourniquet-associated pain: a double-blind, randomized, controlled trial for application in hand surgery. Plast Reconstr Surg. 2015;135(4):721ee730e. 25. Gunasagaran J, Sean ES, Shivdas S, Amir S, Ahmad TS. Perceived comfort during minor hand surgeries with wide awake local anaesthesia no tourniquet (WALANT) versus local anaesthesia (LA)/ tourniquet. J Orthop Surg (Hong Kong). 2017;25(3). 2309499017739499. 26. Miller A, Kim N, Ilyas AM. Prospective evaluation of opioid consumption following hand surgery performed wide awake versus with sedation. Hand (N Y). 2017;12(6):606e609. 27. Kamath J, Shenoy T, Jayasheelan N, Rizwan N, Sachan V, Danda R. Timed wake-up anaesthesia in hand: a modification to wide awake surgery of hand. Indian J Plast Surg. 2016;49(3):378e383. 28. Ruxasagulwong S, Kraisarin J, Sananpanich K. Wide awake technique versus local anesthesia with tourniquet application for minor orthopedic hand surgery: a prospective clinical trial. J Med Assoc Thai. 2015;98(1):106e110.
4. Lalonde D. Minimally invasive anesthesia in wide awake hand surgery. Hand Clin. 2014;30(1):1e6. 5. Lalonde D, Martin A. Tumescent local anesthesia for hand surgery: improved results, cost effectiveness, and wide-awake patient satisfaction. Arch Plast Surg. 2014;41(4):312e316. 6. Braithwaite BD, Robinson GJ, Burge PD. Haemostasis during carpal tunnel release under local anaesthesia: a controlled comparison of a tourniquet and adrenaline infiltration. J Hand Surg Br. 1993;18(2): 184e186. 7. Prasetyono TO. Tourniquet-free hand surgery using the one-per-mil tumescent technique. Arch Plast Surg. 2013;40(2):129e133. 8. Tang JB. Wide-awake primary flexor tendon repair, tenolysis, and tendon transfer. Clin Orthop Surg. 2015;7(3):275e281. 9. McKee DE, Lalonde DH, Thoma A, Dickson L. Achieving the optimal epinephrine effect in wide awake hand surgery using local anesthesia without a tourniquet. Hand (N Y). 2015;10(4): 613e615. 10. Rhee PC, Fischer MM, Rhee LS, McMillan H, Johnson AE. Cost savings and patient experiences of a clinic-based, wide-awake hand surgery program at a military medical center: a critical analysis of the first 100 procedures. J Hand Surg Am. 2017;42(3):e139ee147. 11. Zhang JX, Gray J, Lalonde DH, Carr N. Digital necrosis after lidocaine and epinephrine injection in the flexor tendon sheath without phentolamine rescue. J Hand Surg Am. 2017;42(2):e119ee123. 12. Lalonde DH. "Hole-in-one" local anesthesia for wide-awake carpal tunnel surgery. Plast Reconstr Surg. 2010;126(5):1642e1644. 13. Lalonde DH, Wong A. Dosage of local anesthesia in wide awake hand surgery. J Hand Surg Am. 2013;38(10):2025e2028. 14. Davison PG, Cobb T, Lalonde DH. The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study. Hand (N Y). 2013;8(1):47e53. 15. Hutchinson DT, McClinton MA. Upper extremity tourniquet tolerance. J Hand Surg Am. 1993;18(2):206e210. 16. Lim E, Shukla L, Barker A, Trotter DJ. Randomized blinded control trial into tourniquet tolerance in awake volunteers. ANZ J Surg. 2015;85(9):636e638. 17. Maury AC, Roy WS. A prospective, randomized, controlled trial of forearm versus upper arm tourniquet tolerance. J Hand Surg Br. 2002;27(4):359e360.
