Article

A Cost Analysis of Carpal Tunnel Release Surgery Performed Wide Awake versus under Sedation

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Abstract

Background: Hand surgery under local anesthesia only has been utilized more frequently in recent years. The purpose of this study was to compare perioperative time and cost for carpal tunnel release (CTR) performed under local anesthesia (WALANT) only to those performed under intravenous sedation (MAC). Methods: A retrospective comparison of intra-operative (OR) surgical time and post-operative (PACU) time for consecutive CTR procedures performed under both MAC and WALANT was undertaken. All operations were performed by the same surgeon using the same mini-open surgical technique. A cost analysis was performed via standardized anesthesia billing based on base units, time, and conversion rates. Results: There were no significant differences between the two groups in terms of total OR time, 28 minutes in the MAC group versus 26 minutes in the WALANT group. PACU times were significantly longer in the MAC group (84 minutes) compared to the WALANT group (7 minutes). Depending on conversion rates used, a total of $139-$432 was saved in each case done with WALANT by not using anesthesia services. In addition, a range of $1,320-$1,613 was saved for the full episode of care including anesthesia costs, OR time, and PACU time for each patient undergoing WALANT CTR. Conclusions: CTR surgery performed with the WALANT technique offers significant reduction in cost utilization of anesthesia and PACU resources.

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... Lokal anestezi, karpal tünel cerrahisinde en sık uygulanan anestezi yöntemlerinden birisidir ve güvenilirliği hakkında literatürde birçok yayın bulunmaktadır (2,4,(7)(8)(9). Lokal anestezi ile karpal tünel cerrahisinin, günübirlik yatış şeklinde uygulanabilmesi, uzun ameliyat bekleme sürelerini kısaltması, genel anesteziye bağlı oluşabilecek komplikasyonları önlemesi ve ameliyat öncesi anestezi hazırlığına ihtiyaç duyulmaması gibi avantajları bulunmaktadır (2,(7)(8)(9)(10). ...
... Karpal tünel cerrahisinde lokal anestezi uygulamasının güvenilirliği birçok çalışma ile gösterilmiştir (4,7,9,13). Günübirlik cerrahi şeklinde uygulanabilmesi, cerrahi bekleme sürelerini kısaltması, genel ya da rejyonel anestezi ilişkili komplikasyonları azaltması, ameliyat öncesi kan tahlili ve konsültasyon ihtiyacı olmaması nedeniyle daha düşük sağlık harcamalarına neden olması gibi birçok avantajı bulunmaktadır (1,(8)(9)(10).Çalışmamızdaki lokal anestezi uygulaması sonuçları, düşük postoperatif komplikasyon oranlarına ve sağlık harcamalarına neden olması açısından literatürü destekler niteliktedir. ...
... Çalışmamızdaki kısıtlılıklardan biri, hasta kayıt sisteminin yalnızca ameliyat maliyetini göstermesidir. Periferik sinir bloğu uygulanan grupta, ameliyat öncesi kan tahlilleri, elektrokardiyogram ve akciğer filmi gibi tetkiklerin yapılması, anestezi doktoru muayenesi ve hastaların eşlik eden hastalıkları ile ilgili diğer branş konsültasyonlarının gerekmesi, ameliyat öncesi ve ameliyat sırasında anestezi ekibi ve servis yatışı sırasında hemşirelik hizmetleri gibi ekstra harcamalar dikkate alındığında, mevcut maliyet farkı ciddi anlamda artmaktadır (1,7,9,10). ...
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Abstract Introduction: Carpal tunnel syndrome is one of the most performed hand surgery procedure and an important reason of the increased health costs. The aim of this study was to investigate the effects of the different anesthesia types, local or peripheral nerve blocks, for the surgical treatment of carpal tunnel syndrome on postoperative complications and health costs. Materials and Methods: In the current study, we investigated the postoperative complications and health costs of 323 patients (382 hands), who were operated for carpal tunnel syndrome under local or peripheral nerve blocks between January 2013 and December 2018, retrospectively. Age, gender, date of operation, type of anesthesia, comorbidities, postoperative complications, date of complication, total hospitalization time, total follow-up periods and total costs of procedures of the patients, who were followed at least 12 months postoperatively, were obtained from medical record system. Results: Average costs of procedure with local anesthesia was statistically significantly lower than peripheral nerve blocks(p<0.001). A statistically significant increase in terms of the length of hospital stay was observed in peripheral nerve block group (p=0.005). revision surgeries were needed in two patients in the local anesthesia group in the postoperative fourth and sixth years, however we could not find any correlation between the type of anesthesia and complications (p=0.554). Conclusion: Local anesthesia is a reliable and cost-effective method with low complication rates that could be used in open surgical treatment of carpal tunnel syndrome. Local anesthesia is a cost saving method, whichcould be applied as an outpatient procedure, required no preoperative blood tests or consultations and prevent postoperative complications due to general anesthesia. Keywords: Carpal Tunnel Syndrome; Anesthesia, local; Nerve Block; Postoperative Complications; Cost Analysis
... When compared with IV anesthesia and sedation, Okamura et al. found that patients spent more time in the operating room, averaging an additional 13.5 min, when IV anesthesia was used. Alter et al. and Via et al. found significant time savings for WALANT patients, measured as the time spent in the post-anesthesia care unit (PACU) (average savings of 77 and 22 min, respectively, for the two procedures) [18][19][20]. Patients were able to leave the PACU more promptly following surgery under WALANT. Kamal et al. created a clinical pathway specific to CTR under WALANT that involved particular interventions such as: the administration of local anesthesia in a pre-operative holding room; a CTRspecific surgical tray; and prompt attention in the PACU. ...
... Several studies have estimated the direct cost savings associated with the use of CTR under WALANT. One single-center, single-surgeon study found that the total costs of CTR under WALANT amounted to USD 89.12 compared with USD 1409.28 for intravenous (IV) anesthesia [19]. When introducing hand surgery procedures under WALANT, 34% of which were CTR, a military medical center reported it saved USD 393,100 over a 21-month period [24]. ...
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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.
... Another benefit of the WALANT technique is its cost effectiveness [7,17,26,27]. As no anesthesiologist is needed, there is a resultant reduction in overall cost to the health system and to patients in low and middle-income countries where medical services are often still being paid out-of-pocket by those receiving health care [17,[26][27][28]. ...
... Another benefit of the WALANT technique is its cost effectiveness [7,17,26,27]. As no anesthesiologist is needed, there is a resultant reduction in overall cost to the health system and to patients in low and middle-income countries where medical services are often still being paid out-of-pocket by those receiving health care [17,[26][27][28]. ...
Article
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Backround The aim of this study was to determine, if Wide Awake Local Anesthesia No Tourniquet (WALANT) can be used as an alternative method of providing anesthesia in management of deep infections of the hand. Since the advent of WALANT in 2003, infections of the hand have been regarded as a contraindication to its use. Occasional shortage of anesthesiologic manpower, especially during busy call hours and the current COVID-19 pandemic can lead to delay of treatment where urgent surgery is needed, to prevent progress of an infection, that can result in severe morbidity. Methods In the period from 2015 to 2020, 16 patients with various infections of the hand underwent 17 operations using WALANT in a Hand Trauma and Replantation Center (HTRC) in Germany. Retrospective cohort analysis of their operation reports, with emphasis on location of infection, time and duration of the operation, intraoperative incidents and complications were carried out. We also evaluated the need for revision surgery or necessity to convert to general anesthesia and factors causing delay till the time of surgery. Results No case of inadequate analgesia, the need to convert to general anesthesia, ischemic events or cardiovascular complications with the use of the WALANT solution containing adrenaline and lidocaine in the treatment of deep tissue infections. The highest priority of limb preservation was ensured as no patient progressed to amputation of a digit or the hand. There was a statistically significant difference (p≤0.01) in delay from the time of admission until surgery of up to 9h24m (SD±3h34m) during the week and 4h10m (SD±2h28m) during the weekend. Conclusion The status of infection as an absolute contraindication to the use of WALANT should be revised. Especially when human resources are limited, WALANT is an adequate technique to enable quick anesthesia for urgent treatment to prevent progression of hand infections.
... This study demonstrates for both groups that there was no difference in the patient satisfaction and pain scores which is in line with previous studies that reported that patients felt well satisfied, safe and patient-friendly with the WALANT technique (11)(12)(13)(14) . A study of Koegst et al., revealed that Eighty percent of patients were satisfied with the WALANT technique and they felt good after surgery because of no need to avoid and worry about anesthetics with adrenaline side effects (15) . ...
... The WALANT technique was time-saving and costeffective. Patients felt highly safe and satisfied with shorter time for post-anesthesia care, and no need to admit to the hospital (11,12,16) . ...
