The Many Benefits of Wide-Awake Hand Surgery

No sedation, no IVs and no tourniquets are just a few advantages of this transformative surgical approach.

It’s fitting that wide-awake hand surgery, a surgical approach so simple it’s considered a patient experience as ordinary as a dental appointment, has gained steam by picking up on a technique that dentists have used for decades.

Just as dentists use epinephrine to control bleeding, hand surgeons now do the same in conjunction with the local anesthetic lidocaine. The combination results in an innovative anesthesia technique that could revolutionize how hand procedures such as trigger finger surgeries, carpal tunnel releases, tendinitis procedures and a variety of bump removals are performed.

Many patients now ask for WALANT (wide-awake/local anesthesia/no tourniquet) surgical care, as the idea of not needing to get a bevy of preoperative tests, fast the night before, temporarily stop taking blood thinners and other medications, along with the ability to get home without the escort of a friend or relative, is extremely appealing to them.

Multiple studies have eased physicians’ safety concerns about using epinephrine to extend the effects of lidocaine during hand and wrist procedures. The fear was that epinephrine (adrenaline) in the hands could cause digital ischemia. Now that such resistance has waned, health systems that must now innovate to increase efficiency are looking to use the lidocaine-epinephrine combination more frequently, says Jacques Hacquebord, MD, chief of hand and wrist surgery at NYU Langone Orthopedics in New York City. In addition to soft tissue repairs, fracture repairs in the hand are now performed on a wide-awake basis, as are procedures on the wrist and forearm.

“For a long time, healthcare systems didn’t have to be very efficient,” says Dr. Hacquebord. “Now that there’s a greater need for greater efficiency, we were driven to innovate. I think wide-awake hand surgery is an example of that.”

A nearly bloodless field

Epinephrine is a vasoconstrictor, so in addition to prolonging lidocaine’s effect, it also helps to control the amount of blood in the surgical field. Arm tourniquets can be painful, notes Dr. Hacquebord, because of the pressure they cause. Medication is sometimes needed pre- or intraoperatively for patients to tolerate it.

Once the concern that combining epinephrine and lidocaine was potentially dangerous was deemed incorrect, the next hurdle was surgeon comfort in performing hand surgeries without a tourniquet. As Lana Kang, MD, explains, the cocktail doesn’t remove as much blood from the field as a torniquet does. Some physicians are hesitant to make the conversion because the epinephrine doesn’t completely recreate a tourniquet-like bloodless surgery.

“It comes down to the comfort level of the surgeon,” says Dr. Kang, a hand and upper extremity surgeon at Hospital for Special Surgery in New York City. “You need to have the patience to let the cocktail kick in to start the procedure, as opposed to using a tourniquet and not having to worry about time.” Dr. Kang adds that some say that efficiency can be improved by injecting the anesthetic in the pre-op area so the patient and the OR team aren’t waiting for the cocktail to kick in the OR.

Staff education is important before launching a wide-awake surgery protocol. Some pre-op nurses are often concerned about how much patient monitoring is needed after the surgeon administers the injection.

“There can be a lot of resistance when there is a misconception about the injection of this local anesthetic being as potentially dangerous as a spinal anesthetic that could ascend to a different level of the spinal cord, or a regional block,” says Dr. Hacquebord. “This injection isn’t that invasive. It’s not given near any neurovascular structures. It’s safe, and no monitoring is required.”

Better for the patient

INSTA-REACTIONS Patients can give feedback during wide-awake procedures that helps surgeons know the correction is going as planned.

A wide-awake surgery program increases the patient pool because almost everyone can receive it since there’s no sedation or general anesthesia involved. Even a person with a cardiac history doesn’t need to undergo any preoperative tests for this reason.

“These surgeries involve the patient laying on the bed for about 15 minutes,” explains Dr. Hacquebord. “If a patient is able to do that and tolerate being conscious with no anxiety, then almost every patient can have a wide-awake surgery.”

The patient’s time in the OR or procedure room is much shorter than if they had received general anesthesia or sedation. They don’t need to fast the night before, can arrive about 30 minutes before the procedure and often can have it done in their street clothes. Most discharges take place about 20 minutes after the procedure.

“It’s possible for patients to be there for less than an hour in total,” says Dr. Hacquebord. “It’s much easier to fit this kind of procedure into your day and you don’t need anyone to pick you up afterward, although you probably shouldn’t drive yourself home since it’s a hand procedure.”

The experience is similar to leaving a dental office when your mouth is simply numb for a few hours. There’s no grogginess and none of the hemodynamic effects that sedation and general anesthesia can cause. Also, there is less swelling and bruising using the wide-awake method, so patients are in less pain and don’t’ need any postoperative narcotics.

Superior outcomes

Perhaps the greatest benefit of wide-awake surgery is that surgeons and patients can speak with each other as the work is being done. Surgeons can ask patients to move their hands to test whether their movement is optimal, which helps the physicians know they’ve made the proper corrections.

“If you fix a tendon and the patient is awake, they can bend their finger to test how strong the repair is,” says Dr. Kang. “That’s hugely beneficial. You can’t get that real-time proof when someone is under traditional anesthesia.”

It’s also important to select patients who won’t be anxious because they’re awake to the point where they could become disruptive. This process involves educating the patient prior to surgery, including preparing them for rare events such as the discovery during surgery that perhaps a larger surgical fix is required because the problem was bigger than originally thought.

“The fact is that the vast majority of patients have a very positive experience,” says Dr. Hacquebord. “Any apprehensions they may have had are quickly alleviated when they realize the surgeon is talking to them in reassuring ways. They can concentrate on our conversation instead of what’s going on in their head about what’s happening to them.”

It’s good for the healthcare system

At first glance, the benefit to the providers can be difficult to see. A procedure in an office-based setting with a local anesthetic means that an ASC or HOPD isn’t getting a facility fee or anesthesia fee.

“This wide-awake innovation is very good for patient care, so we have to think about what we can do with it while balancing it with the financial implications of the healthcare systems and the facilities,” says Dr. Hacquebord. “Outpatient surgery centers and hospitals not making money because of this advancement is not a good reason to be resistant to it.”

It’s important to remember that these procedures are a net-positive for healthcare systems because simpler procedures free up surgeons’ schedules and OR times to perform more complex procedures, he says. “Opening up the OR doors for more profitable procedures while providing wide-awake procedures that are best for the patients makes this a win-win for everyone,” he says. OSM