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Achieving the Optimal Epinephrine Effect in Wide Awake Hand Surgery using Local Anesthesia without a Tourniquet

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Abstract

Background: In our experience, for all surgeries in the hand, the optimal epinephrine effect from local anesthesia-producing maximal vasoconstriction and visualization-is achieved by waiting significantly longer than the traditionally quoted 7 min from the time of injection. Methods: In this prospective comparative study, healthy patients undergoing unilateral carpal tunnel surgery waited either 7 min or roughly 30 min, between the time of injection of 1 % lidocaine with 1:100,000 epinephrine and the time of incision. A standardized incision was made through dermis and into the subcutaneous tissue followed by exactly 60 s of measuring the quantity of blood loss using sterile micropipettes. Results: There was a statistically significant reduction in the mean quantity of bleeding in the group that waited roughly 30 min after injection and before incision compared to the group that waited only 7 min (95 % confidence intervals of 0.06 + -0.03 ml/cm of incision, compared to 0.17 + -0.08 ml/cm, respectively) (P = 0.03). Conclusions: Waiting roughly 30 min after injection of local anesthesia with epinephrine as oppose to the traditionally taught 7 min, achieves an optimal epinephrine effect and vasoconstriction. In the hand, this will result in roughly a threefold reduction in bleeding-making wide awake local anesthesia without tourniquet (WALANT) possible. This knowledge has allowed our team to expand the hand procedures that we can offer using WALANT. The benefits of WALANT hand surgery include reduced cost and waste, improved patient safety, and the ability to perform active intraoperative movement examinations.
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... This technique involves injecting the operative site and associated area with local anesthetic and adrenaline solution, leaving sufficient time for the onset of vasoconstriction preoperatively; this aims to provide adequate analgesia without the need for a tourniquet. 1 Safe doses of plain lidocaine are 3mg/kg up to a maximum dose of 200mg, and, when mixed with adrenaline/epinephrine 7mg/kg up to a maximum dose of 500mg. 1 These doses can also be mixed with 0.9% saline to increase the volume of anesthetic fluid, and therefore enable a larger field of anesthetic effect. 1 Numerous studies have demonstrated favorable outcomes and patient satisfaction when using WALANT. 2,3 Performing hand surgery without the use of a tourniquet improves patient comfort, while still maintaining a relatively bloodless surgical field. 1 A wide-awake patient is also able to confirm site and location of surgery which reduces the likelihood of wrong site or wrong side surgery. Integration of WALANT has already taken place in a range of countries with varying levels of health care resources; in low income countries, the technique offers a significant opportunity for performing hand surgery when it may not have been possible previously. ...
... 33,34 By engaging with an awake patient during the operation, there is a significantly reduced chance of wrong site surgery, and the patient is able to give real-time feedback to the surgeon on the quality of the repair. [1][2][3] Tendon transfers performed under WALANT give an opportunity for the patient to perform the new movement intraoperatively, and has been reported to be an excellent tool for accelerating the neuroplastic transfer of nerve signals for the new movement. 33 Hand therapists have also expressed that WALANT makes the process of hand therapy far more effective due to involving the patient in the therapy process at an earlier stage. ...
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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.
... Despite the concern regarding the vasoconstriction caused by the adrenaline used in this technique, many level 1 evidence-based studies have consistently demonstrated the use of adrenaline does not represent a risk when used on fingers. Fentolamine can be used as an antidote when persistent vasoconstriction appears [5,6]. ...
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Forefoot surgery usually requires tourniquet use and anaesthesia is performed using a popliteal or ankle anaesthetic block. Therefore , surgical departments require an anaesthesiologist to trust them with this procedure. The elective nature of forefoot surgery and the lack of anaesthesiologists resulting from the COVID 19 pandemic, has forced Foot and Ankle specialists to dig into other alternatives , in order to continue their surgical practice and to avoid the growth of the waiting list. The wide-awake local anaesthesia non-tourniquet, which was originally described for upper limb surgery, has recently been adjusted to Foot and Ankle surgery. It does not require sedation, nor regional or general anaesthesia and since the patient is wide-awake, they will be able to fully collaborate during the procedure. The use of lidocaine and adrenaline described on the WALANT technique allows us to obtain a local anaesthesia and vasoconstriction. This method permits the surgeon to move forward into surgery with a completely awake patient and no need of tourniquet giving the advantage of a full motor function assessment intraoperatively. WALANT has been proven to be a safe, effective and affordable technique when it comes to foot and ankle surgery. Having gone through a lack of anaesthesiologists, surgery rooms and hospital resources during SARS-CoV2, WALANT emerged and now represents an acceptable alternative to consider and continue to treat selected cases of foot and ankle surgeries.