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PAIN Pain level during local anesthesia administration: 0 1 2 3 4 5 6 7 8 9 10 Pain level during procedure (not related to tourniquet): 0 1 2 3 4 5 6 7 8 9 10 Pain due to tourniquet: 0 1 2 3 4 5 6 7 8 9 10 SATISFACTION General patient satisfaction: 0 1 2 3 4 5 6 7 8 9 10 Would you recommend Wide Awake Hand Surgery to someone else? Y / N Would you do Wide Awake Hand Surgery again (versus general anesthesia)? Y / N
Appendix A. Survey Administered to LA-T Patients Wide Awake Hand Surgery-Tourniquet Postoperative Survey Patient Number:____________________________ Date of Surgery: ______________________ _______ SURGERY Surgery Performed: __________________________ _____________________________________________ _________________ Tourniquet Time (in minutes): ______________ ________________ Complications: ___________________________ _________________________________________ Tourniquet: Forearm cuff j High-arm cuff ANXIETY Did talking to surgeon/OR staff during your procedure make you feel: More comfortable / Less comfortable / Same What was your level of anxiety regarding local anesthesia: 0 1 2 3 4 5 6 7 8 9 10 What was your level of anxiety regarding the procedure: 0 1 2 3 4 5 6 7 8 9 10
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Tourniquet Use for Short Hand Surgery Procedures Done Under Local Anesthesia Without Epinephrine Brandon S. Shulman, MD,* Michael Rettig, MD,* S. Steven Yang, MD,* Anthony Sapienza, MD,* Joseph Bosco, MD,* Nader Paksima, DO, MPH* Purpose Wide-awake local anesthesia no tourniquet (WALANT) is an increasingly popular surgical technique. However, owing to surgeon preference, patient factors, or hospital guidelines, it may not be feasible to inject patients with solutions containing epinephrine the recommended 25 minutes prior to incision. The purpose of this study was to assess pain and patient experience after short hand surgeries done under local anesthesia using a tourniquet rather than epinephrine for hemostasis. Methods Ninety-six consecutive patients undergoing short hand procedures using only local anesthesia and a tourniquet (LA-T) were assessed before and after surgery. A high arm pneumatic tourniquet was used in 73 patients and a forearm pneumatic tourniquet was used in 23. All patients received a local, unbuffered plain lidocaine injection. No patients received sedation. Pain related to local anesthesia, pneumatic tourniquet, and the procedure was assessed using a visual analog scale (VAS). Patient experience was assessed using a studyspecific questionnaire based on previous WALANT studies. Tourniquet times were recorded. Results Mean pain related to anesthetic injection was rated 3.9 out of 10. Mean tourniquet related pain was 2.9 out of 10 for high arm pneumatic tourniquets and 2.3 out of 10 for forearm pneumatic tourniquets. Patients rated their experience with LA-T favorably and 95 of 96 patients (99%) reported that they would choose LA-T again for an equivalent procedure. Mean tourniquet time was 9.6 minutes and only 1 patient had a tourniquet inflated for more than 20 minutes. Tourniquet times less than 10 minutes were associated with less pain than tourniquet times greater than 10 minutes (P < .05); however, both groups reported the tourniquet to be on average less painful than the local anesthetic injection. Conclusion Short wide-awake procedures using a tourniquet are feasible and well accepted. Local anesthetic injection was reported to be more painful than pneumatic tourniquet use. Tourniquets for short wide-awake procedures can be used in settings in which preprocedure epinephrine injections are logistically difficult or based on surgeon preference. (J Hand Surg Am. 2019;-(-):1.e1-e6. Copyright Ó 2019 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Hand surgery, local anesthesia, tourniquet, wide awake, WALANT.
From the *Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY.
Corresponding author: Nader Paksima, DO, MPH, NYU Langone Medical Center, 530 1st Ave., Suite 8U, New York, NY 10016; e-mail: [email protected].
Received for publication September 9, 2018; accepted in revised form October 30, 2019.
0363-5023/19/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2019.10.035
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Ó 2019 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1.e1
1.e2
WIDE-AWAKE SURGERY WITH TOURNIQUET
W
IDE-AWAKE HAND SURGERY IS an increasingly popular surgical technique in which only local injections and no sedatives are used for pain control.1e3 In comparison with traditional anesthesia, wide-awake hand surgery lowers patient burden and cost by obviating the need for traditional anesthesia, intravenous access, postsurgical hospital beds, patient chaperones, and fasting before surgery.1,2,4 The wide-awake local anesthesia no tourniquet (WALANT) technique uses epinephrine instead of a tourniquet to achieve a bloodless field and has been well described as a safe and effective anesthesia technique for hand surgeries.3e8 Traditional thinking has been that tourniquets are poorly tolerated by awake patients, and thus, tourniquet use necessitates general anesthesia.1,2,9 In fact, the lack of tourniquet use and elimination of tourniquetassociated discomfort is commonly described as a main benefit of using the WALANT technique.1,2,10 However, WALANT has some drawbacks. Epinephrine must be injected 25 to 30 minutes prior to incision in order to achieve the maximum hemostasis effect,9 which is not feasible in all surgical settings. Patients can become tremulous from the use of epinephrine and experience blanching long after the conclusion of the procedure, which can be disconcerting.4 Despite a strong safety record and the ability to reverse epinephrine-associated vasoconstriction with phentolamine, there have also been case reports of digital necrosis.5,11 Owing to regulations at our institution prohibiting preprocedure injections of epinephrine, we began performing short, wide-awake hand procedures using a tourniquet for hemostasis. The purpose of this study was to assess pain and patient experience after short hand surgeries done under local anesthesia using a tourniquet rather than epinephrine for hemostasis (LA-T). Our goal was to determine whether LA-T was well tolerated for common hand procedures.
