Wide-awake hand surgery may be safe, yield high patient satisfaction
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Published results showed wide-awake local anesthesia with no tourniquet hand surgery performed in an in-office procedure room may be safe, cost effective and have a high patient satisfaction.
“Patient safety is not an issue [with wide-awake local anesthesia with no tourniquet surgery],” Robert E. Van Demark Jr., MD, told Healio. “In our study group, there were no deep infections. There were no major complications and none of the cases were terminated.”
Van Demark and colleagues surveyed the first 1,011 patients who underwent elective wide-awake local anesthesia with no tourniquet hand surgery in an in-office procedure room regarding their satisfaction and monitored patients for postoperative complications. Researchers also analyzed patient survey results and complications.
Results showed the most common procedure performed was single-digit trigger finger release followed by mass excision, multiple-digit trigger finger releases and carpal tunnel release. Researchers found 4.3% of patients had superficial skin infections, with the majority of skin infections identified in single-digit trigger finger release. However, researchers also noted no deep wound infections, and all infections were managed nonsurgically with oral antibiotics and local wound care.
Overall, 99% of patients rated the in-office procedure room experience as the same as or better than a dental visit, according to results. Researchers noted that patients also reported they would recommend wide-awake anesthesia to a friend or family member and would undergo the procedure again.
“The convenience of wide-awake surgery is probably the big patient satisfier,” Van Demark said. “Patients do not have to undress and put on a gown. They stay dressed for the surgery. Since there is no tourniquet, there is no need for an IV and sedation. Since there is no need to be [nothing by mouth], patients can have breakfast before surgery. As a result, patients can continue their regular medications, including insulin and anticoagulants.”
To decrease surgical waste in minor field sterility procedures, researchers noted “lean and green” hand packs were created at the institution prior to the inception of this study. Researchers found their institution saved more than $65,000 and saved 18.4 tons of waste during the study period with the use of “lean and green” hand packs.
“Along with this direct cost savings, there is another potential large cost savings,” Van Demark said. “Since the cases are done with local anesthesia, there is no need for a preoperative physical, including a chest X-ray, [electrocardiogram] and preoperative labs. The other unknown cost savings is that no one needs to take a day from work to take an elderly patient to a preoperative physical.”
Perspective
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Kelly N. McKnight, MD, and colleagues present their experience performing their first 1,011 hand surgery cases in an office-based procedure room using the WALANT, or “Wide Awake Local Anesthesia No Tourniquet,” technique. This technique of hand surgery, which leverages the use of lidocaine with epinephrine thereby foregoing the need for a tourniquet and sedation, is growing in popularity and utilization in light of its advantages of convenience, efficiencies, avoiding anesthetic complications, cost savings for the patient and surgeon, and less waste production. Several studies to date have already confirmed its safety and efficacy, particularly that epinephrine is safe in the use of the hand. McKnight and colleagues confirm these findings and moreover demonstrate a high level of patient satisfaction with a low complication rate. As the cost of care climbs, surgeon reimbursements keep decreasing and the difficulties of accessing surgical facilities persists, it can be anticipated that the use of WALANT hand surgery will justifiably grow, particularly in the office setting. Fortunately, evidence put forth by McKnight and colleagues and other researchers support this shift in an evidenced-based manner.
References:
Ilyas AM, et al. Orthopedics. 2020;doi:10.3928/01477447-20200827-03.
Lalonde D, et al. J Hand Surg Am. 2005;doi:10.1016/j.jhsa.2005.05.006.
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