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Field sterility for carpal tunnel surgery. More than 90% of Canadian carpal tunnel operations are performed this way in minor procedure rooms with an infection rate of 0.39%. 14

Field sterility for carpal tunnel surgery. More than 90% of Canadian carpal tunnel operations are performed this way in minor procedure rooms with an infection rate of 0.39%. 14

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Field sterility is commonly used for skin and minor hand surgery performed in the ambulatory setting. Surgical site infection (SSI) rates are similar for these same procedures when performed in the main operating room (OR). In this paper, we aim to look at both current evidence and common sense logic supporting the use of some of the techniques and...

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... infection around the incision site occurring within 30 days after a procedure. 3 There is a growing body of evidence indicating that SSI does not differ significantly between main OR sterility and field sterility for many surgical procedures. [4][5][6][7][8][10][11][12][13][14][15] However, the difference in cost and garbage production is immense (Figs. ...

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... This might not be surprising as these concepts have permeated through everyday life and are easily transferrable into health care. Recent work by Lalonde et al. (Yu et al., 2019) on field sterility and Van Denmark's concept of 'lean and green hand surgery' (Van Demark et al., 2018) have also helped by demonstrating that sustainable hand surgery can be practiced economically while maintaining safe surgical standards. Accordingly, the clinical scenario questions addressing 'waste management & recycling in the theatre setting' and 'reduction/limiting the use of drapes and gowns for simple soft tissue procedures' have achieved the highest support. ...
... With this trend, it is important to consider how the procedure room differs from the traditional operating room. First, the use of field sterility instead of main-operating-room sterility has allowed for considerable cost and waste reductions, without impacting upon the likelihood of surgical site infections ( Figure 1) [29][30][31]. Instead of needing the full standard set-up for main-operating-room sterility (which includes head covers, neck-to-knee sterile surgeon gowns, shoe covers, laminar airflow, and full-patient-body sterile draping), CTR can safely be performed in a clinic's procedure room with nothing more than a mask, sterile gloves, and single drape. Importantly, where CTR is performed in such settings, the absence of costly, specialized ventilation systems such as laminar air filtration or high-efficiency particulate air filters has not been linked to worse outcomes. ...
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As surgical management of carpal tunnel release (CTR) becomes ever more common, extensive research has emerged to optimize the contextualization of this procedure. In particular, CTR under the wide-awake, local-anesthesia, no-tourniquet (WALANT) technique has emerged as a cost-effective, safe, and straightforward option for the millions who undergo this procedure worldwide. CTR under WALANT is associated with considerable cost savings and workflow efficiencies; it can be safely and effectively executed in an outpatient clinic under field sterility with less use of resources and production of waste, and it has consistently demonstrated standard or better post-operative pain control and satisfaction among patients. In this review of the literature, we describe the current findings on CTR using the WALANT technique.
... 13,14 Utilization of field sterility reduces the environmental impact of theater waste, and numerous studies have found no differences in infection rates between field sterility and theater sterility. [15][16][17] A 2019 study analyzed the economic impact of WALANT surgery for 150 carpal tunnel and trigger finger surgeries performed in an outpatient setting; they found an average saving of over €1,000 per case with superior postoperative pain scores. 18 In a separate A1 pulley release study, WALANT led to a shorter mean turnover time versus regional anesthesia and tourniquet (mean: 31.1 vs. 65.3 ...
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Wide-awake, local anesthesia, no tourniquet (WALANT) is a technique that removes the requirement for operations to be performed with a tourniquet, general/regional anesthesia, sedation or an anesthetist. We reviewed the WALANT literature with respect to the diverse indications and impact of WALANT to discuss the importance of future surgical curriculum integration. With appropriate patient selection, WALANT may be used effectively in upper and lower limb surgery; it is also a useful option for patients who are unsuitable for general/regional anesthesia. There is a growing body of evidence supporting the use of WALANT in more complex operations in both upper and lower limb surgery. WALANT is a safe, effective, and simple technique associated with equivalent or superior patient pain scores among other numerous clinical and cost benefits. Cost benefits derive from reduced requirements for theater/anesthetic personnel, space, equipment, time, and inpatient stay. The lack of a requirement for general anesthesia reduces aerosol generating procedures, for example, intubation/high-flow oxygen, hence patients and staff also benefit from the reduced potential for infection transmission. WALANT provides a relatively, but not entirely, bloodless surgical field. Training requirements include the surgical indications, volume calculations, infiltration technique, appropriate perioperative patient/team member communication, and specifics of each operation that need to be considered, for example, checking of active tendon glide versus venting of flexor tendon pulleys. WALANT offers significant clinical, economic, and operative safety advantages when compared with general/regional anesthesia. Key challenges include careful patient selection and the comprehensive training of future surgeons to perform the technique safely.
... When superficial infections occur, they can be easily treated, with minimal patient morbidity. 15 The ability to minimize surgical waste with minor hand procedures has also been documented by other authors. 6,26,29,41,42 Patients have been pleased with WALANT surgery done in procedure rooms. ...