TABLE 1.
Demographics
High Arm Tourniquet
Forearm Tourniquet
P
n
73
23
Age, y (mean)
60
55
.15
% Women
56
65
.45
Tourniquet time, min (mean)
9.8
9.0
.58
Tourniquet pain (mean)
2.9
2.3
.34
at the discretion of the treating surgeon. All patients received anesthesia from a local unbuffered plain 1% lidocaine injection administered by the surgeon in the operating room. All injections were given at room temperature using a 25-gauge needle.2,5,12,13 Lidocaine was chosen given the short duration of the procedures, lidocaine’s excellent safety record, and the possibility of additional anesthetics such as bupivacaine producing a touch and pressure numbing effect outlasting its pain control.13 No patient received sedation and no anesthesiologist was present for any case. All surgeries were performed by 1 of 4 fellowship-trained orthopedic hand surgeons (M.R., S.S.Y., A.S., N.P.) at the same surgery center. Patients were administered a survey (Appendix A; available on the Journal’s Web site at www. jhandsurg.org) adapted from previous WALANT studies3,10,14 assessing their anxiety, pain, and experience following their procedure in the postoperative care unit. Inclusion criteria were patients undergoing the following procedures: open carpal tunnel release, trigger finger release, first dorsal compartment release, removal of hardware, or mass excision. An LA-T was offered to every patient who met the inclusion criteria. The decision to undergo LA-T versus surgery with traditional anesthesia was made by the patient. Exclusion criteria were patients who did not speak English as well as patients with the following medical comorbidities who were not deemed safe for operations at our surgery center: resting angina, congestive heart failure, an implanted defibrillator, need for supplemental oxygen, or a brain tumor. Demographic and surgical information, including tourniquet time and location of the tourniquet, was collected on all patients (Table 1). Anxiety related to the administration of local anesthesia and the procedure itself was collected using single-question 0 to 10 scales, with 0 being no anxiety and 10 being maximally anxious. Pain during
MATERIALS AND METHODS A prospective cohort of 96 patients who underwent LA-T at our institution from September 2016 to April 2018 was studied. This was a sample of convenience. From June 2017 to September 2017, no data were collected owing to a personnel change on our research team. In 73 patients, hemostasis was achieved using a high arm pneumatic tourniquet and in 23 patients from a forearm pneumatic tourniquet. Tourniquets were inflated to 100 mg Hg above the systolic blood pressure. The decision to use a high arm versus a forearm pneumatic tourniquet was made J Hand Surg Am.
Differences by Tourniquet Group
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1.e3
WIDE-AWAKE SURGERY WITH TOURNIQUET
the administration of local anesthesia, during the procedure, and related to the tourniquet were collected using visual analog scale (VAS) scores on a 0 to 10 scale, with 0 being no pain and 10 being the worst pain. All patients were asked whether they would choose LA-T again for a similar procedure and whether they would recommend LA-T to a friend or family member. Mean anxiety and pain scores were analyzed as ordinal values. Mann-Whitney U tests were used to determine the relationship between tourniquet-related pain and tourniquet time (> or < 10 minutes). Mann-Whitney U tests were used to evaluate differences in treatment and outcomes between patients treated with high arm tourniquets and patients treated with forearm tourniquets. The institutional review board of our institution approved this study. Significance level was set at P less than .05. This manuscript adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines; the study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki.
Preoperative Preoperative Anxiety Anxiety (Procedure) (Local Anesthesia)
F
FIGURE 1: Survey results. All questions are based on a 0 to 10 VAS or Likert scale; reported results are based on the mean value for the full cohort.