... In a USA study comparing the costs of WALANT versus general anaesthesia for carpal tunnel syndrome surgery, a mean saving of $1,320 on healthcare costs -which included anaesthesia cost, preoperative cost, and postoperative cost -was found. 27 No cost comparison has been reported yet for WALANT versus any other technique for surgery of distal radius fractures. In our study, hospital costs were determined among others by factors such as length of hospital stay, number of complications, and number of people in the operating room. ...
... as well as between WALANT and Bier's block ($305.50), is considerable, although these differences are much smaller than the difference of $1,320 between WALANT and general anaesthesia for carpal tunnel syndrome, most likely because healthcare costs in Pakistan are in general much lower than those in the USA. 27 To put the mean total hospital cost range of $428.50 to $734.00 for the three procedures into perspective, it is relevant to know that the mean annual household income in 2016 in Pakistan was $651. 28 The WALANT technique was only last year reported as an anaesthesia option for surgery of distal radius fractures. ...
Article
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Aims We hypothesized that the wide-awake local anaesthesia with no tourniquet (WALANT) technique is cost-effective, easy to use, safe, and reproducible, with a low learning curve towards mastery, having a high patient satisfaction rate. Furthermore, WALANT would be a suitable alternative for the austere and developing nation environments where lack of funds and resources are a common issue. Methods This was a randomized control trial of 169 patients who required surgery for closed isolated distal radius fractures. The study was performed between March 2016 and April 2019 at a public sector level 1 trauma centre. General anaesthesia was used in 56 patients, Bier’s block in 58 patients, and WALANT in 55 patients. Data were collected on pre-, peri-, and postoperative parameters, clinical outcome, hospital costs, and patient satisfaction. One-way analysis of variance (ANOVA) was used with a p-value of 0.05 being significant. Results Operations with WALANT proceeded sooner, and patients recovered faster, resulting in mean fewer missed working days (7.8 (SD 1.67)) compared with general anaesthesia (20.1 (SD 7.37)) or Bier’s block (14.1 (SD 7.65)) (p < 0.001). The WALANT patients did not develop complications, while the other patients did (p < 0.04). Clinical outcomes did not differ, nor did surgeon qualification affect clinical outcomes. Mean hospital costs were lower for WALANT ($428.50 (SD 77.71)) than for general anaesthesia ($630.63 (SD 114.77)) or Bier’s block ($734.00 (SD 37.54)) (p < 0.001). Patient satisfaction was also higher (p < 0.001). Conclusion WALANT for distal radius fractures results in a faster recovery, is more cost-effective, has similar clinical outcomes, and has fewer complications than general anaesthesia or Bier's block. This makes WALANT an attractive technique in any setting, but especially in middle- and low-income countries. Cite this article: Bone Joint Res 2020;9(7):429–439.
... To make universal claims in this regard is difficult, but cost-effectiveness and efficiency are recurring themes in many WALANT articles. 31,[55][56][57] The medications and equipment required to perform WALANT are inexpensive. Furthermore, 7 mg per kg lignocaine dosing with adrenaline is safely administered without the need for routine preoperative blood testing, preoperative fasting, intraoperative IV access and intraoperative monitoring, which allows for more rapid patient turnover and cost-saving. ...
Article
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Background Wide awake local anaesthesia no tourniquet (WALANT) is a local anaesthetic technique that employs lignocaine combined with adrenaline to maintain a pain-free and bloodless field during surgery on an awake patient, without the use of a tourniquet. Methods This article is a narrative review of the literature on the use of this mode of anaesthesia in orthopaedic and hand surgery. Results The review summarises the existing research pertaining to WALANT. It discusses the anaesthetic solution constituents, administration technique and applications of WALANT, highlighting the safety profile and benefits to patients and healthcare systems alike. Conclusion The WALANT technique is safe, economical, and acceptable to patients. It should form part of the orthopaedic surgeon’s armamentarium. Future research should investigate the benefits of intraoperative functional assessment of the awake patient. Level of evidence: Level 5.
... [1][2][3][4] Local anesthesia enables surgeons to perform operations outside the operating room, reducing nonoperative and operative surgical time, and the need for extensive medical equipment. 7,8 Half of the patients had immediate reconstruction following their frozen section resection. The other half had Mohs surgery followed by reconstruction within a median of 3 days. ...
Article
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The use of local anesthesia in nasal surgery has gained popularity as a cost-effective and safe alternative. With the potential benefit of reconstruction without using general anesthesia, the goal of the study was to evaluate the patient-reported experience in addition to surgical outcomes and perioperative complications. Methods: A mixed-methods study was completed with retrospective chart review and patient-reported outcome questionnaire. The primary outcome measures were demographics, oncologic and surgical details, and postoperative complications. Secondary outcome measures were aesthetic outcomes and procedure tolerance, which were gathered from the FACE-Q questionnaire. Results: Of the 22 patients who met inclusion criteria, nine patients (41%) had forehead flaps performed and 13 patients (59%) had multilayer reconstruction with local flaps and cartilage grafts. The average number of surgeries performed, including revisions, was 2.3 ± 0.2. The overall complication rate for reconstructions and revisions was 20%, most of these were minor complications. The overall subjective rating of patient's appearance was excellent with an average score of 83.9 (± 17.3) out of 100. There was minimal appearance distress as a product of the surgery with an average score of 84.9 (±18.8). On a scale of one to five, patients reported an average of 4.3 for convenience, 3.8 for efficiency of setup and procedure, and 3.4 out of 5 for comfortability with having an operation performed on their face wide awake. Conclusion: Our study demonstrated that complex nasal reconstruction performed under local anesthetic in a minor procedure setting is a feasible and safe option with good patient-reported outcomes.
... 5 However, many other hand and wrist surgical procedures are performed under strictly local anesthesia, allowing for decreased costs and improved patient experience. [6][7][8] Additionally, proponents of wide-awake local anesthesia notourniquet (WALANT) technique cite the ability to assess the full active range of motion (ROM) intraoperatively as an advantage of the technique. 9 The use of local anesthesia can potentially help to mitigate some of the risks of general anesthesia to an older and more frail patient population, 10 which make up a significant proportion of DRFs. ...
Article
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Background The purpose of this systematic review was to analyze the available literature on fixation of distal radius fractures (DRFs) under wide-awake local anesthesia no-tourniquet (WALANT), and to examine postoperative pain scores and functional outcomes, operative data including operative time and blood loss, and the frequency of adverse events. Methods Embase, MEDLINE, Web of Science, and SCOPUS were searched from inception until May 2022 for relevant studies. Studies were screened in duplicate, and data on pain scores, functional outcomes, and adverse events were recorded. Due to methodological and statistical heterogeneity, the results are presented in a descriptive fashion. Results Ten studies were included comprising 456 patients with closed, unilateral DRFs, of whom 226 underwent fixation under WALANT. These patients had a mean age of 52.8 ± 8.3 years, were 48% female, and had a mean follow-up time of 11.6 months (range: 6-24). Operative time for WALANT patients averaged 60.4 ± 6.5 minutes, with mean postoperative pain scores of 1.4 ± 0.6 on a 10-point scale. Studies that compared WALANT to general anesthesia found shorter hospital stays with most WALANT patients being sent home the same day, decreased postoperative pain scores, and decreased costs to the healthcare system. No adverse events were reported for WALANT patients. Conclusions A growing body of literature reports that for closed, unilateral DRF, surgical fixation under WALANT is a safe and effective option. It allows patients to have surgery sooner, with improved pain scores and good functional outcomes, with a very low incidence of adverse events.
... A mean saving of USD 1320 in health care costs, including anesthesia cost, preoperative cost, and postoperative cost, was noted in an American study in which the cost of WALANT was compared with that of GA in surgery for carpal tunnel syndrome (31). Furthermore, despite the MDs in annual household incomes between the United States and Pakistan, Tahir et al. demonstrated that WALANT costs less in hospital spending (USD 202.10; p < 0.001) compared with GA in terms of repairs of distal radius fracture in both countries (2). ...
Article
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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.
... Si bien se han reportado importantes beneficios económicos a favor de la WALANT en comparación con las cirugías con sedación, 10,11 no se han publicado la real satisfacción del paciente y los resultados funcionales entre las cirugías con anestesia local y aquellas con WALANT. ...
Article
Objetivo: Las cirugías con WALANT han ganado gran popularidad hoy en día. La ventaja principal que ofrece esta técnica es la de prescindir del torniquete y así eliminar las molestias que este genera. Nuestra hipótesis es que la descompresión del túnel carpiano con anestesia local y manguito neumático, realizada por un cirujano experimentado, en un tiempo quirúrgico corto, permite obtener similares resultados que con la cirugía con WALANT. Materiales y Métodos: Se diseñó un estudio de cohortes prospectivo comparativo clínico. Se incluyeron 23 pacientes (30 manos) con síndrome del túnel carpiano. Se asignó a los pacientes en forma aleatorizada, a 2 grupos: grupo 1, operados con anestesia local y grupo 2, operados con WALANT. Se realizó un análisis estadístico. Resultados: Todas las variables mostraron diferencias estadísticamente significativas respecto a los valores preoperatorios para los dos grupos. Respecto a la relación entre los dos grupos, los resultados funcionales de dolor y grado de satisfacción posoperatorios no mostraron diferencias con significancia estadística. Conclusiones: En nuestro estudio, la descompresión del túnel carpiano con anestesia local y torniquete y la realizada con WALANT arrojaron similares resultados. En cirujanos con experiencia posiblemente la anestesia local con torniquete sea suficiente para realizar el procedimiento, y así evitar las bajas, pero complejas complicaciones de la epinefrina.
