Clinically Important Pharmacologic Considerations for Wide Awake Local No Tourniquet (WALANT) Hand Surgery

Abstract

Summary: Understanding the clinically important pharmacokinetics (what the body does to the drug) and pharmacodynamics (what the drug does to the body) of medications used in surgery will help surgeons use them more safely and effectively. The goal of this article is to provide an overview of these considerations for the 2 medications used in wide-awake local anesthesia with no tourniquet upper extremity surgery (ie, lidocaine and epinephrine) to establish a better understanding of lidocaine and epinephrine in tumescent local anesthesia, as well as adverse reactions and how to manage them.

New Frontiers in Wide-Awake Surgery

“…the procedures last longer than 3 hours. Lidocaine is much safer than bupivacaine, 9 and bupivacaine has the annoying effect of having the "numbness to touch" effect lasting twice as long as the "numbness to pain" effect. 10 However, in facial surgery such as wide-awake rhytidectomy, the senior author (D.H.L.)…”

WALANT surgery of the hand: state of the art

“…Shared decision-making of surgeons and patients remains the basis of successful treatment (45). Infection surgery is no longer considered a relative contraindication (46,47,48).…”

“…If more volume is required, simply add saline. About 0.25% lidocaine with 1:400 000 gives you a comfortable 3 h to perform most operations without the need to add longer-lasting local anesthetics (48). By using enough injection volume, the soft tissue swelling will elevate the overlying skin 2 cm beyond the marked area, which you can see and palpate while injecting.…”

“…WALANT is not large nerve block anesthesia. It takes up to 100 min for lidocaine molecules to reach the center of large nerves in non-ultrasound-guided nerve blocks (48). WALANT tumescence bathes all nerves, large and small.…”