Tourniquet-Free Hand Surgery Using the One-per-Mil Tumescent Technique

Abstract

BackgroundA pneumatic tourniquet is generally used to achieve a bloodless operation field in hand surgery. However, this has changed with tumescent solution-based wide-awake surgery. This study is a preliminary prospective case series study to elaborate the formula and indications of the tumescent technique in hand surgery without a tourniquet.MethodsSeven patients (age range, 4 months to 37 years) underwent hand or upper extremity surgery for conditions such as nerve palsy, electric burn defect, fingertip injury, contracture, constriction ring syndrome, or acrosyndactyly. A "one-per-mil" tumescent solution (epinephrine 1:1,000,000+20 mg lidocaine/50 mL saline) was used to create a bloodless operating field without a tourniquet. Observation was performed to document the amount of solution injected, the operation field clarity, and the postoperative pain.ResultsThe "one per mil" epinephrine solution showed an effective hemostatic effect. The tumescent technique resulted in an almost bloodless operation field in the tendon and in the constriction ring syndrome surgeries, minimal bleeding in the flap and contracture release surgeries, and acceptable bleeding in acrosyndactyly surgery. The amount of solution injected ranged from 5.3 to 60 mL. No patient expressed significant postoperative pain. Flap surgeries showed mixed results. One flap was lost, while the others survived.ConclusionsEpinephrine 1:1,000,000 in saline solution is a potential replacement for a tourniquet in hand surgery. Further studies are needed to delineate its safety for flap survival.

Challenging the Dogma of Tourniquet Pressure Requirements for Upper Extremity Surgery

“…This has been used in a variety of procedures including burn contractures and congenital hand and upper extremity surgeries, and has shown to be effective in creating a bloodless operative field. 12,13 Despite research related to establishing different methods for determining occlusion pressure, there is a lack of evidence assessing the practical effects of intraoperatively reducing tourniquet pressures. The primary aim of this study was to determine if reduced tourniquet pressures negatively affected operative variables in patients undergoing mini-open carpal tunnel release.…”

Experimental Study of Tumescence Injection to Provide Anesthesia Without Local Anesthetics

“…This notion was based on our experience in the study of tumescence effect to peripheral perfusion and surgical cases in the clinical setting. 3,10,16 Further studies are needed to prove those hypotheses and to determine how much pressure is required to produce a local anesthesia effect.…”

“…The one-per-mil tumescent technique utilized tumescent solution comprising 1:1,000,000 epinephrine and 0.2% lidocaine. 3,10 This solution is injected by using tumescent technique around the incision area. The distinctive goal of the tumescent technique is to create a swollen tissue caused by profuse fluid injection.…”

“…[12][13][14] On the other hand, one-per-mil tumescent technique achieved a local anesthesia effect without exceeding the standard maximum dose of lidocaine (7 mg/kg). 3,10 This observation prompted an idea that tumescence environment within the local tissue may contribute to this effect.…”

Die Verbrannte Hand – Neuheiten und aktuelle Forschung

“…Heutzutage können über 95 % aller handchirurgischen Eingriffe mit Tumeszenzanästhesie durchgeführt werden, und der Mythos von Fingernekrosen durch Verwendung von Epinephrin haltiger Tumeszenzlösung sollte der Vergangenheit angehören [50,51]. Bei Erwachsenen wird die Tumeszenzanästhesie bei der Korrektur von Flexionskontrakturen an der Hand erfolgreich angewandt [52]. Bashir et al [53] konnten anhand von 160 pädiatrischen Patienten in einer randomisierten Studie zeigen, dass die Tumeszenzanästhesie in Standardverdünnung auch bei der Korrektur der Flexionskontraktur von verbrannten Händen sicher und zuverlässig angewandt werden kann.…”