Local anesthesia mixed with epinephrine and sodium bicarbonate , this mixture is called WIDE AWAKE , and it got an injection technique ...this is in brief called "WALANT" (wide awake local anesthesia no tourniquet) #dr_azanki

1. WALANT SURGERY
TECHNIQUE
Making surgery easy !!!!
Abdallah Ibrahim Jomaa El Azanki
Orthopedic Surgery Resident – R4
Mansoura University Hospital
December 2017

2. All anaesthesiologists agree that
less sedation is safer than more
sedation,So the safest sedation
is therefore no sedation .

3. WALANT in Brief

4. - Wide awake, no tourniquet, no sedation hand surgery, and making hand
surgery as simple as a dental procedure.
- Only Buffered lidocaine with epinephrine are injected in a tumescent
fashion directly into the area of surgery.
- Tumescent means enough local anaesthesia that it is visible and palpable
wherever dissection or bone manipulation will occur. (like the
extravascular Bier block, but only where it is needed to eliminate pain and
decrease bleeding).
(Leblanc et al., 2007).

5. - There is No intravenous insertion, No monitoring, No routine
preoperative testing, and No fasting.
-
- This technique is known as WALANT (wide awake local anaesthesia no
tourniquet). It can be performed in the outpatient setting or office with
field sterility with safety
(Leblanc et al., 2007).

6. Epinephrine’s Safety

7. - In 2001 landmark article of 120 years of literature reviewed
only 48 cases of finger death attributed to local anaesthesia,
with not one case involving lidocaine with epinephrine.
Keith Denkler (2001).
- This study regained surgeons hope in epinephrine mixed in local
anesthesia, and requisitioned some old myth!!.

8. - The myth states that epinephrine is not safe originated before 1950.
- Procaine was the first and only synthetic injectable local anesthetic until 1948 when
lidocaine was invented.
- Procain starts with a pH of 3.6 and became more acidic as it aged. The old yellow
like procaine was injected to patients before the 1972 when expiry dates were
mandated in the USA.
(Thomson et al., 2007), (Uri and Adler, 1950) .

9. - In 1948, the FDA warned that they had found procaine batches with
pH of 1 being injected into patients.
- Procaine caused necrosis to fingers at this very acidic pH, but
epinephrine took the blame.
- All the 48 finger loss caused by local anesthesia happened before
1950.
(Denkler, 2001),(Ross et al., 2016).

10. - Most the cases were with procaine without
epinephrine.

11. - Many studies reported the use of epinephrine in the finger in more than 6,000 cases
since the year 2001 and they had no single lost.
- There were no need to use phentolamine to reverse adrenaline vasoconstriction.
- Even the high dose of epinephrine (1:1000) was not harmful to fingers.
(Fitzcharles-Bowe et al., 2007) ,(Nodwell and Lalonde, 2003).

12. Does WALANT mixing
matters the pH !!!!

13. - In WALANT surgery the injected mixture consists of lidocaine with epinephrine
buffered with 10:1 8.4% bicarbonate (warmed to body temperature).
- Plain 1% lidocaine had a mean pH of 6.09 ±0.16, and plain 2% lidocaine had a
mean pH of 6.00±0.27
- 1% lidocaine with 1:100,000 epinephrine had a mean pH of 4.24 ±0.42.
- 2% lidocaine with 1:100,000 epinephrine had a mean pH of 3.93±0.43.
(Frank and Lalonde, 2012 )

14. - Epinephrine increases the duration of lidocaine’s anesthetic effect and decreases
surgical bleeding, so it’s a main player beside the Lidocaine.
- 1% lidocaine with 1:100,000 epinephrine is a factor of 1000 more
acidic than subcutaneous tissue ( pH in SC tissues 7.3 to 7.6 )
- Momsen et al verified that the proper volume ratio of 8.4%
bicarbonate to 1% lidocaine with 1:100,000 epinephrine is
approximately 1 mL:10 mL to neutralize the WALANT mixture’s pH to
7.4.
(Gerweck and Seetharaman, 1996), (Momsen et al., 2000), (Frank and Lalonde, 2012 )

15. HOW MUCH WALANT MIXTURE
TO INJECT ?!

16. Be generous with local anaesthetic volume !!!
It is better to have way too much than not enough,
as long as we keep a safe total dose.