... They concluded that patients undergoing the second required less postoperative analgesia, highlighting an important fact: the reduction in costs using this WALANT technique. Alter et al. 20 Tang et al. 19 , in their descriptive study, report the experience of applying the WALANT technique in two reference centers in China. Furthermore, like the other works, they emphasize the important effectiveness of the technique. ...
Article
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Carpal tunnel syndrome is one of the most common pathologies in the upper limb; it is the most common compressive neuropathy, causing significant morbidity. Many of those affected need surgical treatment; thus, the WALANT technique would be an excellent option to allow faster treatment of patients waiting for it. This study aims to carry out an integrative review on applying the WALANT technique for the surgical treatment of carpal tunnel syndrome, emphasizing the efficacy and safety of the procedure. An integrative literature review was performed using the “Wide Awake Local Anesthesia No Tourniquet” descriptor. Sixteen studies were selected from the PubMed and VHL databases, applying the eligibility criteria. The selected studies do not report complications associated with applying the WALANT technique. The WALANT technique has evident efficacy and safety for the surgical treatment of carpal tunnel syndrome, with no reports of complications. Keywords: Carpal tunnel syndrome; Median neuropathy; Epinephrine; Lidocaine; Anesthesia
... No skin necrosis was detected in our cases, thus providing reliable evidence on the safety of using epinephrine in flap surgeries. In addition, this technique was cost-effective as an anesthesiologist was not required to monitor the anesthesia-related care; hence, about 11% of the whole cost could be saved on each patient of our hospital [38,39]. ...
Article
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Background Wide-awake local anesthesia no tourniquet (WALANT) technique has emerged among hand surgeons with other indications. Surgeries involving pedicled flap and revascularization are no longer used as contraindications. The present study aimed to evaluate the feasibility and merits of the WALANT technique in random skin flap surgery. Methods From May 2018 to March 2019, 12 patients with finger skin defects repaired with random skin flaps were reviewed. Abdominal skin flaps or thoracic skin flaps were used to cover the wound. Both the fingers and the donor sites were anesthetized by the WALANT technique. A 40-mL conventional volume consisted of a mixture of epinephrine and lidocaine. A volume of 5 mL was injected at the distal palmar for nerve block, the other 5 mL was injected around the wound for hemostasis, and the remaining was injected at the donor site of flaps for both analgesia and hemostasis. Baseline data with respect to sex, age, side, type of finger, donor sites, flap size, dosage of anesthetics, usage of finger tourniquet, intraoperative and postoperative pain, hemostasis effect, operation time, Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) score, and hospitalization expense, were collected. Results All patients tolerated the procedure, and none of them needed sedation. Single finger skin defect in 8 patients and double finger skin defect occurred in 4 patients; 5 patients were repaired by abdominal skin flaps, and 7 patients were repaired by thoracic skin flaps. The good surgical field visibility was 91.7%. All flaps survived adequately, without necrosis, pulling fingers out, and other complications. The average visual analog scale (VAS) score of the maximal pain was 1.1 in fingers vs. 2.1 in donor sites during the operation. On postoperative day one, the average VAS score of the maximal pain in fingers and donor sites was 1.3 and 1.1, respectively. The average hospitalization expense before reimbursement of the whole treatment was 11% less expensive compared to the traditional method. The average QuickDASH score was 9.1. Conclusions Under wide-awake anesthesia, patients have the ability to control their injured upper extremities consciously, avoiding the complications due to pulling flap pedicles. With the merits of safety, painlessness, less bleeding, and effectivity, the WALANT technique in random skin flaps is feasible and a reliable alternative to deal with finger skin defect.
... More recently, significant research is being put forward examining hand surgeries performed Wide-Awake, with Local Anesthesia only, and No Tourniquet (WALANT), including for CTR surgeries. When compared with sedation, the WALANT technique has been demonstrated to be significantly less expensive saving $1,320 to $1,613 per CTR case when performed in an operating room, 41 while also being equally effective. 44 Moreover, a 2019 study found improved pain control for 24 hours postoperatively with WALANT versus standard anesthesia. ...
Article
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Carpal tunnel release (CTR) surgery continues to evolve. Carpal tunnel syndrome remains a primarily clinical diagnosis, although ultrasound has supplemented electrodiagnostic testing as a confirmatory tool. Magnetic resonance imaging of the carpal tunnel has also showed some promise as an alternative method for the examination of the median nerve. Open CTR surgery remains the traditional, and most popular, method of CTR. Wide-Awake, with Local Anesthesia only, and No Tourniquet CTR has emerged as a means to decrease cost and improve pain control and convenience for patients. Endoscopic CTR is increasing in popularity due to its more rapid recovery. The safety profile of endoscopic CTR has improved, and recent studies show similar rates of major complications between open and endoscopic techniques. Nonsurgeon operated ultrasound-guided techniques for release of the transverse carpal ligament have emerged. While promising in early studies, the current evidence in their favor is limited in terms of patient numbers and direct comparison with other techniques. The outcomes of CTR continue to be excellent. Recent research has demonstrated that nerve conduction continues to recover postoperatively over a longer period of time than previously believed. Patient psychological factors play a significant role in outcomes after surgery but do not appear to limit the improvement provided by intervention.
... Fixation may be performed in minor surgery (MS) under local anesthesia 4 or in the main operating room (OR) under a regional block or general anesthesia. 2 Previous cost-analysis studies have identified that procedures performed under local anesthesia offer a significant economic advantage over those performed in the main OR. 2,5 Reports comparing the From the *Section of Plastic Surgery, University of Calgary, Calgary, Alberta, Canada; and †Department of Surgery, Calgary, Alberta, Canada. ...
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Background: The objective of this study was to compare the costs of performing metacarpal fracture fixation in minor surgery (MS) versus the main operating room (OR) at a tertiary care center in Calgary, Alberta, from the institutional perspective. Methods: Data were extracted from the Operating Room Information System and the Business Advisory System by a financial analyst. All data were based on actual expenses from the 2016–2017 fiscal year (US$). Direct costs included: staffing, supply, day (outpatient) surgery unit, post-anesthesia care unit (PACU), and anesthesia (anesthesiologist and equipment) costs. Surgeon and hardware costs were deemed neutral and excluded from the analysis. Results: The total cost of metacarpal fixation in MS was $250, compared to $2,226 in the OR, after surgeon and hardware costs were excluded. Staffing costs are a major contributing factor to cost by location ($75 in MS versus $233 in OR), largely attributable to 0.5 nursing staff per room in MS compared to 3 nursing staff per room in the OR. Supply costs (minor tray, $94 versus case cart, $247) are also greater for OR cases. The combined costs for DSU ($465), PACU ($435), and anesthesia ($247) totaled $1,147 and are only incurred for OR cases. Conclusions: Repair of metacarpal fractures in MS represents a substantial costminimization strategy from the institutional perspective. Staffing and supply costs by location and the additional combined costs of DS, PACU, and anesthesia are all contributing factors.
Article
Background: Simple postaxial polydactyly (type B) is a common congenital hand malformation often treated by suture or clip ligation. Methods: We present a case series of patients with simple postaxial polydactyly treated by surgical excision using local anesthesia in an office setting. Results: The procedure was performed on 78 digits in 48 children with a mean age of 10.2 weeks. There were no intraoperative or early postoperative complications. A follow-up by phone interview was performed at an average of 3.2 years postoperatively. All patients were reported to be pain-free and have normal function without a perceived range of motion deficits. All parents selected the highest level of satisfaction regarding cosmetic outcomes and overall experience with the procedure. Conclusions: These results demonstrate that an office-based surgical excision is a safe, effective, and economical treatment option and has developed into our standard of care for this common condition.