DISCUSSION Our results confirmed our hypothesis that LA-T for simple hand surgeries of less than 20 minutes is feasible and well tolerated. Previous studies of WALANT outcomes have demonstrated similar patient experiences. Teo et al3 reported that 86% of patients would prefer to have WALANT for a similar surgery, and 88% of patients would definitely or probably recommend WALANT to a friend. Davidson et al14 reported that 93% of patients who underwent an open carpal tunnel release via WALANT would chose WALANT again for a similar surgery. Numerous previous studies have commented on tourniquet tolerance in awake subjects. Hutchinson and McClinton in 199315 reported that, at 300 mm Hg, high arm tourniquet tolerance averaged 29 minutes and forearm tolerance averaged 42 minutes. Lim et al16 compared high arm tourniquet pressures of 200 mm Hg and 250 mm Hg in the upper extremity and found that all subjects tolerated tourniquets for 20 minutes regardless of pressure, but did note lower tourniquet pressures were associated with less pain. Multiple other studies have reported that the majority of patients can tolerate high arm tourniquets inflated to 100 mm Hg above the systolic blood pressure for approximately 20 minutes.17e20 Our findings support the existing literature because all patients tolerated their tourniquet for the length of their short procedures. Furthermore, although tourniquet times of less than 10 minutes were associated with lower tourniquetrelated pain scores, patients with tourniquet times of greater than10 minutes still reported comparatively less pain from the tourniquet than from the local lidocaine injection based on score comparison. This leads us to believe that tourniquet inflation for less than 20 minutes is nearly universally well tolerated. The notion that there is secondary
RESULTS Results of VAS and experience scores are displayed in Figure 1. Ninety-five of 96 patients (99%) reported that they would choose LA-T for an equivalent procedure in the future. Ninety-five of 96 patients (99%) reported that they would recommend LA-T to a friend. Mean pain related to anesthetic injection was rated 3.9 of 10. Overall, there were no differences in tourniquet time or tourniquet-related pain between patients with pneumatic high arm tourniquets and patients with pneumatic forearm tourniquets (Table 1). Mean tourniquet time was 9.6 minutes and only 1 patient had a tourniquet inflated for more than 20 minutes. Tourniquet times of less than 10 minutes were associated with less tourniquet-related pain than tourniquet times 10 minutes or greater (P < .05); however, both groups reported the tourniquet to be, on average, less painful than the local anesthetic injection (1.7 tourniquet pain vs 4.5 injection pain and 3.2 tourniquet pain vs 4.3 injection pain, respectively). No tourniquets were let down prematurely owing to tourniquet-related pain. No complications, defined as nontransient loss of strength, nontransient diminished sensation, or continued pain on clinical examination were encountered. In addition to a postoperative examination in the surgery center, patients were reexamined between 2 and 6 weeks following their surgery. J Hand Surg Am.
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reperfusion pain that begins a few minutes after deflation, as described by Prodhomme et al,18 was not found to be clinically relevant in our study. All surveys were administered in the postoperative care unit approximately 10 to 30 minutes after tourniquet deflation, at which point we expected both inflation- and reperfusion-related pain to be captured. Furthermore, patients reported that pain related to the tourniquet was, on average, less painful than local injection with unbuffered plain lidocaine. We likely could have decreased the pain caused by our local injections by using buffered solutions, 27gauge instead of 25-guage needles, and warming the anesthetic prior to injection.2,12,21 It should be noted that injection-related pain scores of 0 to 2 have been reported using these practices in addition to proper injection technique.22 Lees et al23 reported that exsanguinating the upper extremity prior to tourniquet inflation led to significantly less tourniquet-related pain than elevation alone. White et al24 reported that giving patients 50% oxygen 3 minutes prior to and throughout tourniquet inflation led to decreased pain compared with placebo. We routinely exsanguinated limbs using an Esmarch bandage prior to tourniquet inflation, but did not use supplemental oxygen. Relatively little data have been published regarding LA-T. Braithwaite et al in 19936 compared a variation of WALANT (different administration technique than described by Lalonde and Wang13) with LA-T on contralateral limbs of patients undergoing bilateral carpal tunnel release. They reported less pain in the modified WALANT group, but shorter surgery times in the LA-T.6 There were no differences in postoperative pain.6 Gunasagaran et al25 recently compared WALANT with LA-T in Malaysian patients and reported that WALANT was associated with less pain, but longer preoperative preparation times. However, they did not comment on the position or pressure of their tourniquets and did not assess patient experience. Miller et al,26 Kamath et al,27 Ruxasagulwong et al,28 and Davidson et al14 all compared WALANT with tourniquet use under light sedation and found relatively equal rates of patient satisfaction. Although notable for suggesting that patients are relatively happy regardless of anesthesia plan, these 4 studies did not address tourniquet use in fully awake patients. Although we did not directly compare WALANT with LA-T in our study, we believe that, given our results, LA-T is, at minimum, a viable alternative to WALANT. J Hand Surg Am.