17. - Inject enough volume so that there is tumescence at least 1–2cm beyond
anywhere you will have a painful stimulus.
- Most of the world uses the 1948 generated 7 mg/kg of lidocaine with
epinephrine is the upper limit of safe dosage.
- experiences in liposuction showing safe lidocaine blood levels with
up to 35mg/kg.
(DH. Lalonde, 2013) , (Burk et al., 1996; Klein, 1990).

18. Finally Novais and Costa in 2014 gave the ideal ratio to volume needed
(RAF Novais Junior, JRB Costa, 2014)

19. (D Lalonde, C Eaton, 2013)

20. How to inject Wide Awake Mixture !!!!

21. REMEMBER TO KEEP YOUR NEEDLE
SUBCUTANEOUSLY 0.5-1 CM BACKWARD
WHILE INJECTING

22. Minimal pain injection using the ‘hole in one’ technique in CTR or Cubital
tunnel release and “SIMPLE block” technique in the fingers limits the
pain to a single poke of a 27-gauge needle
(S Al Youha, DH Lalonde, M AL Wong, 2013)

23. Pinch skin into needle when injecting
no more than 2 ml in the subcutaneous
fat for a SIMPLE finger block, pinch
the skin three times.
(S Al Youha, DH Lalonde, 2013)

24. - Remember that WALANT needs some minutes while
injecting, don’t hurry up, and don’t push to relax.
- Time needed for CTR injection is 4-6 minutes and that’s
the maximum you'll need.
- Triple holder needle may be helpful
(S Al Youha, DH Lalonde, M AL Wong, 2013)

25. (McKee et al., 2013)

26. WHERE TO INJECT !!!!!

27. For CTR For Trigger finger
release
Every diagram will give 3 hints :
1- Site of injection start point
2- Site of surgery line
3- Anesthesia distribution zone
(D Lalonde, C Eaton, P Amadio, J Jupiter, M AL Wong, 2015)

28. For tendon repair, tenolysis,
Dupuytren's contracture
treatment
For trapizectomy,
de quervain’s ,
bennet fractures,
CMC fusion etc..
(D Lalonde, C Eaton, P Amadio, J Jupiter, M AL Wong, 2015)

29. For cubital tunnel release surgery
(D Lalonde, C Eaton, P Amadio, J Jupiter, M AL Wong, 2015)
Dorsal injection for MCB
fracture

30. Dorsal and Volar points of injection through the hand
(D Lalonde, C Eaton, P Amadio, J Jupiter, M AL Wong, 2015)

31. WALANT Benefits

32. - No nausea, vomiting, urinary retention, and other unwanted side effects
of opiates or sedation.
- Patients do not need to endure unnecessary tourniquet pain, even for 5
minutes.
- Hand surgery under WALANT is much less expensive than with
sedation, so many more can afford it.
(Hustedt et al., 2017), (Lalonde et al., 2016a).

33. - WALANT is safer for patients than sedation, especially those with medical
comorbidities.
- Spending less time at the hospital for the procedure (no recovery time)
- Patients get to know and talk to their surgeon during the local anaesthesia
injection and during surgery for advice on how to avoid complications, when to
return to work, and how to take pain medication.
(Hustedt et al., 2017), (Lalonde et al., 2016a).

34. - No need for preoperative anaesthetic assessment visits, chest X-ray, and
needles for blood tests ,intravenous needle insertion pain also disappears.
- Pain is only at a single poke with a 27-30 gauge needle in the hand when
local anaesthesia is injected with minimal pain technique
- Patients can see their repaired tendons, bones and fingers work during
the surgery after tendon laceration, tenolysis, tendon transfer, hand
fracture, or Dupuytren’s contracture, this motivates them in postoperative
therapy and recovery
(Hustedt et al., 2017), (Lalonde et al., 2016a).

35. - Patients do not need to fast or change medication schedules, which is
particularly helpful in diabetics.
- Patients with sore elbows, shoulders, or backs can position themselves
comfortably and shift to more comfortable positions during the surgery
because there is no tourniquet or anaesthesiology equipment (can easily
turn on their side).
(Hustedt et al., 2017), (Lalonde et al., 2016a).

36. - Patients do not need to suffer the humility of undressing for hand surgery when we
use field sterility.
- No need to discontinue anticoagulation medication with epinephrine
vasoconstriction.