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      Tumescent Local Anesthesia for Hand Surgery: Improved Results, Cost Effectiveness, and Wide-Awake Patient Satisfaction

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          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          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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          Epinephrine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia.

          Donald Lalonde, Alison Martin (2013)
          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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            A detailed cost and efficiency analysis of performing carpal tunnel surgery in the main operating room versus the ambulatory setting in Canada.

            F Lalonde, Janice Lalonde, M. LeBlanc (2007)
            Our goals were to analyze cost and efficiency of performing carpal tunnel release (CTR) in the main operating room (OR) versus the ambulatory setting, and to document the venue of carpal tunnel surgery practices by plastic surgeons in Canada. A detailed analysis of the salaries of nonphysician personnel and materials involved in CTR performed in these settings was tabulated. Hospital statistical records were used to calculate our efficiency analysis. A survey of practicing plastic surgeons in Canada documented the venue of CTR performed by most. In a 3-h surgical block, we are able to perform nine CTRs in the ambulatory setting versus four in the main OR. The cost of CTR in the ambulatory setting is $36/case and $137/case in the main OR in the same hospital. Only 18% of Canadian respondents use the main OR exclusively for CTR, whereas 63% use it for some of their cases. The ambulatory setting is used exclusively by 37%, whereas 69% use it for greater than 95% of their cases. The majority of CTR cases (>95%) are done without an anesthesia provider by 73% of surgeons. Forty-three percent use epinephrine routinely with local anesthesia and 43% avoid the use of a tourniquet for at least some cases by using epinephrine for hemostasis. The use of the main OR for CTR is almost four times as expensive, and less than half as efficient as in an ambulatory setting. In spite of this, many surgeons in Canada continue to use the more expensive, less efficient venue of the main OR for CTR.
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              A critical look at the evidence for and against elective epinephrine use in the finger.

              F Lalonde, Anton Feicht, David J. S. Roberts … (2006)
              Medical texts continue to perpetuate the belief that epinephrine should not be injected in fingers. Little attention has been paid to analyze the evidence that created this belief to see whether it is valid. The significance is that elective epinephrine finger injection has been shown to remove the need for a tourniquet, and therefore delete sedation and general anesthesia for much of hand surgery. All of the evidence for the antiadrenaline dogma comes from 21 mostly pre-1950 case reports of finger ischemia associated with procaine and cocaine injection with epinephrine. The authors performed an in-depth analysis of those 21 cases to determine their validity as evidence. They also examined in detail all of the other evidence in the literature surrounding issues of safety with procaine, lidocaine, and epinephrine injection in the finger. The adrenaline digital infarction cases that created the dogma are invalid evidence because they were also injected with either procaine or cocaine, which were both known to cause digital infarction on their own at that time, and none of the 21 adrenaline infarction cases had an attempt at phentolamine rescue. The evidence that created the dogma that adrenaline should not be injected into the fingers is clearly not valid. However, there is considerable valid evidence in the literature that supports the tenet that properly used adrenaline in the fingers is safe, and that it removes the need for a tourniquet and therefore removes the need for sedation and general anesthesia for many hand operations.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Arch Plast Surg
                Journal ID (iso-abbrev): Arch Plast Surg
                Journal ID (publisher-id): APS
                Title: Archives of Plastic Surgery
                Publisher: The Korean Society of Plastic and Reconstructive Surgeons
                ISSN (Print): 2234-6163
                ISSN (Electronic): 2234-6171
                Publication date (Print): July 2014
                Publication date (Electronic): 15 July 2014
                Volume: 41
                Issue: 4
                Pages: 312-316
                Affiliations
                Department of Surgery, Dalhousie University, Saint John, NB, Canada.
                Author notes
                Correspondence: Donald Lalonde. Department of Surgery, Dalhousie University, Hilyard Place, Suite C204, 600 Main Street, Saint John, NB E2K 1J5, Canada. Tel: +1-506-648-7950, Fax: +1-506-652-8042, drdonlalonde@ 123456nb.aibn.com
                Article
                DOI: 10.5999/aps.2014.41.4.312
                PMC ID: 4113687
                PubMed ID: 25075350
                SO-VID: 8e173c83-4489-4c39-b0fd-130d275f2b64
                Copyright © Copyright © 2014 The Korean Society of Plastic and Reconstructive Surgeons
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 05 August 2013
                Date revision received : 08 September 2013
                Date accepted : 08 September 2013
                Categories
                Subject: Review Article

                ScienceOpen disciplines: Surgery
                Keywords: epinephrine,local anesthesia,tourniquet
                Data availability:
                ScienceOpen disciplines: Surgery
                Keywords: epinephrine, local anesthesia, tourniquet

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