Article
Purpose Dorsal wrist ganglions are treated commonly with aspiration, or open or arthroscopic excision in operating room (OR) or procedure room (PR) settings. As it remains unclear which treatment strategy is most cost-effective in yielding cyst resolution, our purpose was to perform a formal cost-minimization analysis from the societal perspective in this context. Methods A microsimulation decision analytic model evaluating 5 treatment strategies for dorsal wrist ganglions was developed, ending in either resolution or a single failed open revision surgical excision. Strategies included immediate open excision in the OR, immediate open excision in the PR, immediate arthroscopic excision in the OR, or 1 or 2 aspirations before each of the surgical options. Recurrence and complications rates were pooled from the literature for each treatment type. One-way sensitivity and threshold analyses were performed. Results The most cost-minimal strategy was 2 aspiration attempts before open surgical excision in the PR setting ($1,603 ± 1,595 per resolved case), followed by 2 aspirations before open excision in the OR ($1,969 ± 2,165 per resolved case). Immediate arthroscopic excision was the costliest strategy ($6,539 ± 264 per resolved case). Single aspiration preoperatively was more cost-minimal than any form of immediate surgery ($2,918 ± 306 and $4,188 ± 306 per resolved case performed in the PR and OR, respectively). Conclusions From the societal perspective, performing 2 aspirations before surgical excision in the PR setting was the most cost-minimal treatment strategy, although in reference to surgeons who do not perform this procedure in the PR setting, open excision in the OR was nearly as cost-effective. As patient preferences may preclude routinely performing 2 aspirations, performing at least 1 aspiration before surgical excision improves the cost-effectiveness of dorsal wrist ganglions treatment. Type of study/level of evidence Economic decision analysis II.
Article
Entrapment of peripheral nerves can occur as they travel through restrictive spaces. This nerve compression can result in a constellation of signs and symptoms, which are often called syndromes. Patients initially report pain, paraesthesia and numbness, followed by weakness and clumsiness and, ultimately, muscle wasting. The specific region of paraesthesia and pain and the specific muscle weakness is determined by the peripheral nerve involved and the location of the entrapment. Diagnosis is mainly based on history and examination. Further investigations are available for atypical presentations. Each syndrome has its own set of risk factors, but repetitive action and muscle overuse are commonly associated with most syndromes. The treatment is activity modification followed by steroid injection and finally surgical decompression for ongoing persistent symptoms or severe initial presentation. This article outlines the history, examination, possible investigations and management for common peripheral nerve entrapments of the median, ulnar and radial nerves.
Article
Introduction: The anaesthetic modality "wide-awake" or "WALANT" (wide awake local anaesthesia not tourniquet) is based on the combination of a local anaesthetic with a vasoconstrictor to reduce bleeding during surgery and to avoid the use of a pneumatic tourniquet. The combination of 1% lidocaine together with 1:100,000 epinephrine is the most commonly used formula. The objective of this work is to carry out a review of the literature about this anaesthetic modality in the field of orthopaedic surgery and traumatology. Methods: PubMed and Embase databases were consulted with clearly defined operators. Two independent searches were conducted by two investigators who were combined. Experimental, observational comparative studies, descriptive studies with n> 5 cases and cost studies were included. The individual results of the included studies are described. Results: A total of 8,794 entries were collected of which a total of 36 studies were included in the review. A large number of these studies have been published since 2010 and refer almost entirely to hand surgery, with multiple indications applied. There is heterogeneity regarding the type of study design and variables studied, among others. In addition, there is a disparity when defining the methodology of the WALANT technique between the different studies. Conclusions: This is the first comprehensive and reproducible review of the current state of the WALANT modality. There is great heterogeneity in terms of the study populations, the different comparators, variables studied between the different studies, and a lack of precise details regarding the WALANT technique. Level of evidence: III, Therapeutic study
Article
Waste in medicine can be defined narrowly by including only physical waste. It can be defined widely by including the concept of wasting time, energy, money and waste of materials. We will provide an overview of waste mitigation and how it can be a union between saving money and protecting the environment.
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The United States spends more on health care than any other country in the world based on the percentage of gross domestic product. This fact is coupled with health care facilities contributing nearly one-tenth of all greenhouse gas emissions in the United States, and with the health care industry’s waste contributions to landfills being second only to those of the food industry. In some instances, operating rooms produce the majority of total landfill waste from hospitals; therefore, patients undergoing surgical procedures can have both financial and environmental impacts. Recently, the wide-awake, local anesthesia, no tourniquet technique in hand surgery has grown in popularity. This technique has reportedly allowed surgeons to decrease operating room costs, time, and waste, but without compromising patient safety or outcomes. This comprehensive literature review summarizes the current literature related to the economic and environmental impacts of the wide-awake, local anesthesia, no tourniquet technique in hand surgery.
Article
Distal upper limb surgery is performed under WALANT (Wide Awake Local Anesthesia No Tourniquet) in many outpatient centers because the benefits are numerous: simple, low-cost technique, with fast turnover and short length of stay. In view of a paucity of data concerning patient satisfaction, this non-randomized cohort study was designed to compare EVAN-LR anesthesia satisfaction questionnaire results (information, pain, expectation, attention, discomfort: 0-100 points) between patients receiving WALANT or axillary nerve block (AxB). After IRB approval, patients (>18 years, stable ASA 1-3) scheduled for outpatient distal upper limb surgery were prospectively enrolled in the two groups. At discharge, patients in both groups received standard information on postoperative recovery and care, with a multimodal analgesic regime (acetaminophen and ketoprofen for 5 days). The primary endpoint was EVAN-LR score before discharge. Secondary endpoints were pain relief and side-effects over a 7-day period. Results were recorded as median and 25-75% interquartile range. Propensity-score-matched analysis was performed. Over the study period, from October 2019 to November 2020, 183 patients were included; 48 WALANT patients were propensity-score matched to 48 AxB patients. Pre-procedural APAIS anxiety score was lower in the WALANT than the AxB group: 9 (IQR, 6-12) vs 12 (IQR, 8-14) (p = 0.01). EVAN-LR scores were similar between the WALANT (78 [72-82]) and the AxB group (73[67-80]. Incidences of paresthesia and of pain (NRS pain score, opioid rescue) were similar. WALANT patients had shorter length of stay: 135 (110-175) min vs 170 (110-250) min (p = 0.01). The present study demonstrated that WALANT was associated with a high level of patient satisfaction. For clinical relevance and quality of care, WALANT should be proposed in first line for distal limb surgery.
Article
Background Recommendations and expectations regarding return to work (RTW) after carpal tunnel release (CTR) are often inconsistent. The study aim was to describe preferences of American Society for Surgery of the Hand (ASSH) members for perioperative management of patients following CTR, emphasizing surgeon preference regarding RTW. Methods A survey was sent to all ASSH members with active e-mail addresses. The primary outcome was the recommended time frame for patients to RTW full duty. Secondarily, associated factors with RTW were evaluated. Results In total, 4109 e-mail surveys were sent with 632 responses (15%). The highest proportion of respondents perform >100 CTRs per year (43.2%), have been practicing for >20 years (38.1%), and perform CTR using standard, open approach at outpatient surgery centers. The primary surgeon made recommendations about RTW in 99.5% of cases. For desk-based duties, the median recommended RTW time was 3 days; for duties requiring repetitive, light lifting of <10 lbs, the median recommended RTW time was 10 days; and for heavy manual duties, the median recommended RTW time was 30 days after CTR, according to the respondents. The 3 factors considered most influential for RTW were type of work, employer support, and financial considerations. Conclusions Our study demonstrates consistency among ASSH members in the perioperative management of CTR patients. The most important factors affecting RTW were type of work performed, employer support, and financial considerations. This study provides a meaningful foundation to manage expectations and guide patients, medical providers, and employers on the amount of time likely to be missed from work after CTR.
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.
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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.
Article
Background and aim WALANT procedures are becoming more popular, and are particularly useful in the COVID-19 pandemic. Procedures can be performed without needing access to general theatres and anaesthetic support, minimising the number of patient-healthcare interactions and avoiding aerosolisation. Our unit has taken this approach and aim to present a case series that demonstrates the efficacy and safety of WALANT. Methods A prospective analysis of WALANT cases in a single plastic surgery centre during March-August 2020 was performed. All procedures using a WALANT approach were included, that would have otherwise required general anaesthetic or regional block. Data was collected on a number of variables, including patient satisfaction. Results: 37 procedures were included in analysis. The majority of the injuries consisted of hand trauma. There were no cases of post-operative complications, although one required completion in main theatres due to technicality. No patients required additional anaesthetic during the procedure and all reported pain score as 0/10. Overall patient satisfaction was 10/10 for 26 patients, 9/10 for 10 patients and 7/10 for one patient. Conclusions Results show the use of WALANT can facilitate an effective plastic surgery trauma service during COVID-19. Most of the procedures were performed in the outpatient department setting, without the need for main operating theatres or anaesthetic support. All procedures were performed within 24 hours of initial presentation and were able to be discharged on the same day. In addition, patient satisfaction remained high and post-operative complications were minimal. We propose that the use of WALANT should continue and increase beyond the current pandemic.