... By adding epinephrine to the local anesthesia, a vasoconstrictive effect is created, which causes minor blood loss during surgery. 5 Several studies have been conducted on the effects of tourniquet use on perioperative pain. [6][7][8][9][10] A systematic review by Evangelista et al 2 examined whether there was a difference in WALANT technique versus regional and local anesthesia with tourniquet concerning perioperative and short-term outcomes. ...
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Background:. Surgeons often prefer to use a tourniquet during minor procedures, such as carpal tunnel release (CTR) or trigger finger release (TFR). Besides the possible discomfort for the patient, the effect of tourniquet use on long-term results and complications is unknown. Our primary aim was to compare the patient-reported outcomes 1 year after CTR or TFR under local anesthesia with or without tourniquet. Secondary outcomes included satisfaction, sonographically estimated scar tissue thickness after CTR‚ and postoperative complications. Methods:. Between May 2019 and May 2020, 163 patients planned for open CTR or TFR under local anesthesia were included. Before surgery, and at 3, 6, and 12 months postoperatively, Quick Disabilities of the Arm, Shoulder and Hand and Boston Carpal Tunnel questionnaires were administered, and complications were noted. At 6 months postoperatively, an ultrasound was conducted to determine the thickness of scar tissue in the region of median nerve. Results:. A total of 142 patients (51 men [38%]) were included. The Quick Disabilities of the Arm, Shoulder and Hand questionnaire and Boston Carpal Tunnel Questionnaire scores improved significantly in both groups during follow-up, wherein most improvements were seen in the first 3 months. No difference in clinical outcome and scar tissue formation was found between the two groups after 12 months. The complication rate was comparable between both groups. Thirty-two (24%) patients had at least one complication, none needed surgical interventions, and no recurrent symptoms were seen. Conclusions:. Our study shows similar long-term clinical outcomes, formation of scar tissue, and complication rates for patients undergoing CTR or TFR with or without a tourniquet. Tourniquet usage should be based on shared decision-making.
... However, in recent years, it has been revealed that the mixture of local anesthesia and epinephrine applied in appropriate doses does not cause circulatory problems and can be used safely. [22][23][24] In our study, no circulatory problems or skin necrosis related to local anesthetic injection were observed. ...
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Objectives: The issue of performing a hallux valgus operation with the wide-awake local anesthesia with no tourniquet (WALANT) technique has not been evaluated before. The objective of this study was to compare the clinical results of patients who underwent the WALANT technique during hallux valgus operation and patients who underwent the procedure with traditional anesthesia (TA). Patients and methods: In this cross-sectional, retrospective study, 34 patients (17 males, 17 females; mean age: 46.1±8.3 years; range, 36 to 62 years) who underwent first metatarsal osteotomy with the diagnosis of hallux valgus disease between November 1, 2018, and June 1, 2020, were divided into two groups according to the surgical approach determined by patient choice: the WALANT group and the TA group. Demographic characteristics, Visual Analog Scale (VAS) scores for pain and anxiety, postoperative satisfaction levels, and complications were recorded. Results: There was no significant difference between the groups in terms of demographic characteristics. The VAS pain score during needle insertion was significantly higher in the WALANT group compared to the TA group (p<0.001). Conversely, the VAS anxiety score was significantly higher in the WALANT group compared to the TA group (p<0.001). The median follow-up time was 5.4 months (interquartile range, 5-6 months). Conclusion: This is the first study demonstrating that adequate anesthetic efficacy can be achieved with the WALANT technique for the hallux valgus operation. Acceptable pain scores can be achieved with this technique, and costs are reduced.
... a At each dot, 10 mL of the WALANT solution was injected at different angles into the volar (4 mL), lateral (2 mL) and posterior (4 mL) aspects of the radius within the periosteal layer. (23,24) proposed waiting approximately 30 min after administering the injection to maximize hemostasis before making an incision. The widely accepted maximal dose of lidocaine that is believed to be safe for upper extremity surgery is 7 mg/kg (25). ...
