WALANT–Epinephrine injection may lead to short term, reversible episodes of critical oxygen saturation in the fingertips

Abstract

Introduction Although the WALANT technique’s long-term safeness has been demonstrated in many studies, there are only few data investigating its short-term effects on tissue perfusion and oxygen levels. It was hypothesized that, temporarily, critical levels of tissue perfusion may occur. Methods Seventeen patients, who were scheduled for different procedures in WALANT technique, were injected with 5–7 ml of 1% Articain containing 1:200,000 epinephrine at the finger base. Capillary-venous oxygen saturation, hemoglobin volume in the capillaries, and relative blood flow in the fingertips were recorded once per second by white light spectrometry and laser Doppler flowmetry before, during and after injection for an average of 32 min. Results Clinically, no persistent tissue malperfusion was observed, and there were no postoperative complications. Capillary-venous oxygen saturation was reduced by ≥ 30% in seven patients. Critical levels of oxygen saturation were detected in four patients during 13 intervals, each lasting for 132.5 s on average. Oxygen saturation returned to noncritical values in all patients by the end of the observation period. Blood flow in the fingertips was reduced by more than 30% in nine patients, but no critical levels were observed, as with the hemoglobin. Three patients demonstrated a reactive increase in blood flow of more than 30% after injection. Conclusions Injection of tumescent local anesthesia containing epinephrine into finger base may temporarily cause a substantial reduction in blood flow and lead to critical levels of oxygen saturation in the fingertips. However, this was fully reversible within minutes and does not cause long-term complications.

Optimization of Carpal Tunnel Syndrome Using WALANT Method

“…This falls below the generally accepted maximal dose of lidocaine with epinephrine (seven mg/kg, equating to 50 mL in a 70-kg adult) [51]. Additionally, easy access to phentolamine allows for quick and efficacious reversal of any epinephrine-induced ischemia [52].…”

Digital ischemia after lidocaine with epinephrine injection in a patient with primary Raynaud’s phenomena

“…When examined closely however, these studies still present findings that may be concerning when applied to at-risk populations. Several articles have found that after epinephrine injection there are changes in distal oxygen saturation [ 13 , 14 ].…”

“…All levels returned to normal within 30 min but each decline had an average length of 132.5 s for a total average length of 463 s per patient. The longest patient had a total critical ischemia time of 684 s [ 14 ]. Alitinyazar et al.…”

WALANT: A Discussion of Indications, Impact, and Educational Requirements

“… 2 While adrenaline has been shown to cause a temporary reduction in oxygen saturation in the fingertips, numerous studies have found no risk for long-term ischemia; this is supported by a large series of consecutive cases of adrenaline use in the fingers (3,110 fingers) which reported no episodes of finger ischemia. 2 5 Careful patient selection is, however, still essential, as those with peripheral vascular disease or Raynaud's disease may be at a higher risk of finger ischemia, and those with cardiac disease may suffer adverse effects from systemic absorption of local anesthetic. 6 While the novel coronavirus disease 2019 (COVID-19) pandemic caused decreased anesthetic coverage for hand surgeries, the demand for hand trauma operating remained high; WALANT has proven to be an extremely useful tool during this time.…”