The main limitation of this study was our inability to use a validated outcomes measure. Because we needed to assess intraoperative outcomes of awake patients and most validated instruments assess postoperative outcomes of sedated patients, we found that the available validated outcomes instruments did not address our hypothesis. We based our survey on the surveys used by Davison et al,14 Teo et al,3 and Rhee et al10 to assess WALANT procedures, although changes had to be made to incorporate tourniquetrelated pain and better specify the use of a VAS (Appendix A; available on the Journal’s Web site at www.jhandsurg.org). Another major limitation of this study is its inherent selection bias because only patients who elected to have LA-T were included in the study and most had no point of comparison with surgery with sedation. Patients who elected for traditional anesthesia may have had higher anxiety and pain scores and a worse experience had they only been offered a wide-awake procedure but preferred to be sedated. We were further unable to directly compare outcomes of our protocol with the WALANT protocol because our institution prohibits preprocedure injections. However, our intention is not to diminish the benefits of WALANT, but to bring to light that, in appropriate patients, LA-T is feasible and well tolerated. This study shows that performing LA-T is a well-tolerated technique for short hand surgical procedures. The LA-T obviates the need for extra postoperative monitoring and consideration of epinephrine reversal. It also has the advantage of having a nearly identical workflow and operative setup to traditional hand surgery cases. Local anesthesia using a tourniquet is a useful option for many patients undergoing short procedures. ACKNOWLEDGMENTS The authors thank Adam Jacobs, BA, for data collection and Lorraine Hutzler, BA, for research coordination. Research Conducted at the Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY 10003. REFERENCES 1. Lalonde DH. Conceptual origins, current practice, and views of wide awake hand surgery. J Hand Surg Eur. 2017;42(9):886e895. 2. Lalonde D, Eaton C, Amadio P, Jupiter J. Wide-awake hand and wrist surgery: a new horizon in outpatient surgery. Instr Course Lect. 2015;64:249e259. 3. Teo I, Lam W, Muthayya P, Steele K, Alexander S, Miller G. Patients’ perspective of wide-awake hand surgery—100 consecutive cases. J Hand Surg Eur. 2013;38(9):992e999.
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18. Prodhomme G, Mouraux D, Dugailly PM, Chantelot C, Fontaine C, Schuind F. Tolerance of upper extremity pneumatic tourniquets and their effect on grip strength. J Hand Surg Eur. 2008;33(3):266e271. 19. Tanpowpong T, Kitidumrongsook P, Patradul A. The deleterious effects of exsanguination with a tight bandage on tourniquet tolerance in the upper arm. J Hand Surg Eur. 2012;37(9):839e841. 20. Yousif NJ, Grunert BK, Forte RA, Matloub HS, Sanger JR. A comparison of upper arm and forearm tourniquet tolerance. J Hand Surg Br. 1993;18(5):639e641. 21. Hogan ME, vanderVaart S, Perampaladas K, Machado M, Einarson TR, Taddio A. Systematic review and meta-analysis of the effect of warming local anesthetics on injection pain. Ann Emerg Med. 2011;58(1):86e98.e1. 22. Farhangkhoee H, Lalonde J, Lalonde DH. Teaching medical students and residents how to inject local anesthesia almost painlessly. Can J Plast Surg. 2012;20(3):169e172. 23. Lees DA, Penny JB, Baker P. A single blind randomised controlled trial of the impact on patient-reported pain of arm elevation versus exsanguination prior to tourniquet inflation. Bone Joint J. 2016;98B(4):519e525. 24. White N, Dobbs TD, Murphy GR, Khan K, Batt JP, Cogswell LK. Oxygen reduces tourniquet-associated pain: a double-blind, randomized, controlled trial for application in hand surgery. Plast Reconstr Surg. 2015;135(4):721ee730e. 25. Gunasagaran J, Sean ES, Shivdas S, Amir S, Ahmad TS. Perceived comfort during minor hand surgeries with wide awake local anaesthesia no tourniquet (WALANT) versus local anaesthesia (LA)/ tourniquet. J Orthop Surg (Hong Kong). 2017;25(3). 2309499017739499. 26. Miller A, Kim N, Ilyas AM. Prospective evaluation of opioid consumption following hand surgery performed wide awake versus with sedation. Hand (N Y). 2017;12(6):606e609. 27. Kamath J, Shenoy T, Jayasheelan N, Rizwan N, Sachan V, Danda R. Timed wake-up anaesthesia in hand: a modification to wide awake surgery of hand. Indian J Plast Surg. 2016;49(3):378e383. 28. Ruxasagulwong S, Kraisarin J, Sananpanich K. Wide awake technique versus local anesthesia with tourniquet application for minor orthopedic hand surgery: a prospective clinical trial. J Med Assoc Thai. 2015;98(1):106e110.
