Overview of Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery
Wide-awake Local Anesthesia No Tourniquet (WALANT) is a method used during hand surgeries that involves using local numbing medication and blood clotting agents. This allows the surgery to be done without the need for sedation (making you unconscious) or a tourniquet (a device used to control bleeding). The major advantage of this approach is that it can be performed outside the operating room in a more comfortable and less formal setting.
Not needing to use a method to put the patient to sleep benefits the patient by making the process safer and also cuts down on costs. This technique was first introduced by Dr. Lalonde, a hand surgeon from Canada. His goal was to reduce the waiting time for surgeries. Since he launched this approach in 2005, it has been adopted and used globally.
Anatomy and Physiology of Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery
When your doctor plans to operate, they take into account factors like the location of the problem and the best points at which to inject drugs for numbing. One example is in a procedure called “WALANT carpal tunnel release,” where the injection is made just a bit (about 5 – 6mm) above the wrist fold, to target a nerve that runs down the middle of your forearm.
There are two main types of numbing drugs, or “local anesthetics” – amides and esters. In the WALANT procedure, they usually use amides like Lidocaine and Bupivacaine. These drugs block certain pathways in nerve cells and help lessen the sensation of pain. These are broken down and removed from the body by the liver.
Another drug, epinephrine, is often used together with the numbing drug. This drug helps control bleeding by causing blood vessels to narrow, a process called “vasoconstriction.” This not only slows down the absorption of the numbing drug (which means it lasts longer) but also makes it safer to use Lidocaine. Additionally, epinephrine contributes to the control of bleeding by making blood cells called platelets stick together, or “aggregate.”
One of the unique benefits of the WALANT method is that, because the patient can move their hand earlier, there is less risk of body tissues sticking together after surgery, which is called “adhesion formation.” This is because movement can begin right in the middle of the operation, which is great because our bodies start producing a protein called collagen (essential for healing) around three days after surgery. It’s important to start moving as early as possible after hand procedures, under guidance, to prevent stiffness and adhesions from developing. If you don’t move your hand for a long time, tendons and other soft tissues could stick to healing bones and the protective layers around tendons, leading to joints that can’t move properly.
Why do People Need Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery
Several common hand surgeries can be successfully conducted using WALANT, also known as “Wide-Awake Local Anesthesia No Tourniquet.” This technique uses a local — not general — anesthetic, meaning you’re awake during the procedure. It’s particularly beneficial for patients who might have other health conditions, such as heart problems or sleep apnea, that can make surgeries under sedation risky. It’s also a good option if you can’t have a tourniquet applied during surgery.
One of the advantages of WALANT is that you don’t need an operating room or an anesthesia team to use it. This makes it a helpful option for places that are quite a way from a hospital or have limited resources. Several studies have shown that WALANT is consistently cheaper and more efficient when compared to surgeries performed in an operating room, providing an ambulatory or outpatient surgical care option. This is especially useful given the COVID-19 pandemic, as it reduces unnecessary hospital visits and overnight stays, helping to keep people safe from potential exposure.
Another significant benefit of WALANT is its versatility. It can be used just as effectively in an operating room for complex procedures. Lastly, WALANT offers a safer option for patients, improved access to surgical treatments, and more accurate diagnoses and assessments during surgery as patients are awake and responsive.
Pre-surgery benefits of using WALANT include decreased wait times from the initial consultation to surgery day and the fact that patients can drive themselves to the facility and have breakfast beforehand. Additionally, the pre-surgery phase is shorter as patients can arrive shortly before their surgery, and there’s no need for an intensive preoperative workup.
WALANT eliminates risks associated with tourniquet use, such as potential damage to muscles and nerves and reduces the risk of respiratory complications for patients with certain conditions. Thanks to WALANT, surgeons can make more accurate diagnoses and assessments during surgery, particularly with complex procedures such as flexor tendon repairs. This is because the patient can actively participate during the surgery, providing more accurate feedback to the surgeon.
After the surgery, WALANT has several significant benefits. It leads to high patient satisfaction with many patients reporting they would choose WALANT again for future surgeries. Studies also show less post-surgery pain compared to surgeries performed under sedation with a tourniquet. WALANT also promotes better communication between patients and healthcare providers, leading to improved instructions following surgery. As a result, patients spend less time in the post-surgery phase, decreasing costs for both the facility and the patient.
Finally, research has shown that opioid use after surgery is either the same or less with WALANT when compared to other methods. And perhaps best of all, patients can safely drive themselves home after their procedure.
When a Person Should Avoid Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery
There are certain conditions where a person might not be able to undergo a certain medical procedure. Here are a few key reasons:
Absolutely, a lack of an individual’s agreement to the procedure or the person being unwilling to participate (which is fairly usual in children) can prevent the medical procedure from being carried out.