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Background Distal radius fractures are treated using open reduction and internal fixation and using general anesthesia (GA) or regional blocks. A new technique, wide-awake local anesthesia with no tourniquet (WALANT), allows this operation to be conducted in nonsedated patients without the use of tourniquets.Objective We analyzed whether WALANT yields better outcomes than GA in the treatment of patients with distal radius fractures.Evidence ReviewWe searched the PubMed, Cochrane Library, Embase, and Scopus databases for cases of distal radius fractures treated using WALANT or GA. The outcomes of interest were duration of preparation for surgery, duration of surgery, blood loss, and length of postoperative hospitalization; visual analog scale (VAS), Mayo wrist score, and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire score on postoperative day 1; range of motion (ROM); time until bone union; and complication rate.FindingsWe systematically reviewed 4 studies with a total of 263 patients (128 with WALANT and 135 with GA). In comparison with GA, WALANT required less time for preparation for surgery, shorter postoperative hospitalization, and lower postoperative day 1 VAS scores; however, blood loss was greater. Functional outcomes (ROM, QuickDASH score, and Mayo wrist score), complication rates, and times until union did not differ considerably between the two methods.Conclusion The included studies demonstrated that durations of preparation for surgery and postoperative hospitalization were shorter and pain on postoperative day 1 was less severe with WALANT than with GA. Although blood loss in surgery was greater with WALANT, this technique is a novel and promising alternative to GA.
... It is a good alternative to general anesthesia and can be used for patients with numerous medical comorbidities. 1 However, in WALANT, the solution must be injected 25-30 min before incision for maximum hemostatic effect. 7 During the waiting period, patients might have increased anxiety and discomfort from strange place. Surgeon may require additional resources for pre-injection and being on standby to monitor the patient. ...
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Purpose: Hemostasis and local anesthetic injection are essential for minor hand surgeries under local anesthesia (LA). Wide awake local anesthesia no tourniquet (WALANT) became popular for achieving hemostasis without a tourniquet. However, a recent study reported that injection is more painful than tourniquet use in minor hand surgery. Therefore, this study aimed to compare three LA methods that differ according to injection and hemostasis, namely, the combination of a tourniquet and buffered lidocaine solution (CTB), WALANT, and conventional LA. Methods: This randomized prospective single-center study included 169 patients who underwent minor hand surgery between 2017 and 2020. We randomly allocated the patients to each group and recorded the pain and anxiety score during the surgery, as well as satisfaction after the surgery. Results: Pure lidocaine injection was significantly more painful than buffered lidocaine and WALANT solution injection ( p < 0.001). Local anesthesia injection was significantly more painful than tourniquet use in all groups ( p < 0.001). The intraoperative anxiety score was significantly lower in the CTB group than in the conventional LA and WALANT groups ( p < 0.001). The satisfaction score was significantly higher in the CTB and WALANT groups than in the conventional LA group ( p < 0.001). Conclusion: CTB for minor hand surgery under LA is associated with less injection pain and patient anxiety. The tourniquet is tolerable without much pain and waiting time. Thus, CTB in minor hand surgery is a good alternative to WALANT and conventional LA.
