Keeping the Finger on the Pulse: Cardiac Arrhythmias in Hand Surgery Using Local Anesthesia with Adrenaline

Abstract

Background: The wide-awake local anesthesia no tourniquet (WALANT) technique in hand surgery is gaining popularity. The authors aimed to prospectively analyze the frequency and type of arrhythmias in patients undergoing hand surgery under local anesthesia and to examine whether the addition of adrenaline affects their incidence. Methods: Adult patients undergoing hand surgery under local anesthesia were randomized into two groups: group 1, local anesthesia with lidocaine and tourniquet; and group 2, local anesthesia with lidocaine and adrenaline (WALANT). Patients with a history of arrhythmias were excluded. Patients were connected to Holter electrocardiographic monitoring before surgery and up until discharge. The records were blindly compared between the groups regarding types of arrhythmias, and frequency and timing relative to injection and tourniquet inflation. Results: One hundred two patients were included between August of 2018 and August of 2019 (age, 59.7 ± 13.6 years; 71 percent women; 51 in each group). No major arrhythmia (ventricular tachycardia, ventricular fibrillation, atrial fibrillation) or arrhythmia-related symptoms were recorded for either group. Minor arrhythmias (including atrial premature beats, ventricular premature beats, and atrial tachycardia) were recorded in 68 patients (66.6 percent), with no statistical difference between the groups. There were three patients with minor arrhythmias during inflation of the tourniquet. Patients in the adrenaline group had 2 percent sinus tachycardia during injection and 4 percent asymptomatic bradyarrhythmias. These findings do not require any further treatment. Conclusions: The authors’ results show that hand operations using WALANT technique in patients with no history of arrhythmia are safe and are not arrhythmogenic; therefore, there is no need for routine perioperative continuous electrocardiographic monitoring. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Wide-Awake Hand Surgery Has Its Benefits: A Study of 1,011 Patients

“…Procedure rooms are less expensive and more efficient. 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 The savings begin before the patient steps foot in the procedure room, with no need for preoperative laboratory testing and medical evaluations. In a study of preoperative carpal tunnel patients, Greenfield et al 8 found a per-patient average cost of $858.74 was spent on preoperative work-ups and nonsurgical management of patients who underwent carpal tunnel release.…”

“… 8 Additionally, there are cost savings associated with the decreased need for surgical drapes, equipment, and hospital staffing. 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 There is also a decrease in the waste generated by these procedures, as they are typically done under minor field sterility, which consists of sterile prep, a single drape, a minor instrument tray, sterile gloves and a mask (no gown or antibiotics), and local anesthesia. 16 , 29 …”

Optimization of Carpal Tunnel Syndrome Using WALANT Method

“…Farkash et al monitored heart rhythms during hand procedures under WALANT and did not find any arrhythmogenic properties associated with the local anesthesia used. They concluded that heart monitoring is not needed during these procedures in patients who have no history of arrhythmias [47]. Another potential risk of using epinephrine during WALANT is digital ischemia.…”

WALANT – Wide Awake Local Anaesthesia No Tourniquet: Komplikationen bei elektiven und akut-traumatologischen handchirurgischen Eingriffen

“…Farkash und Mitarb. untersuchten in einer aktuellen Studie 102 handchirurgische, in Lokalanästhesie operierte Patienten bezüglich des Auftretens von Arrhythmien 13 . Die Patienten wurden in 2 Gruppen randomisiert.…”