There are also relative reasons why a procedure may not occur:
If a person feels overly nervous about the procedure, or if they have a strong fear of needles (needle-phobia), they may not proceed. Moreover, having a condition that affects the blood vessels, like peripheral vascular disease, or having overly thick blood (hypercoagulable), can make the procedure risky.
An overreaction to a common local anesthetic called lidocaine (lidocaine hypersensitivity), or an active infection can also hinder the procedure. Similarly, if a person has been through multiple injuries (polytrauma), it can make the procedure difficult.
Other issues such as lack of qualified staff or inadequate equipment and facility could prevent the procedure. Communication issues due to differences in language or culture, or patients who are deaf can also pose significant challenges.
Considering patient’s health conditions like liver disease, or if they’re on anticoagulants (blood thinners which is still a debated area), it may prevent the procedure. Even patient’s preference towards complete sleep during medical procedures (general anesthesia), or their inability to lie flat on their back (like those with a history of back pain, obstructive sleep apnea, etc.) could make the procedure infeasible.
Equipment used for Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery
In medical procedure rooms there needs to be enough light, and they usually also have a headlamp available just in case. A comfortable chair is set up to help reduce the chance of the patient feeling faint during the procedure. Pillows are also used, especially when dealing with persistent back and neck pain. Equipment to help in case of emergencies, like resuscitation tools, should be readily available and so should things to help if a patient faints, like smelling salts. Sterile tools like instrument packs, gloves, towels, various cleaning solutions should also be present.
For injections, generally smaller needles (25 to 27 gauge) are chosen. This is because they hurt less when they puncture the skin and it prevents the injection from going too fast, which can be uncomfortable for the patient if the lidocaine (a type of numbing medication) is really acidic.
The most common numbing and clotting solution is 1% lidocaine mixed with a 1:100,000 ratio of epinephrine (a medication that narrows blood vessels and opens airways). However, other concentrations of this mixture have been shown to work well in situations like tendon repair in the wrist and fracture manipulation. Occasionally, a solution of 8.4% bicarbonate mixed with the numbing solution in a ratio of 1 ml:10 ml is used to reduce the acidity of the lidocaine during the injection. Bupivacaine (a long-lasting numbing medication) might be added to the mixture if a procedure is expected to last more than 2.5 hours. Lastly, Phentolamine (a medication that helps block the effects of certain nerves in your blood vessels) should always be available. It’s mixed into a saline solution, which is a sterile salt water solution, and given if needed.
Who is needed to perform Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery?
To ensure the best outcome in a type of surgery called WALANT, a team of highly skilled medical professionals is needed. This team works together during three crucial phases of your surgery to make sure everything runs smoothly. The team includes:
1. The surgeon — This is a doctor who performs the surgery.
2. A “distractive anesthesia” team member — This person’s job is to help you stay calm and minimize your anxiety during the surgery. They might use different techniques to distract you and make the process less stressful.
3. A scrub tech — This person helps with the technical aspects of your surgery, making sure all the medical instruments are clean and ready to use.
4. A first assist — This person can be another doctor, a nurse, or other healthcare professional who provides direct assistance to the surgeon during the surgery.
5. A circulating nurse — This is a specialized nurse who helps manage the operating room, ensure safety, and handle necessary equipment in the surgery room.
6. A hand therapist — If your surgery involves your hand, a hand therapist may be part of the team. They will work with you after surgery to help you regain movement and strength in your hand.
Together, these professionals work to provide you with the best care possible during your surgery.
Preparing for Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery
Before undergoing a medical procedure, it’s suggested that patients arrive at least 30 minutes early. If you’re unsure of any medical terms or nervous about being awake during the procedure, feel free to ask your healthcare team to explain everything using everyday language. Due to the COVID-19 outbreak, extra precautions are being taken to reduce risk. Protective equipment will be worn and efforts are made to minimize the number of people in waiting rooms.
About half an hour before the procedure, you’ll receive an injection of a medication – lidocaine with epinephrine – that will numb the area and reduce bleeding. You’ll be moved into the operation room 15 minutes before the operation starts. If necessary, doctors have other medications ready to reverse the effects of the initial medicine, control pain, or help stop any bleeding. Another medicine, Cefazolin, will be given before your procedure to help prevent infections.
Throughout the procedure, medical staff will frequently check key health indicators (like blood pressure, heart rate, and more) to ensure everything is going well. Doctors will explain any tests performed during the procedure, and give you information on what to expect and how to take care of yourself after the operation. If your procedure involves your hand, a hand therapist may help in placing a splint at the end of the operation.