Article
Purpose The annual high volume of carpal tunnel releases (CTRs) has a large financial impact on the health care system. Validating the cost drivers related to CTR in a large, diverse patient population may aid in developing cost reduction strategies to benefit health care systems. Methods Adult patients with carpal tunnel syndrome who underwent CTR were identified in the New York Statewide Planning and Research Cooperative System database from 2016 to 2017. The Statewide Planning and Research Cooperative System is a comprehensive all-payer database that collects all inpatient and outpatient preadjudicated claims in New York. A multivariable mixed model regression with random effects was performed for the facility to assess the variables that contributed significantly to the total charge. The variables included were patient age, sex, anesthesia method, whether the surgery took place in an ambulatory surgery center or a hospital outpatient department, operation time in minutes, primary insurance type, race, ethnicity, Charlson Comorbidity Index, and categories for billed procedure codes. Results During the period of 2016 to 2017, 8,717 claims were included, with a mean charge per claim of $4,865. General anesthesia was associated with higher charges than local anesthesia. A procedure at a hospital outpatient department was associated with an approximately 48.2% increase in the total charge compared with that at an ambulatory surgery center. A 1-minute increase in the operation time was associated with a 0.3% increase in the total charge. Claims with antiemetics, antihistamines, benzodiazepines, intravenous fluids, narcotic agents, or preoperative antibiotics were associated with higher total charges than claims that did not bill for these. Compared with endoscopic procedures, open procedures had a 44.3% decrease in the total charges. Conclusions This comprehensive multivariable model has validated that general anesthesia, hospital-based surgery, the use of antibiotics and opioids, longer operative times, and endoscopic CTR significantly increased the cost of surgery. Type of study/level of evidence Economic and decision analyses II.
Article
Purpose Wide-Awake Local Anesthetic No Tourniquet (WALANT) hand surgery avoids many medical risks associated with traditional anesthesia options. However, patients may be hesitant to choose the WALANT approach because of concerns about being awake during surgery. The purpose of this study was to characterize patients’ thoughts and concerns about being awake during hand surgery and determine factors that may affect their decision about anesthesia options. Methods Qualitative interviews were conducted with 15 patients with a diagnosis of carpal tunnel syndrome, trigger finger, or De Quervain’s tenosynovitis who were receiving nonoperative care. Interviews were conducted using a semi-structured interview guide. Inductive thematic analysis was used to identify themes, concerns, and potential intervention targets. Results Eight participants reported that patients have a general bias against being “knocked out,” 7 of whom described concerns of uncertainty about emerging from anesthesia. All participants would consider WALANT, with some reservations. Recurrent themes included ensuring they would not feel, see, or hear the surgery and a preference toward distractions, such as music or engaging conversation. Of 15 participants, 13 would not want to see the surgery. For patients who found WALANT appealing, they valued the decreased time investment compared to sedation and the avoidance of side effects or exacerbation of comorbidities. A recurring theme of trust between surgeon and patient arose when deciding about anesthesia type. Conclusions Most patients are open to WALANT, but have concerns of hearing the surgery or feeling pain. Potential interventions to address these concerns, beyond establishing a trusting physician-patient relationship, include music or video with headphones and confirming skin numbness prior to surgery. Clinical relevance This study provides insights into patients’ thought processes regarding WALANT hand surgery and give the surgeon talking points when counseling patients on their anesthesia type for hand surgery.
Article
Hypothesis: Wide awake local anesthesia with no tourniquet (WALANT) and office-based procedures are used in hand surgery. There are limited literature data on patient satisfaction when comparing methods of anesthesia and location of surgery. Methods: We conducted a retrospective single-surgeon study with patient reported satisfaction in three groups. We compared patient impressions of anesthesia type; WALANT vs loco regional anesthesia plus sedation. We also compared satisfaction in three surgery settings; office surgery vs hospital ambulatory minor procedure room vs. main operating room. Group 1 office surgery patients had ultrasound guided surgery with WALANT. Group 2 main operating room surgery patients also had ultrasound guided surgery with WALANT. Group 3 main operating room patients had endoscopic surgery with sedation and a tourniquet. Each group had 30 patients with a minimum follow up of 2 months. We measured overall satisfaction, satisfaction with the organization of care, satisfaction with the administration of anesthesia, and satisfaction with the quality of anesthesia. We also collected secondary data on the resolution of the neuropathic symptoms. Results: Procedures performed in an office-based setting showed higher rates of patient satisfaction when compared to the ambulatory day surgery setting. WALANT anesthesia also showed significantly higher rates of patient satisfaction on a numerical analog scale when compared to sedation based on, irrespective of the surgical setting. All patients had resolution of their neuropathic symptoms regardless of the technique performed. Conclusion: We found that carpal tunnel releases performed in an office-based setting produces superior patient satisfaction. WALANT anesthesia also provides improved patient satisfaction when compared to sedation and monitoring techniques, irrespective of the surgical setting and location. Carpal tunnel release with WALANT in an office-based setting is better for patient comfort and satisfaction, with no evidence of lesser clinical outcomes at a short term follow up. Level of evidence: III
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Background: There are several anesthetic techniques for surgical treatment of carpal tunnel syndrome (CTS). Results from this surgery using the "wide awake local anesthesia no tourniquet" (WALANT) technique have been described. However, there is no conclusive evidence regarding the effectiveness of the WALANT technique, compared with the usual techniques. Objective: To evaluate the effectiveness of the WALANT technique, compared with intravenous regional anesthesia (IVRA; Bier's block), for surgical treatment of CTS. Design and setting: Randomized clinical trial, conducted at Hospital Alvorada Moema and the Discipline of Hand Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil. Methods: Seventy-eight patients were included. The primary outcome was measurement of perioperative pain through a visual analogue scale (VAS). The secondary outcomes were the Boston Questionnaire score, Hospital Anxiety and Depression Scale (HADS) score, need for use of analgesics, operating room times, remission of paresthesia, failures and complications. Results: The WALANT technique (n = 40) proved to be superior to IVRA (n = 38), especially for controlling intraoperative pain (0.11 versus 3.7 cm; P < 0.001) and postoperative pain (0.6 versus 3.9 cm; P < 0.001). Patients spent more time in the operating room in the IVRA group (59.5 versus 46 minutes; P < 0.01) and needed to use more analgesics (10.8 versus 5.7 dipyrone tablets; P = 0.02). Five IVRA procedures failed (5 versus 0; P = 0.06). Conclusions: The WALANT technique is more effective than IVRA for CTS surgery.
Article
Virtual reality is an immersive experience that has been gaining acceptance in the field of medicine as a tool for reducing patient anxiety. We recently observed the effectiveness of this technology in wide-awake local anaesthesia no tourniquet (WALANT) surgeries. Here we report two cases of patients who used a virtual reality device during hand surgery using the WALANT technique. Both patients reported that the use of VR technology reduced their anxiety and improved their overall experience during surgery. This case report highlights the novel use of virtual reality during hand surgeries where the patients were awake. Based on these two cases, virtual reality may have the potential to reduce anxiety during the perioperative period and enhance a patient’s overall experience in WALANT surgeries.
Article
Background The optimal anesthesia modality for umbilical hernia repair is unclear. We hypothesized that using local rather than general anesthesia would be associated with improved outcomes, especially for frail patients. Methods We utilized the 1998-2018 Veterans Affairs Surgical Quality Improvement Program to identify patients who underwent elective, open umbilical hernia repair under general or local anesthesia. We used the Risk Analysis Index to measure frailty. Outcomes included complications and operative time. Results There were 4958 Veterans (13%) whose hernias were repaired under local anesthesia. Compared to general anesthesia, local was associated with a 12%-24% faster operative time for all patients, and an 86% lower (OR 0.14, 95%CI 0.03-0.72) complication rate for frail patients. Conclusions Local anesthesia may reduce the operative time for all patients and complications for frail patients having umbilical hernia repair.
Article
Background The use of minor field sterility in hand/upper extremity cases has been shown to improve workflow efficiency while maintaining patient safety. As this finding has been limited to specific procedures, we investigated the safety of performing a wide array of hand/upper extremity procedures outside the main operating room using minimal field sterility with Wide-Awake Local Anaesthesia No Tourniquet (WALANT) anaesthesia by evaluating superficial and deep infection rates across a diverse series of cases. Methods This study was a case series conducted between October 2017 and June 2020. Of all, 217 patients underwent hand/upper extremity procedures performed in a minor procedure room via WALANT technique with field sterility. Primary outcome measures include superficial and deep surgical site infections within 14 days post-surgery. Results Of all, 217 patients were included in this study; 265 consecutive hand/upper extremity operations were performed by a single surgeon, with notable case diversity. The majority of patients (n = 215, 99.1%) did not report or present with signs of infection before or after their operation. We report 0% 14-day and 0.37% 30-day surgical site infection rates for such hand/upper extremity procedures performed in a minor procedure room with field sterility. Conclusion Hand/upper extremity procedures performed via WALANT technique with field sterility in a minor procedure room are associated with low surgical site infection rates. These rates are comparable to surgical site infection rates for similar surgeries performed in main operating rooms with standard sterilization procedures. Thus, the implementation of this technique may allow for improved workflow efficiency and reduced waste, all while maintaining patient safety.