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Purpose Wide-awake local anesthesia with no tourniquet has dramatically changed hand surgery practice. Using lidocaine with epinephrine and no tourniquet has allowed many procedures to be moved from the main operating room to an in-office procedure room. Previous studies have shown that using local anesthesia is safe and cost effective, with high patient satisfaction. This study evaluated patient satisfaction and complications for the first 1,011 elective hand surgeries performed using wide-awake anesthesia in an in-office procedure room. Methods The first 1,011 patients who underwent elective hand surgery in an in-office procedure room were surveyed regarding their satisfaction. The patients were monitored for postoperative complications. Patient survey results and complications were logged in a database and analyzed. Results Single-digit trigger finger release was the most common procedure performed (n = 582), followed by mass excision (n = 158), multiple-digit trigger finger releases (n = 109), and carpal tunnel release (n = 41). There were 43 (4.3%) superficial skin infections, with the majority seen in single-digit trigger finger releases (n = 27). There were no deep wound infections. All infections were managed nonsurgically with oral antibiotics and local wound care. Ninety-nine percent of the patients rated the in-office procedure room experience as the same as or better than a dental visit, would recommend wide-awake anesthesia to a friend or family member, and would undergo the procedure again. Using “lean and green” hand packs saved our institution more than $65,000 and saved 18.4 tons of waste during this study period. Conclusions Surgical procedures performed with wide-awake local anesthesia with no tourniquet in an in-office procedure room can be performed safely with a low infection rate, are cost effective, and have high patient satisfaction. Clinical relevance Minor hand surgery done in an in-office procedure room is safe, is cost effective, and has high patient satisfaction.
... Over the past 20 years, several studies have supported that simplified field sterility alone is suitable for many hand procedures. [6][7][8][9][10] To address the patient experience whilst undergoing WALANT, we have applied the developing technology of wide-awake virtual reality. 11 Procedures done in the office are also significantly less costly than those performed in the main operating room. ...
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Background:. We transitioned our hand practice from the operating room (OR) to our office-based procedure room (OPR) to offer wide-awake, local anesthesia, no tourniquet (WALANT). We have established that using wide-awake virtual reality improves patient comfort and anxiety during wide-awake procedures and helps facilitate our patients’ choice of venue. We aimed to assess the effect of this transition on infection rates for procedures performed by a single surgeon in the OR versus the OPR. Methods:. A retrospective chart review was performed on a single surgeon’s adult patients who underwent elective and closed traumatic upper limb surgeries. A surgical site infection was defined as superficial or deep, based on clinical examination conducted by the surgeon, and was treated with antibiotics within a 4-week postoperative window. Results:. From August 2017 to August 2019, 538 (216 OR and 322 OPR) consecutive cases met inclusion criteria. There were six (2.78%) superficial infections and zero deep space infections in the OR cohort compared with four (1.24%) superficial and zero deep space infections in the OPR cohort with no statistical significance. Two-thirds of cases were converted to WALANT and delivered in the office. Conclusions:. This narrative study concurs with the current literature that WALANT in the office setting is as safe as the hospital OR-based procedures for selected elective cases. By transitioning suitable cases from the OR to the OPR, a surgeon’s overall infection rate should not change.
... Adopting the same standards of an operating room for CSIR procedures may be unnecessary when considering an analogous comparison in the surgical literature: minor hand and skin surgery. In Canada, the most common procedural setting for carpal tunnel surgery is an ambulatory procedure room using "field sterility," defined by the use of a surgical mask, sterile gloves, and small sterile drape [22,23]. No gown or hat is worn. ...
... Considering rising healthcare costs and the production of approximately four billion pounds of medical waste annually in the USA, it behooves proceduralists to weigh the theoretical benefit of infection rate reduction by PPE with the costs, both financially and environmentally. Increased healthcare costs associated with more stringent requirements for operating room attire has been extensively published in the surgical literature [23,25,[29][30][31][32][33]. The healthcare industry is estimated to be responsible for 8% of the greenhouse gas emissions in the USA [7]. ...
Article
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Purpose To determine institutional practice requirements for personal protective equipment (PPE) in cross-sectional interventional radiology (CSIR) procedures among a variety of radiology practices in the USA and Canada. Methods Members of the Society of Abdominal Radiology (SAR) CSIR Emerging Technology Commission (ETC) were sent an eight-question survey about what PPE they were required to use during common CSIR procedures: paracentesis, thoracentesis, thyroid fine needle aspiration (FNA), superficial lymph node biopsy, deep lymph node biopsy, solid organ biopsy, and ablation. Types of PPE evaluated were sterile gloves, surgical masks, gowns, surgical hats, eye shields, foot covers, and scrubs. Results 26/38 surveys were completed by respondents at 20/22 (91%) institutions. The most common PPE was sterile gloves, required by 20/20 (100%) institutions for every procedure. The second most common PPE was masks, required by 14/20 (70%) institutions for superficial and deep procedures and 12/12 (100%) institutions for ablation. Scrubs, sterile gowns, eye shields, and surgical hats were required at nearly all institutions for ablation, whereas approximately half of institutions required their use for deep lymph node and solid organ biopsy. Compared with other types of PPE, required mask and eye shield use showed the greatest increase during the SARS-CoV-2 pandemic. Conclusion PPE use during common cross-sectional procedures is widely variable. Given the environmental and financial impact and lack of consensus practice, further studies examining the appropriate level of PPE are needed. Graphical abstract
... 4 Avoiding sedation eliminates nausea and vomiting, unnecessary anesthetic risks, costs, hospital admissions, and the main operating room environment. [5][6][7] Pure local anesthesia is safer than sedation in patients with multiple medical comorbidities. Wide awake surgery makes it more affordable and grants access to millions of the worlds' poor patients who currently cannot afford sedative surgery in the main operating room. ...
