Wide Awake Hand Surgery

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
26
•
Phentolamine manu acturers recommend a dosage o phentolamine
o 5 mg intravenously to lower blood pressure.12 The dosage to re-
verse adrenaline vasoconstriction in the nger is to inject 1 mg o
phentolamine in 1 ml or more o saline solution into the subcutaneous
at wherever there is severe epinephrine pallor in the skin. This small
extravascular dose will not a ect blood pressure. The nger will pink
up within an hour or two.
TH E D ALH OUSIE PROJECT EXPERIMEN TAL PH ASE
We needed to prove that phentolamine did in act reliably reverse epi-
nephrine vasoconstriction in the human nger. In Hali ax in 2002, we
per ormed a prospective, randomized, double-blind controlled trial called
the Dalhousie Project. In the level I evidence experim ental phase, we in-
jected both hands o 18 Dalhousie University alumnus hand surgeons who
volunteered to have both their ring ngers injected in three sites with
1.8 ml o 2% lidocaine with epinephrine 1:100,000.2 One hour later, we
injected each o the three sites o one hand with 1 mg (1 ml) o phen-
tolamine, and the three sites on the other hand were injected with 1 ml
o saline solution. In the gure you can see the “phentolamine blush,”
where redness is returning around the three phentolamine injection sites
one hour a ter we injected phentolamine in the le t hand. The conclu-
sion was that it took an average o 85 minutes or epinephrine-injected
ngers to return to normal color a ter phentolamine injection, whereas it
took an average o 320 minutes or epinephrine-injected ngers to return
to normal color a ter injection o saline solution (no phentolamine).
Phentolamine reversal of vasoconstriction after injection of 2% lidocaine with epinephrine
1:100,000. In the left hand, the arrows indicate that 2 ml of lidocaine and epinephrine only were
injected. In the right hand, the arrows indicate lidocaine and epinephrine were injected, and 1 hour
later, phentolamine was injected (1 mg in 1 ml).

Ch apt er 3 ° Saf e Epin eph r in e in t h e Fin g er Mean s N o To u r n iq u et
27
MAN AGIN G TH E WH ITE FIN GERTIP
•
Although nger in arction is rare, there is one reported case in which
epinephrine with lidocaine may have played a partial role in a nger
loss.13
•
Most white ngertips will resolve without any treatment. However, to
be on the sa e side, you can reverse the white ngertip by injecting
phentolamine wherever you have injected epinephrine be ore the pa-
tient leaves your acility.
•
When you inject lidocaine with 1:100,000 epinephrine in the proximal
or middle phalanx subcutaneous at, those areas will go white, but the
ngertip or thumb tip will usually remain pink.
•
I you inject the local anesthetic into the sheath instead o the sub-
cutaneous at, it di uses to the distal phalanx, where it has a greater
chance o making the ngertip white. Local anesthetic injected into
the sheath hurts more than local anesthetic injected into the subcuta-
neous at.
TREATMEN T OF ACCID EN TAL IN JECTION OF H IGH -
D OSE (1:10 0 0 ) EPIN EPH RIN E IN TH E FIN GER
•
Accidental injection o high-dose epinephrine occurs when people
attempt to sel -administer EpiPen or Ana-Kit injections to treat ana-
phylaxis in situations such as bee stings. Even though most o these
individuals did not receive phentolamine rescue, in the hundreds o
cases in the literature, there has been no reported nger loss.5,14
•
You should treat these cases with phentolamine to prevent ischemic
neurapraxia and ischemic reper usion pain, which can both occur
when it takes 14 hours or a nger to pink up.6 The dosage to reverse
epinephrine vasoconstriction in the nger is to inject 1 mg o phen-
tolamine in 1 ml or more o saline solution into the subcutaneous at
wherever there is severe epinephrine pallor in the skin.
References
1. Denkler K. A comprehensive review of epinephrine in the finger: to do or not to do. Plast
Reconstr Surg 108:114, 2001.
2. Nodwell T, Lalonde DH. How long does it take phentolamine to reverse adrenaline-
induced vasoconstriction in the finger and hand? A prospective randomized blinded
study: the Dalhousie project experimental phase. Can J Plast Surg 11:187, 2003.
3. Lalonde DH, Bell M, Benoit P, Sparkes G, Denkler K, Chang P. A multicenter prospective
study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the
Dalhousie Project clinical phase. J Hand Surg Am 30:1061, 2005.
4. Chowdhry S, Seidenstricker L, Cooney DS, Hazani R, Wilhelmi BJ. Do not use epineph-
rine in digital blocks: myth or truth? Part II. A retrospective review of 1111 cases. Plast
Reconstr Surg 126:2031, 2010.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
28
5. Fitzcharles-Bowe C, Denkler K, Lalonde D. Finger injection with high-dose (1:1,000) epi-
nephrine: does it cause finger necrosis and should it be treated? Hand (N Y) 2:5, 2007.
6. Muck AE, Bebarta VS, Borys DJ, Morgan DL. Six years of epinephrine digital injections:
absence of significant local or systemic effects. Ann Emerg Med 56:270, 2010.
7. Thomson CJ, Lalonde DH, Denkler KA, Feicht AJ. A critical look at the evidence for and
against elective epinephrine use in the finger. Plast Reconstr Surg 119:260, 2007.
8. Uri J, Adler P. The disintegration of procaine solutions. Curr Res Anesth Analg 29:229,
1950.
9. Hydrolysis of procaine in aqueous buffer solutions. Acta Pharmacol 5:353, 1949.
10. Health Sciences Institute drug expiration dates. Available at
08/26/drug-expiration-dates-2/.
11. Food and Drug Administration. Warning—procaine solution. JAMA 138:599, 1948.
12. Phentolamine description. Available at
13. Ruiter T, Harter T, Miladore N, Neafus A, Kasdan M. Finger amputation after injection with
lidocaine and epinephrine. Eplasty 14:ic43, 2014.
14. Muck AE, Bebarta VS, Borys DJ, Morgan DL. Six years of epinephrine digital injections:
absence of significant local or systemic effects. Ann Emerg Med 56:270, 2010.