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The wide-awake local anesthesia with no tourniquet (WALANT) technique has become popularized for various hand/upper extremity procedures. Before surgery, patients receive local anesthetic, consisting of lidocaine with epinephrine, and remain awake for the entire procedure. The purpose of this review was to investigate the advantages, diverse application, outcomes, cost benefits, use in challenging environments, patient considerations, and contraindications associated with WALANT. Methods: A comprehensive review of the literature on the WALANT technique was conducted. Search terms included: WALANT, wide-awake surgery, no tourniquet, local anesthesia, hand, wrist, cost, and safety. Results: The WALANT technique has proven to be successful for common procedures such as flexor tendon repair, tendon transfer, trigger finger releases, Depuytren disease, and simple bony procedures. Recently, the use of WALANT has expanded to more extensive soft-tissue repair, fracture management, and bony manipulation. Advantages include negating preoperative evaluation and testing for anesthesia clearance, eliminating risk of monitored anesthesia care, removal of anesthesia providers and ancillary staff, significant cost savings, and less waste produced. Intraoperative evaluations can be performed through active patient participation, and postoperative recovery and monitoring time are reduced. WALANT is associated with high patient satisfaction rates and low infection rates. Conclusions: The WALANT technique has proven to be valuable to both patients and providers, optimizing patient satisfaction and providing substantial healthcare savings. As its application continues to grow, current literature suggests positive outcomes.
Article
PURPOSE : Recently, local anaesthesia has become popular among hand surgeons. We hypothesized that using the ‘’wide awake local anaesthesia, no tourniquet’’ (WALANT) approach would result in lower global costs and in an increase of the operating room's efficiency. METHODS : All cases of carpal tunnel and trigger finger releases performed over 2016 and 2017 were divided into four groups, following which anaesthesia method was used. Total operating room occupation time, surgical time and the ‘’all but surgery’’ time were analysed. A common minimal bill per anaesthesia was generated. RESULTS : WALANT or local anaesthesia & tourniquet increase the operating room's throughput by having shorter operation room occupation times than other methods (17.5-33%). Costs of the two procedures are reduced by 21-31% when using local anaesthesia methods. CONCLUSION : Preferring those techniques for carpal tunnel and trigger finger releases has a notable beneficial impact on the costs and on the operating room's efficiency. This effect is more evident on short surgical procedures. LOE : Level of evidence III, economic analysis.
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Purpose Carpal tunnel release (CTR) surgical costs are minimized when performed in the procedure room (PR) setting, compared with the operating room. However, it remains unclear whether outcomes differ between surgical settings. Our purpose was to compare outcomes at 1 year or greater follow-up after open CTR between patients treated in PR versus operating room settings using the Boston Carpal Tunnel Questionnaire (BCTQ). Methods A change in clinical care protocols at our institution occurred in 2014. Before this, all CTRs were performed in the operating room; thereafter, these were transitioned to the PR. Adult patients who underwent isolated unilateral or bilateral open CTR in either surgical setting were considered for inclusion, in which procedures were conducted between January 2014 and October 2018 for the PR group and January 2009 and March 2014 for the operating room group. The Functional Status Scale (FSS) and the Symptom Severity Scale (SSS) components of the BCTQ were collected for all eligible patients at a minimum of 1 year after surgery. We used univariate and multivariable linear regression to determine whether postoperative BCTQ scores were equivalent between PR and operating room groups within a threshold of one-fourth of the lowest estimates of the minimal clinically important difference. Results No differences in demographics, comorbidities, or insurance type were observed between the 104 PR and 112 operating room patients. Survey response rate was 25% and 25% for the PR and operating room patients, respectively. At a mean follow-up of 3 ± 1 years, FSS and SSS scores were equivalent between PR and operating room groups on bivariate analysis. The multivariable equivalence test also demonstrated equivalent FSS and SSS scores between PR and operating room groups within a one-fourth minimal clinically important difference threshold while controlling for age, sex, presence of diabetes or thyroid disease, unilateral versus bilateral CTR, and surgeon. Conclusions Clinical outcomes did not differ between PR and operating room settings after open CTR. Type of study/level of evidence Therapeutic III.
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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.
Article
Purpose: The goal of this study was to determine whether the type of anesthesia (monitored anesthesia care [MAC] vs wide-awake local anesthesia no tourniquet technique [WALANT]) or the surgical technique (mini-open vs endoscopic) would affect patient satisfaction with postoperative pain control, postoperative pain, or opioid use after carpal tunnel release (CTR). The hypothesis was that endoscopic and open CTR surgery would have the same patient satisfaction with postoperative pain control, postoperative pain, and opioid use, but WALANT surgery would have higher patient satisfaction with postoperative pain control, postoperative pain, and opioid use than MAC. Methods: This prospective study examined all patients undergoing carpal tunnel surgery by 4 hand surgeons at our institution. Two surgeons perform primarily 1-incision endoscopic CTR and the other 2 perform mini-open CTR. Two surgeons perform all procedures under WALANT; the other 2 employ MAC with a local anesthetic. Postsurgical questionnaires were completed at the 2-week postoperative visit. Patients reported remaining pills, average pain, highest pain, lowest pain, and overall satisfaction with postoperative pain control. Results: A total of 93 patients underwent CTR by the 4 participating hand surgeons. Of these, 43 underwent open CTR and 50 underwent endoscopic CTR. Sixty-two were performed under MAC and 31 with WALANT. With regard to anesthesia type, overall there was 5.5 mean morphine equivalents (MME) less prescribed and an average of 3.6 MME more remaining on the first postoperative visit with WALANT compared with MAC. Patient satisfaction with postoperative pain control was an average score of 7.9 for MAC and 7.4 for WALANT. With regard to surgical technique, overall, there was 15.2 MME less prescribed and an average of 1.03 MME more remaining on the first postoperative visit with endoscopic CTR compared with open CTR. Patient satisfaction with postoperative pain control between endoscopic and open release demonstrated an average score of 7.1 and 8.0, respectively. Conclusions: This study demonstrates minimal differences in opioid pain medication use, patient satisfaction with postoperative pain control, and pain scores in a comparison of surgical technique as well as anesthesia type. Type of study/level of evidence: Therapeutic IV.
Article
Hand and upper extremity surgery performed with the patient wide awake involves the use of a local anesthetic and epinephrine. Controversy persists as to whether epinephrine is safe for use in the hand. The goal of this study was to evaluate the safety of epinephrine in hand and upper extremity surgery. The hypothesis was that epinephrine is safe and can be used for a wide breadth of surgical procedures of the hand and upper extremity. A 4-year retrospective chart review was conducted of consecutive patients undergoing wide-awake surgery performed by 2 surgeons at a single institution. All procedures were performed with local anesthesia and epinephrine. Data collected included patient demographics, procedure volume, procedure type, surgical setting, and complications related to epinephrine use. During the study period, 4054 consecutive patients underwent 4287 wide-awake procedures with local anesthesia and epinephrine. Average patient age was 59 years, and 64% of patients were female. No complications occurred as a result of the use of epinephrine, and no tissue necrosis, phentolamine reversal, anaphylaxis, or readmissions occurred. No patients required conversion to general anesthesia or monitored anesthesia care. This analysis of more than 4000 consecutive patients undergoing wide-awake hand and upper extremity surgery with epinephrine confirmed that epinephrine use is safe, with no reported cases of tissue necrosis, reversal, readmission, anaphylaxis, or anesthetic conversion. Epinephrine is safe for use in the hand and upper extremity for patients undergoing wide-awake hand surgery with a local anesthetic. [Orthopedics. 2020;43(6):e529-e532.].
Article
Background: Pediatric outcomes after flexor tendon repairs are variable, and evidence in the literature remains scarce. Methods: Repair of pediatric flexor tendon injuries was reviewed over a 10-year period (2005-2015). Data collection consisted of patient demographics, injury characteristics, anesthetic choice, repair technique, rehabilitation protocol, American Society for Surgery of the Hand Total Active Motion (TAM) scores, and complications. Results: There were 109 patients included in our study, with a total of 162 digits injured and 235 flexor tendon injuries. The mean age was 12 ± 4.6 years. The small finger (48 of 162; 30%) and the flexor digitorum profundus tendon (126 of 235) were the most commonly injured. The mechanism of injury was mainly from a knife (46 of 109; 42.2%) in zone II (82 of 159; 52%). Injuries were mostly repaired under general anesthetic (61 of 104; 56%). The Kessler technique was the predominant repair mechanism (111 of 225 repairs; 49%). Most patients (103 of 109; 95%) had excellent or good TAM scores with 5 postoperative ruptures reported. The most common complication was stiffness (17 of 121 complications; 14%), with most patients having no complications ( 74 of 109 patients; 68%). Patients were commonly immobilized (mean 8.4 ± 10.3 weeks) with a splint (93 of 109; 85%). There were 85 patients who followed a postoperative rehabilitation protocol for 12 ± 18 weeks. Patient demographics, time of repair, injury characteristics, anesthetic choice, and rehabilitation protocol were not significantly correlated with TAM scores or complication rates. Conclusions: Pediatric tendon injuries have good outcomes with no predictive factors identified. Surgical repairs performed under local anesthetic have similar outcomes without increased rates of complications, but remain underused in the pediatric population.