4. Lalonde D. Minimally invasive anesthesia in wide awake hand surgery. Hand Clin. 2014;30(1):1e6. 5. Lalonde D, Martin A. Tumescent local anesthesia for hand surgery: improved results, cost effectiveness, and wide-awake patient satisfaction. Arch Plast Surg. 2014;41(4):312e316. 6. Braithwaite BD, Robinson GJ, Burge PD. Haemostasis during carpal tunnel release under local anaesthesia: a controlled comparison of a tourniquet and adrenaline infiltration. J Hand Surg Br. 1993;18(2): 184e186. 7. Prasetyono TO. Tourniquet-free hand surgery using the one-per-mil tumescent technique. Arch Plast Surg. 2013;40(2):129e133. 8. Tang JB. Wide-awake primary flexor tendon repair, tenolysis, and tendon transfer. Clin Orthop Surg. 2015;7(3):275e281. 9. McKee DE, Lalonde DH, Thoma A, Dickson L. Achieving the optimal epinephrine effect in wide awake hand surgery using local anesthesia without a tourniquet. Hand (N Y). 2015;10(4): 613e615. 10. Rhee PC, Fischer MM, Rhee LS, McMillan H, Johnson AE. Cost savings and patient experiences of a clinic-based, wide-awake hand surgery program at a military medical center: a critical analysis of the first 100 procedures. J Hand Surg Am. 2017;42(3):e139ee147. 11. Zhang JX, Gray J, Lalonde DH, Carr N. Digital necrosis after lidocaine and epinephrine injection in the flexor tendon sheath without phentolamine rescue. J Hand Surg Am. 2017;42(2):e119ee123. 12. Lalonde DH. "Hole-in-one" local anesthesia for wide-awake carpal tunnel surgery. Plast Reconstr Surg. 2010;126(5):1642e1644. 13. Lalonde DH, Wong A. Dosage of local anesthesia in wide awake hand surgery. J Hand Surg Am. 2013;38(10):2025e2028. 14. Davison PG, Cobb T, Lalonde DH. The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study. Hand (N Y). 2013;8(1):47e53. 15. Hutchinson DT, McClinton MA. Upper extremity tourniquet tolerance. J Hand Surg Am. 1993;18(2):206e210. 16. Lim E, Shukla L, Barker A, Trotter DJ. Randomized blinded control trial into tourniquet tolerance in awake volunteers. ANZ J Surg. 2015;85(9):636e638. 17. Maury AC, Roy WS. A prospective, randomized, controlled trial of forearm versus upper arm tourniquet tolerance. J Hand Surg Br. 2002;27(4):359e360.
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PAIN Pain level during local anesthesia administration: 0 1 2 3 4 5 6 7 8 9 10 Pain level during procedure (not related to tourniquet): 0 1 2 3 4 5 6 7 8 9 10 Pain due to tourniquet: 0 1 2 3 4 5 6 7 8 9 10 SATISFACTION General patient satisfaction: 0 1 2 3 4 5 6 7 8 9 10 Would you recommend Wide Awake Hand Surgery to someone else? Y / N Would you do Wide Awake Hand Surgery again (versus general anesthesia)? Y / N
Appendix A. Survey Administered to LA-T Patients Wide Awake Hand Surgery-Tourniquet Postoperative Survey Patient Number:____________________________ Date of Surgery: ______________________ _______ SURGERY Surgery Performed: __________________________ _____________________________________________ _________________ Tourniquet Time (in minutes): ______________ ________________ Complications: ___________________________ _________________________________________ Tourniquet: Forearm cuff j High-arm cuff ANXIETY Did talking to surgeon/OR staff during your procedure make you feel: More comfortable / Less comfortable / Same What was your level of anxiety regarding local anesthesia: 0 1 2 3 4 5 6 7 8 9 10 What was your level of anxiety regarding the procedure: 0 1 2 3 4 5 6 7 8 9 10
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