Article
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After reading this article, the participant should be able to (1) almost painlessly inject tumescent local anesthesia to anesthetize small or large parts of the body, (2) improve surgical safety by eliminating the need for unnecessary sedation in patients with multiple medical comorbidities, and (3) convert many limb and face operations to wide awake surgery. We recommend the following 13 tips to minimize the pain of local anesthesia injection: (1) buffer local anesthetic with sodium bicarbonate; (2) use smaller 27- or 30-gauge needles; (3) immobilize the syringe with two hands and have your thumb ready on the plunger before inserting the needle; (4) use more than one type of sensory noise when inserting needles into the skin; (5) try to insert the needle at 90 degrees; (6) do not inject in the dermis, but in the fat just below it; (7) inject at least 2 ml slowly just under the dermis before moving the needle at all and inject all local anesthetic slowly when you start to advance the needle; (8) never advance sharp needle tips anywhere that is not yet numb; (9) always inject from proximal to distal relative to nerves; (10) use blunt-tipped cannulas when tumescing large areas; (11) only reinsert needles into skin that is already numb when injecting large areas; (12) always ask patients to tell you every time they feel pain during the whole injection process so that you can score yourself and improve with each injection; (13) always inject too much volume instead of not enough volume to eliminate surgery pain and the need for "top ups."
... In a minimally painful fashion, I inject as much tumescent local anaesthesia as required to have numbness and vasoconstriction at least 2 cm beyond wherever I will be likely to cause pain with fracture manipulation, surgical dissection or hardware insertion (Lalonde, 2016). This approach has enabled Canadians to perform a lot of our hand surgery outside of the main operating room, at a greatly reduced cost, with much less trash going to the environment (Leblanc et al., 2007;Yu et al., 2019). ...
... Previous studies focused on outcomes related to infection to demonstrate the safety of MPRs. 12,14,15,24 Operating rooms have strict infection control guidelines for environmental cleaning and disinfection, sterilization of instruments, air handling, and personnel management. A systematic review reported low surgical site infection rates in office-based MPRs. ...
Article
Full-text available
Purpose There is a high demand for minor hand surgeries within the veteran population. The objective of this study was to compare clinical outcomes and resource use at a Veterans Affairs Medical Center (VAMC) of hand surgeries performed in minor procedure rooms (MPR) and operating rooms using local anesthesia with or without monitored anesthesia care. Methods We retrospectively evaluated all patients undergoing carpal tunnel release, de Quervain's release, foreign body removal, soft tissue mass excision, or A1 pulley release at a VAMC over a 5-year period. Data collected included demographic information, mental health comorbidities, presence of preoperative and postoperative pain, complications after surgery, time to surgery, number of personnel in surgery, turnover time between cases, and time spent in the postanesthesia care unit. Statistical analysis included Fisher exact or chi-square analysis to compare MPR versus operating room groups and Student t test or Mann-Whitney test to compare continuous variables. Results In this cohort of 331 cases, 123 and 208 patients underwent surgery in MPRs and operating rooms, respectively. Preoperative and postoperative pain were similar between the MPR and operating room groups. Complications were slightly lower in the MPR group versus the operating room group (0% MPR vs 2.9% operating room). Median time from surgical consult to surgery was 6 days less for MPR patients (15 vs 21). The MPR cases also used fewer personnel during surgery, averaging 4.76 versus 4.99 people. The MPR patients spent 9 minutes less in the postanesthesia care unit (median, 36 vs 45 minutes) and turnover time between cases was nearly 8 minutes faster in MPRs than in operating rooms (median, 20 vs 28 minutes). Conclusions Minor procedure rooms at a VAMC allow more veteran patients to be scheduled for minor hand surgeries within a shorter time frame, utilize less staff and postoperative monitoring, and maintain excellent outcomes with limited complications. Clinical relevance Minor hand surgeries in MPRs have outcomes equivalent to those of operating rooms with improved time savings and resource use.
... While on the surface these may appear to be purely an expedient response to current limitations, there are advantages to reconsidering treatment pathways. In particular we can reassess routine assumptions; for example, that vasoconstrictor is harmful in digits [3], adequate sterility for short procedures [4], the balance of non-surgical management in hand fractures [5], and that general anesthesia is benign or that a negative wound exploration under it should be routine [6]. Other specialties are making similar reevaluations, such as increasing the non-surgical treatment of appendicitis [7]. ...