Article
Introduction Wide awake open carpal tunnel decompression is a procedure performed under local anesthesia. This study aimed to present the effect of various local anesthetics in peri and postoperative analgesia in patients undergoing this procedure. Materials and Methods A total of 140 patients, with 150 hands involved, underwent carpal tunnel release under local anesthesia. Patients were divided in five groups according to local anesthetic administered: lidocaine 2%, ropivacaine 0.75%, ropivacaine 0.375%, chirocaine 0.5%, and chirocaine 0.25%. Total 400 mg of gabapentin were administered to a subgroup of 10 cases from each group (50 cases totally), 12 hours before surgery. Patients were evaluated immediately, 2 weeks and 2 months after surgery according to VAS pain score, grip strength, and two-point discrimination. Results In all patients, pain and paresthesia improved significantly postoperatively, while the use of gabapentin did not affect outcomes. Grip strength recovered and exceeded the preoperative value 2 months after surgery, without any difference between the groups. No case of infection, hematoma, or revision surgery was reported. Conclusion Recovery after open carpal tunnel release appears to be irrelevant of the type of local anesthetic used during the procedure. Solutions of low local anesthetic concentration (lidocaine 2%, ropivacaine 0.375%, and chirocaine 0.25%) provide adequate intraoperative analgesia without affecting the postoperative course.
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Tendon surgery is unique because it should ensure tendon gliding after surgery. Tendon surgery now can be performed under local anesthesia without tourniquet, by injecting epinephrine mixed with lidocaine, to achieve vasoconstriction in the area of surgery. This method allows the tendon to move actively during surgery to test tendon function intraoperatively and to ensure the tendon is properly repaired before leaving the operating table. I applied this method to primary flexor tendon repair in zone 1 or 2, tenolysis, and tendon transfer, and found this approach makes tendon surgery easier and more reliable. This article describes the method that I have used for tendon surgery.
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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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Among the many advances in local anesthesia of the hand, some of the most significant changes in the last 5 years have been the following: (1) the acceptance of safety of locally infiltrated epinephrine with lidocaine for hemostasis, which has removed the need for sedation, brachial plexus blocks, and general anesthesia for most common hand surgery operations and minor hand trauma. (2) The elimination of the 2 injection finger block technique in favor of the single injection palmar block. (3) Local anesthesia can now be consistently injected in the hand with minimal pain. (4) Liposomal release of local anesthetic after injection into the surgical site can provide pain control up to 3 days. This article reviews the impact and best evidence related to these changes.
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With advancement in biomechanical and biological research on idiopathic carpal tunnel syndrome, the insight on the pathophysiology of carpal tunnel syndrome has gained much clinical relevance. Open carpal tunnel release is still a gold standard procedure for carpal tunnel syndrome, which has evolved into mini-open procedure with development of new devices. Endoscopic carpal tunnel release has become popular in recent practice of hand surgery with an advantage of early recovery of hand function with minimal morbidity. However, endoscopic carpal tunnel release has its own limitation such as long learning curve with obvious surgical risk reported in the literature. In this review article, various treatment protocols for idiopathic carpal tunnel syndrome are presented with special highlight on endoscopic carpal tunnel release, which is gaining popularity in current practice.
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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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The wide-awake hand surgery (WAHS) technique involves injecting lidocaine with adrenaline for hand surgical procedures that are done without the use of tourniquets, sedation, regional or general anaesthetic. This is a retrospective review of the first 100 consecutive patients who underwent operations using this technique at our centre. The operations included carpal and cubital tunnel decompression, trapeziectomy, tendon transfer, and tenolysis. A questionnaire adapted from Lalonde's previous work on wide-awake surgery was used to assess patients' experiences. Sixty-five percent of the patients responded to the postal questionnaire, the majority reporting a high satisfaction level. Ninety-one percent of responders reported that the operation was less painful or comparable with a procedure at the dentist; 86% would prefer to be wide-awake if they needed to have hand surgery again, and 90% stated they would recommend WAHS to a friend.
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Untreated, one third of patients who undergo surgery will have postoperative nausea and vomiting. Although many trials have been conducted, the relative benefits of prophylactic antiemetic interventions given alone or in combination remain unknown. We enrolled 5199 patients at high risk for postoperative nausea and vomiting in a randomized, controlled trial of factorial design that was powered to evaluate interactions among as many as three antiemetic interventions. Of these patients, 4123 were randomly assigned to 1 of 64 possible combinations of six prophylactic interventions: 4 mg of ondansetron or no ondansetron; 4 mg of dexamethasone or no dexamethasone; 1.25 mg of droperidol or no droperidol; propofol or a volatile anesthetic; nitrogen or nitrous oxide; and remifentanil or fentanyl. The remaining patients were randomly assigned with respect to the first four interventions. The primary outcome was nausea and vomiting within 24 hours after surgery, which was evaluated blindly. Ondansetron, dexamethasone, and droperidol each reduced the risk of postoperative nausea and vomiting by about 26 percent. Propofol reduced the risk by 19 percent, and nitrogen by 12 percent; the risk reduction with both of these agents (i.e., total intravenous anesthesia) was thus similar to that observed with each of the antiemetics. All the interventions acted independently of one another and independently of the patients' baseline risk. Consequently, the relative risks associated with the combined interventions could be estimated by multiplying the relative risks associated with each intervention. Absolute risk reduction, though, was a critical function of patients' baseline risk. Because antiemetic interventions are similarly effective and act independently, the safest or least expensive should be used first. Prophylaxis is rarely warranted in low-risk patients, moderate-risk patients may benefit from a single intervention, and multiple interventions should be reserved for high-risk patients.
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The literature generally supports the safety of epinephrine injection in the digits, but recent case reports describe ischemic adverse events associated with the use of lidocaine and epinephrine in which phentolamine rescue was not performed. We present a case of finger necrosis and subsequent amputation in a patient after 1% lidocaine with 1:100,000 epinephrine was injected in the fat and flexor sheaths in the palm for a 3-finger trigger release. Phentolamine rescue was not performed. All surgeons who use epinephrine in the finger should be prepared to reverse vasoconstriction with phentolamine rescue if there is persistently inadequate perfusion of the fingertip.
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Background: There has been recent interest in wide awake hand surgery, also referred to as "wide awake local anesthesia with no tourniquet" (WALANT) surgery. Using a model of single trigger finger release (TFR) surgery, a hypothesis was made that WALANT would result in decreased hospital time and cost than patients receiving sedation with monitored anesthetic care (MAC). Methods: Consecutive cases of single TFR surgery with MAC were compared with WALANT. All surgeries were performed in the same manner, at the same facility, and by the same surgeon. Total operating room (OR) time, surgical time, recovery time, and anesthesia costs were analyzed. Results: There were 78 patients: 31 MAC and 47 WALANT. The MAC group averaged 27.2 minutes of OR time; the WALANT group averaged 25.2 minutes. The MAC group surgical time was 10.2 minutes versus WALANT of 10.4 minutes. Post-operatively, the MAC group averaged 72.3 minutes in the recovery room compared with WALANT group of 30.2 minutes. Each case performed under MAC had a minimum of excess charges from anesthesia of approximately $105. Conclusions: Patients undergoing single TFR surgery under WALANT trended toward less time in the OR, had similar surgical times, and spent significantly less time in the recovery room, compared with MAC, thereby resulting in less indirect costs. Each MAC case also had minimum direct excess anesthesia charges of $105, which knowingly underestimates overall charges as it excludes material and fixed costs associated with the delivery of anesthesia. Avoiding sedation for high-volume procedures such as TFR may result in significant systemic savings to payers, and in the future with bundling and episode-based payments can become increasingly important to patients, facilities, and surgeons.
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The aim of this study was to evaluate the cost of an operating room using data from our hospital. Using an accounting-based method helped us. Over the year 2012, the sum of direct and indirect expenses with cost sharing expenses allowed us to calculate the cost of the operating room (OR) and of the post-anaesthesia care unit (PACU). The cost of the OR and PACU was €10.8 per minute of time offered. Two thirds of the direct expenses were allocated to surgery and one third to anaesthesia. Indirect expenses were 25% of the direct expenses. The cost of medications and single use medical devises was €111.45 per anaesthesia. The total cost of anaesthesia (taking into account wages and indirect expenses) was €753.14 per anaesthesia as compared to the total cost of the anaesthesia. The part of medications and single use devices for anaesthesia was 14.8% of the total cost. Despite the difficulties facing cost evaluation, this model of calculation, assisted by the cost accounting controller, helped us to have a concrete financial vision. It also shows that a global reflexion is necessary during financial decision-making. Copyright © 2015 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.