Article
Résumé Hypothèse La WALANT (Wide awake local anesthesia with no tourniquet) ainsi que les procédures de type « office surgery » deviennent de plus en plus populaires en chirurgie de la main. Il n’y a que peu de données dans la littérature concernant la satisfaction des patients comparant les méthodes d’anesthésie et la localisation de réalisation du geste chirurgical. Méthodes Nous avons réalisé une étude rétrospective, monocentrique, rapportant la satisfaction des patients répartis en trois groupes, en comparant le ressenti des patients vis-à-vis de l’anesthésie type WALANT et l’anesthésie loco-régionnale. Nous avons également comparé trois types de prise en charge : office surgery vs. bloc opératoire ambulatoire vs. bloc opératoire principal. Le Groupe 1 comporte des patients pris en charge sous WALANT en « office surgery » avec une procédure écho-guidée. Le Groupe 2 concerne des patients pris en charge sous WALANT en salle opératoire sans personnel d’anesthésie avec une procédure écho-guidée. Le Groupe 3 concerne la prise en charge au bloc principal, sous ALR avec utilisation d’un garrot et sous endoscopie. Chaque groupe comprend 30 patients avec un recul minimum de 2 mois postopératoire. Les critères d’évaluations regroupent : la satisfaction globale, la satisfaction concernant l’organisation du parcours de soin, l’administration et la qualité de l’anesthésie. Nous avons également recueilli les données concernant la résolution du syndrome acroparesthésique, la survenue de complications neurologiques, vasculaires ou infectieuses. Résultats Les procédures réalisées en « office surgery » montrent un taux de satisfaction plus élevé comparé à la prise en charge au bloc, de même que l’anesthésie type WALANT comparé à l’ALR quel que soit le lieu de prise en charge. Nous n’avons pas mis en évidence de majoration des complications. Une résolution des symptômes neuropathiques a été constatée chez tous les patients. Conclusion Les résultats de cette étude montrent une augmentation de la satisfaction des patients pour les procédures réalisées en « office surgery ». Les résultats montrent également une augmentation de la satisfaction des patients sous WALANT comparé à l’ALR quel que soit le lieu de prise en charge. En conclusion il semblerait que la libération du canal carpien sous WALANT en « office surgery » apporte une amélioration significative du confort et de la satisfaction des patients, sans différence significative concernant les résultats cliniques. Niveau de preuve III.
Article
The Wide-Awake Local Anesthesia No Tourniquet (WALANT) technique uses local anesthesia based on lidocaine and adrenaline, enabling surgery without the tourniquet normally used in hand surgery. Only a few studies have been conducted on the use of WALANT for emergency hand surgery in teaching hospitals. We therefore set up the WALANT procedure in our emergency department in the university hospital of Bordeaux, France, to evaluate its feasibility and the satisfaction of patients and operators. Between April and June 2020, we included 58 patients undergoing surgery for acute trauma of the hand/wrist. WALANT was performed following a specific protocol. A tourniquet was systematically available on standby. After the procedure, patients and operators were asked to complete a questionnaire. Patients rated pain on a 0-10 numerical analog scale. Surgeons reported their feelings about bleeding and patient cooperation. All patients underwent a nearly painless operation, with a mean pain score of 0.36/10. The mean pain score during injection was 2.57, and postoperatively 5.2. Bleeding complications were reported to be absent or slight by 43% of operators, moderate but acceptable by 47%, and significant by 10%. Bipolar forceps were used in 76% of cases. No digital necrosis or prolonged ischemia requiring the use of phentolamine was reported. WALANT offers a simple, safe, and effective alternative to traditional anesthesia techniques in an emergency setting. Patients and surgeons reported overall satisfaction, with no increase in the complications rate.
Article
Purpose: Epinephrine is used in local anesthetics to induce vasoconstriction and thus reduce bleeding and prolong the anesthetic effect. Finding the optimal delay between the administration of the anesthetic and skin incision to ensure vasoconstriction and minimize bleeding is important and has recently become the subject of debate. This is the first study to assess blood perfusion and oxygen saturation (sO2) simultaneously in response to a local anesthetic containing epinephrine in human oculoplastic surgery. Methods: A local anesthetic consisting of lidocaine and epinephrine (20 mg/ml + 12.5 μg/ml) was injected in the eyelids of 9 subjects undergoing blepharoplasty. The perfusion and sO2 of the eyelids were monitored using laser speckle contrast imaging and hyperspectral imaging, respectively. Results: Laser speckle contrast imaging monitoring showed a decrease in perfusion over time centrally at the site of injection. Half-maximum effect was reached after 34 seconds, and full effect after 115 seconds, determined by exponential fitting. The drop in perfusion decreased gradually further away from the injection site and hypoperfusion was less prominent 4 mm from the injection site, with a spatially dependent half-maximum effect of 231 seconds. Hyperspectral imaging showed only a slight decrease in sO2 of 11 % at the injection site. Conclusions: The optimal time delay for skin incision in oculoplastic surgery is approximately 2 minutes after the injection of lidocaine with epinephrine. Longer delay does not lead to a further decrease in perfusion. As sO2 was only slightly reduced after injection, the results indicate that the use of epinephrine is safe in the periocular region.