After the operation, your vital signs (like your heart rate, breathing, blood pressure, temperature) will be monitored every 30 minutes for the first few hours. You’ll typically be given a pain management plan that includes over-the-counter pain killers and calcium supplements for 10 days. Most recovery plans involve gently starting to move the operated area early on, under the supervision of a specialist to avoid causing pain.
How is Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery performed
WALANT, an acronym for Wide Awake Local Anaesthesia No Tourniquet, is a technique that is based on three main principles: pain control, bleeding control, and anxiety control. Pain control is achieved through the use of a local anesthetic called Lidocaine. Bleeding control is achieved with a drug called epinephrine. Anxiety control involves creating a comforting and relaxed environment.
The injection is given when you’re sitting up to prevent feelings of lightheadedness, known as a vasovagal response. The doctor does not move the needle around and tries to keep it as still as possible. When the needle is inserted, it is done so at a right angle to the skin. Instead of pushing the needle into the skin, your body part is moved towards the needle to lessen any discomfort you might feel.
As the needle goes under the skin, they inject up to 10 ml of the medication, going forward and always keeping at least one centimeter of swollen skin (a “wheel”) in front of the needle tip. If they need to inject more medication, they put the needle back into areas that are already numb. When this is done properly, you should only feel pain with the first injection.
The volume and location of injections vary based on the medical procedure being done. Here are a few examples:
To treat carpal tunnel syndrome, a condition that causes numbness and tingling in your hand, the doctor injects 10 ml of the mixture about 5 mm away from your wrist crease and 5 mm away from a nerve in your wrist called the median nerve, and another 10 ml is injected deeper into the incision site.
If you have a condition called trigger finger, where your finger or thumb gets stuck in a bent position, the doctor injects 4 ml of the mixture just underneath the skin, avoiding injection into the sheath, a protective layer around your tendons.
For a finger sensory block, which is when the feelings in your finger need to be temporarily turned off, the doctor injects 2 ml of the mixture into your upper finger bone or below your palm crease.
In the case of metacarpal fractures (broken bones in your hand), the doctor injects 40 ml of the mixture around the broken bone.
If you are having a surgery to treat Dupuytren’s contracture—a hand deformity that usually develops over years and causes fingers to bend towards the palm—the doctor injects 10 ml of the mixture into your palm, and another 2 ml into your middle sections of your finger.
If you broke the radius bone (bone in the forearm) and need a surgical procedure known as “Open Reduction and Internal Fixation,” the doctor injects the mixture in specific points around the distal radius (lower part of the radius bone), and leverages more concentrated Lidocaine for better bleeding control.
Possible Complications of Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery
WALANT, a kind of local anesthesia used for minor surgeries, does have some side effects, although they are not common. The most usual side effects include fainting because of a response from the body known as vasovagal response, and an increase in anxiety in patients who are worried about being conscious during the surgery. Some patients can also feel jittery or restless after receiving lidocaine, a drug used in WALANT.
There’s a popular belief that using WALANT can lead to a high risk of poor blood flow in fingers due to a drug called epinephrine. The misunderstanding started from a study that used a different drug, procaine, paired with epinephrine. Procaine, unlike lidocaine, can increase the chance of poor blood flow because it is more acidic. However, many research studies show that lidocaine mixed with epinephrine in controlled amounts is safe to use in fingers.
A very uncommon complication of WALANT is that it can cause heart problems due to the use of epinephrine. Seizures and changes in thinking and awareness have been reported when lidocaine is mistakenly injected into a blood vessel. Similarly, injecting bupivacaine, another local anesthetic, into a blood vessel can cause heart issues and death, but these incidences are also extremely rare. One key difference between lidocaine and bupivacaine is that pain-relief with bupivacaine fades away before the numbness does.
What Else Should I Know About Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery?
WALANT hand surgery is a type of procedure that enhances patient safety by avoiding the risks related to sedation and using a tourniquet, which is a device used to stop blood flow. This straightforward and uncomplicated procedure is beneficial in outpatient settings, meaning patients don’t need to stay overnight at the hospital. This approach allows for better access to healthcare, especially for those who live far from a hospital or in areas with less advanced healthcare.
Other benefits of WALANT hand surgery include less out-of-pocket costs for the patient, fewer days taken off work for treatment, and less waiting time to schedule the surgery.
In the era of the COVID-19 pandemic, WALANT surgery offers a chance for patients to get the surgical care they need without taking up much-needed operating room time for emergency cases. It also reduces the risk of exposure between patients, hospital, and staff, as it can be done outside of the traditional operating room.
Regarding the opioid crisis, which refers to high rates of addiction to strong pain medications, WALANT surgery has been shown to have similar or even better results in terms of the amount of painkillers needed after surgery compared to traditional surgeries that use general sedation.