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Modern anesthetic agents have allowed for the rapid expansion of ambulatory surgery, particularly in hand surgery. The choice between general anesthesia, peripheral regional blocks, regional intravenous anesthesia (Bier block), local block with sedation, and the recently popularized wide-awake hand surgery depends on several variables, including the type and duration of the procedure and patient characteristics, coexisting conditions, location, and expected length of the procedure. This article discusses the various perioperative and postoperative analgesic options to optimize the hand surgical patients' experience. Copyright © 2015 Elsevier Inc. All rights reserved.
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This article provides video and narration to describe the technical details of how to inject local anesthesia and perform the extensor indicis proprius to extensor pollicis longus tendon transfer in patients with wide-awake local anesthesia and no tourniquet. Lidocaine for anesthesia and epinephrine for hemostasis are the only 2 medications given to the patient. Sedation and the tourniquet are not required. Wide-awake patients are comfortable, cooperative, and educable, and are able to help the surgeon set the correct tension for the transfer. They flex and extend the thumb before the skin is closed to make sure the transfer is not too tight or too loose. It helps that they remember seeing the thumb move nicely during the surgery when they are in postoperative hand therapy.
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Purpose To evaluate the time to onset of anesthesia, duration of anesthesia, and pain on injection of local anesthetics. Methods A systematic search of the English literature was performed of the Medline, Cochrane Central Register of Controlled Trials, The Allied and Complementary Medicine Database (AMED), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. The study selection process was adapted from the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement, and 6 articles were complied with the study inclusion criteria. Results Six studies (335 nerve blocks) were included in our final analysis measuring 6 local anesthetic preparations (lidocaine, lidocaine with epinephrine, bupivacaine, bupivacaine with epinephrine, lidocaine with bupivacaine, and ropivacaine). Lidocaine demonstrated the shortest mean onset of anesthesia (3 1 min) and bupivacaine the longest (7.6 min). Lidocaine also demonstrated the shortest mean duration of anesthesia (1.8 h) and ropivacaine the longest mean duration (21.5 h). Lidocaine with epinephrine demonstrated the least mean pain on injection (26 mm on a visual analog scale) and bupivacaine with epinephrine the most mean pain (53 mm). Conclusions Lidocaine with epinephrine provides a good short-term anesthesia and may reduce the risk of injury or complication while the finger in still anesthetized. Bupivacaine with lidocaine provides good long-term anesthesia and may reduce the need for postprocedural anesthesia. Ropivacaine likely provides the longest duration of anesthesia but the absence of epinephrine means a tourniquet must be used to create a bloodless field and thus is contraindicated in some procedures such as flexor tendon repairs where active testing may be required. (Copyright (C) 2014 by the American Society for Surgery of the Hand. All rights reserved.)
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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 purpose of this study was to provide prospective independently analyzed evidence on how patients feel about a carpal tunnel release (CTR) performed under local anesthesia only (no sedation or tourniquet) versus with local anesthesia, intravenous (IV) sedation, and a tourniquet. Methods This prospective cohort study compared 100 consecutive CTRs done with only lidocaine and epinephrine in Saint John, New Brunswick to 100 consecutive CTRs done with IV sedation in Davenport, Iowa. Patient perspectives on the anesthesia were captured in a blinded questionnaire 1 week postoperatively. Results For subsequent surgery, 93 % of wide awake patients would choose local anesthesia only and 93 % of sedated patients would choose sedation. Wide awake patients spent less time at the hospital (M = 2.6 h) than sedated patients (M = 4.0 h; p < .001). Preoperative blood work, electrocardiograms, and/or chest radiographs were done for 3 % of wide awake patients and 48 % of sedated patients (p < 0.001). Preoperative anxiety levels for wide awake patients were lower than for sedated patients (p = 0.007); postoperative anxiety was similar. There were no anesthesia complications in either group. Narcotics were used by 5 % of unsedated patients and 67 % of sedated patients (p < 0.001). Adequate pain control was reported by 89 % and 90 % of patients, respectively. Conclusions The majority of patients from both cohorts liked whichever method of anesthesia they received and would choose it again. However, sedated patients spent more time at the hospital, required more preoperative testing, and reported greater preoperative anxiety.
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At the Dalhousie Plastic Surgery Alumni Reunion at the Atlantic Plastic Surgery meeting in Halifax, Nova Scotia, in September 2001, 22 subjects, including 18 certified hand surgeons, were injected with 1.8 mL of 2% lidocaine with 1:100,000 adrenaline in three places in one finger of each hand. One hour later, the same sites of one hand were injected with phentolamine (1 mg in 1 mL), and the other hand was injected with saline. Subjects were blinded as to which hand received the phentolamine. It took an average of 85 min for the adrenaline-injected fingers to return to normal colour after phentolamine injection. It took an average of 320 min for the adrenaline-injected fingers to return to normal colour after saline injection (no phentolamine). We also observed that lidocaine with adrenaline provided an average of 549 min of anesthesia in nonphentolamine-injected fingers. Phentolamine consistently and reliably reversed adrenaline-induced vasoconstriction in the finger.
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Traditionally, surgeons were taught that local anesthesia containing epinephrine should not be injected into fingers. This idea has since been refuted in many basic and clinical scientific studies, and today, injection of lidocaine plus epinephrine is widely used for digital and hand anesthesia in Canada. The key advantages of the wide-awake technique include the creation of a bloodless field without the use of an arm tourniquet, which in turn reduces the need for conscious sedation. The use of local anesthesia permits active motion intraoperatively, which is particularly helpful in tenolysis, flexor tendon repairs, and setting the tension on tendon transfers. Additional benefits of wide-awake anesthesia include efficiencies and cost savings in outpatient surgical case flow due to the absence of conscious sedation.
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In an era of growing economic constraints on healthcare delivery, anesthesiologists are increasingly expected to understand cost analysis and evaluate clinical practices. Postoperative nausea and vomiting (PONV) are distressing for patients and may increase costs in an ambulatory surgical unit. The authors compared the cost-effectiveness of four prophylactic intravenous regimens for PONV: 4 mg ondansetron, 0.625 mg droperidol, 1.25 mg droperidol, and placebo. Adult surgical outpatients at high risk for PONV were studied. Study drugs were administered intravenously within 20 min of induction of nitrous oxide-isoflurane or enflurane anesthesia. A decision-tree analysis was used to group patients into 12 mutually exclusive subgroups based on treatment and outcome. Costs were calculated for the prevention and treatment of PONV. Cost-effectiveness analysis was performed for each group. Two thousand sixty-one patients were enrolled. Efficacy data for study drugs have been previously reported, and the database from that study was used for pharmacoeconomic analysis. The mean-median total cost per patient who received prophylactic treatment with 4 mg ondansetron, 0.625 mg droperidol, 1.25 mg droperidol, and placebo were $112 or $16.44, $109 or $0.63, $104 or $0.51, and $164 or $51.20, respectively (P = 0.001, active treatment groups vs. placebo). The use of a prophylactic antiemetic agent significantly increased patient satisfaction (P < 0.05). Personnel costs in managing PONV and unexpected hospital admission constitute major cost components in our analysis. Exclusion of nursing labor costs from the calculation did not alter the overall conclusions regarding the relative costs of antiemetic therapy. The use of prophylactic antiemetic therapy in high-risk ambulatory surgical patients was more effective in preventing PONV and achieved greater patient satisfaction at a lower cost compared with placebo. The use of 1.25 mg droperidol intravenously was associated with greater effectiveness, lower costs, and similar patient satisfaction compared with 0.625 mg droperidol intravenously and 4 mg ondansetron intravenously.
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Population-based epidemiologic studies have uncovered the high prevalence and wide severity spectrum of undiagnosed obstructive sleep apnea, and have consistently found that even mild obstructive sleep apnea is associated with significant morbidity. Evidence from methodologically strong cohort studies indicates that undiagnosed obstructive sleep apnea, with or without symptoms, is independently associated with increased likelihood of hypertension, cardiovascular disease, stroke, daytime sleepiness, motor vehicle accidents, and diminished quality of life. Strategies to decrease the high prevalence and associated morbidity of obstructive sleep apnea are critically needed. The reduction or elimination of risk factors through public health initiatives with clinical support holds promise. Potentially modifiable risk factors considered in this review include overweight and obesity, alcohol, smoking, nasal congestion, and estrogen depletion in menopause. Data suggest that obstructive sleep apnea is associated with all these factors, but at present the only intervention strategy supported with adequate evidence is weight loss. A focus on weight control is especially important given the expanding epidemic of overweight and obesity in the United States. Primary care providers will be central to clinical approaches for addressing the burden and the development of cost-effective case-finding strategies and feasible treatment for mild obstructive sleep apnea warrants high priority.