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Purpose Wide-Awake Local Anesthesia No Tourniquet (WALANT) is a novel anesthesia technique in distal radius and ankle fracture fixation. However, to date, there are limited studies in diaphyseal plating of forearm fractures under WALANT. This research is to study the feasibility of the use of WALANT technique in plating of diaphyseal fractures of the forearm as well as peri-operative outcomes. Methods Sixty-one adult patients who underwent diaphyseal plating of the forearm under WALANT between the period of January 2019 and January 2021. It consists of 31 radius fractures, 15 ulna fractures and 15 ipsilateral radius and ulna fractures. Outcomes evaluated were duration of stay, peri-operative numerical pain rating scale, peri-operative blood pressure and heart rate, visual analogue scale for anxiety, blood loss, surgery duration, adverse effect, patient’s satisfaction and any complications at 6 months follow up. Results Fifty-four patients (88.5%) were male and 7 patients (11.5%) were female with a mean age of 31.7 years (SD = 13.564). Thirty-eight out of 61 patients were totally pain free throughout the surgery. Ten (13%) patients reported pain during muscle dissection, 14 (18%) patients reported pain during bone manipulation and 12 (16%) patients reported pain during bone drilling. There was no significant difference in pain score between radius and ulna bones (P > .05). There was a significant change in blood pressure after LA infiltration (P < .01). The mean estimated blood loss was 27.39 ml (SD = 11.44) and the mean duration of post-surgery hospital stay was 1 day (SD = 1.026). Fifty-six patients (92%) recommended diaphyseal plating of the forearm under WALANT. None of the patients required conversion to general anesthesia and had any adverse events or infection during 6 months follow up. Conclusions Diaphyseal plating of the forearm under WALANT is a feasible alternative anesthesia technique and is well tolerated by patients. Type of study/level of evidence Therapeutic III.
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This is a review article of the wide-awake approach to hand surgery. More than 95% of all hand surgery can now be performed without a tourniquet. Epinephrine is injected with lidocaine for hemostasis and anesthesia instead of a tourniquet and sedation. This is sedation-free surgery, much like a visit to a dental office. The myth of danger of using epinephrine in the finger is reviewed. The wide awake technique is greatly improving results in tendon repair, tenolysis, and tendon transfer. Here, we will explain its advantages.
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Over 70% of Canadian carpal tunnel syndrome (CTS) operations are performed outside of the main operating room (OR) with field sterility and surgeon-administered pure local anesthesia [LeBlanc et al., Hand 2(4):173-8, 14]. Is main OR sterility necessary to avoid infection for this operation? This study evaluates the infection rate in carpal tunnel release (CTR) using minor procedure room field sterility. This is a multicenter prospective study reporting the rate of infection in CTR performed in minor procedure room setting using field sterility. Field sterility means prepping of the hand with iodine or chlorhexidine, equivalent of a single drape, and a sterile tray with modest instruments. Sterile gloves and masks are used, but surgeons are not gowned. No prophylactic antibiotics are given. One thousand five hundred four consecutive CTS cases were collected from January 2008 to January 2010. Six superficial infections were reported and four of those patients received oral antibiotics. No deep postoperative wound infection was encountered, and no patient required admission to hospital, incision and drainage, or intravenous antibiotics. A superficial infection rate of 0.4% and a deep infection rate of 0% following CTR using field sterility confirm the low incidence of postoperative wound infection using field sterility. This supports the safety and low incidence of postoperative wound infection in CTR using minor procedure field sterility without prophylactic antibiotics. The higher monetary and environmental costs of main OR sterility are not justified on the basis of infection for CTR cases.
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Wide-awake flexor tendon repair in tourniquet-free unsedated patients permits intraoperative Total Active Movement examination (iTAMe) of the freshly repaired flexor tendon. This technique has permitted the intraoperative observation of tendon repair gapping induced by active movement when the core suture is tied too loosely. The gap can be repaired intraoperatively to decrease postoperative tendon repair rupture rates. The authors record their rupture rate in the first 15 years of experience with iTAMe. This was a retrospective chart review of 102 consecutive patients with wide-awake flexor tendon repair (no tourniquet, no sedation, and pure locally injected lidocaine with epinephrine anesthesia) in which iTAMe was performed by two hand surgeons in two Canadian cities between 1998 and 2008. Intraoperative gapping and postoperative rupture were analyzed. The authors observed intraoperative bunching and gap formation with active movement in flexor tendon repair testing (iTAMe) in seven patients. In all seven cases, they redid the repair and repeated iTAMe to confirm gapping was eliminated before closing the skin, and those seven patients did not rupture postoperatively. In 68 patients with known outcomes, four of 122 tendons ruptured (tendon rupture rate, 3.3 percent) in three of 68 patients (patient rupture rate, 4.4 percent). All three patients who ruptured had accidental jerk forced rupture. All those patients who did what we asked them did not rupture. Tendons can gap with active movement if the core suture is tied too loosely. Gapping can be recognized intraoperatively with iTAMe and repaired to decrease postoperative rupture.
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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.
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Background: The time until maximal cutaneous vasoconstriction after injection of lidocaine with epinephrine is often given in textbooks and multiple choice examinations as 7 to 10 minutes. However, in our experience, there is significantly less cutaneous bleeding if one waits considerably longer than 7 to 10 minutes after injection of local anesthesia with epinephrine for most procedures on human skin. Methods: This was a prospective, randomized, triple-blind study where 12 volunteers were injected simultaneously in each arm with either 1% lidocaine with epinephrine (study group) or 1% plain lidocaine (control group), after which the relative hemoglobin concentration of the underlying skin and soft tissues was measured over time using spectroscopy. Results: In the epinephrine group, the mean time at which the lowest cutaneous hemoglobin level was obtained was 25.9 minutes (95 percent CI, 25.9 ± 5.1 minutes). This was significantly longer than the historical literature values of 7 to 10 minutes for maximum vasoconstriction after injection. Mean hemoglobin index values at every time measurement after postinjection minute 1 were significantly different between the study group and the control group, with use of a two-tailed paired t test (p < 0.01). Conclusions: If optimal visualization is desired, the ideal time for the surgeon to begin the incision should be 25 minutes after injection of local anesthetic with epinephrine. It takes considerably longer than 7 to 10 minutes for a new local equilibrium to be obtained in relation to hemoglobin quantity.
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The effectiveness of local anesthetics is improved by the addition of a vasoconstrictor which increases duration of action and decreases both systemic toxic reactions and local bleeding. Epinephrine, the standard drug for vasoconstriction, has some limitations due to potential dose-related cardiac and local toxic effects. The authors examined the minimal effective epinephrine concentration required for maximal cutaneous vasoconstriction in the human subject so as to limit potential dose-related side effects. In a randomized, double-blinded prospective study, 23 patients undergoing head and neck surgical procedures under general anesthesia were enrolled to quantify the effect of subdermal infiltration of 1% lidocaine with epinephrine at varying concentrations on local cutaneous bloodflow utilizing laser Doppler flowmetry. A comparison of the onset of vasoconstriction and magnitude of diminished bloodflow was made for several commonly used concentrations of epinephrine, with 1% lidocaine and normal saline serving as controls. There were no significant differences (P>.05) between epinephrine concentrations of 1:400,000, 1:200,000, 1:100,000, and 1:50,000 when examining onset and magnitude of vasoconstriction.
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Quantification of the effect of subcutaneous infiltration of saline with epinephrine and of lidocaine with epinephrine on local cutaneous blood flow was accomplished utilizing the laser Doppler method. A comparison of the onset of vasoconstriction, magnitude of diminished blood flow, and duration of effect was made for several commonly used concentrations of epinephrine. Injected solutions containing epinephrine in concentrations of 1: 200,000 and higher offered good vasoconstrictor effects when both the magnitude and duration of flow reduction were considered. There was a significant (P = 0.0001) difference in flow between epinephrine concentrations of 1:400,000 and all others. There were no significant differences (P > 0.05) between concentrations of 1:200,000 and 1:100,000 or 1:100,000 and 1:50,000.
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Wide awake hand surgery means no sedation, no tourniquet, and no general anesthesia for hand surgery. The only medications given to the patient are lidocaine with epinephrine. Lidocaine is for anesthesia, and epinephrine provides hemostasis, which deletes the need for a tourniquet. The advantages are: (1) the ability of the comfortable unsedated tourniquet-free patient to perform active movement of the reconstructed structures during surgery so the surgeon can make alterations to the reconstruction before the skin is closed to improve the outcome of many surgeries; and (2) the deletion of all risks, costs, and inconveniences of sedation and general anesthesia.