29
Tumescent local anesthesia means injecting a large enough volume o
local anesthetic that you can see it plump up the skin and eel its slightly
rm consistency with your nger through the skin.
•
Tumescent local anesthesia is like an extravascular Bier block, but the
anesthetic is placed only where you need it. This technique avoids the
risk associated with intravascular injection and the pain o a tourni-
quet.
•
Always inject rom proximal to distal so you are blocking nerves at the
beginning o the injection process.
•
Never elicit paresthesia with the needle. The presence o paresthesia
means that you may have lacerated nerve ascicles. I you inject tumes-
cent local anesthetic near any nerve, it will numb i given time. The
larger the nerve, the longer it takes or anesthesia to peak. Our yet-
unpublished studies have shown that median nerve anesthesia con-
tinues to increase 45 minutes a ter injection o tumescent local anes-
thetic.
•
Local anesthetic will not impair visibility, because it is as clear as water.
In act, tumescent local anesthetic hydrodissects the tissue planes or
the surgeon and acilitates the dissection.
•
You can inject large areas such as the whole orearm and wrist with
tumescent anesthetic in such a way that the patient only eels the rst
sting o a 27-gauge needle i you ollow the simple guidelines pre-
sented in Chapter 5. Patients are amazed and delighted that the injec-
tion discom ort is minimal.
•
You can also inject large areas with tumescent local anesthetic much
more quickly with less bruising and minimal pain using blunt-tipped
cannula needles (see more on cannula injection in Chapter 5).
•
The use o tumescent local anesthetic injection with no tourniquet
also helps signi cantly in cases requiring general anesthesia. It will de-
crease the bleeding, reduce the narcotic requirements administered by
the anesthesiologist, and avoid having to deal with let-down bleeding
that would occur when you release a tourniquet. The tumescent solu-
tion is simply injected as soon as the patient is asleep. You can then go
scrub, prep, and drape the patient, and complete other tasks while the
epinephrine takes e ect.
Clip 4-1 Principles
of tumescent local
anesthesia.
Ch a P t e r 4
Tu mes c en t Lo c al An es t h esia
Donald H. Lalonde, Alistair Phillips, Duncan McGrouther

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
30
TOO MUCH VOLUME IS BETTER TH AN N OT EN OUGH
VOLUME OF LOCAL AN ESTH ETIC—EXCEPT IN TH E
FIN GERS
•
Patients never complain o being too numb, but we have all had pa-
tients say that they were not numb enough and that we were hurting
them.
•
Strive to never have patients ask or “top-ups” or additional local an-
esthetic because they eel pain during the surgery. This creates an un-
necessary, unpleasant memory or the patient. It is a sign o improper
planning o the injection; the usual cause is not enough volume, with
anesthetic not distributed widely enough.
•
I you stay within sa e limits o the total dosage o lidocaine and epi-
nephrine, erring on the side o too much volume will eliminate the
risk o requiring a top-up additional injection o local anesthetic be-
cause the patient reports eeling pain during an operation.
•
The only exception to the rule o “too much local anesthetic is better
than not enough” is in the ngers. No more than 2 ml o local anes-
thetic is required in each o the volar and dorsal sides o the proximal
and middle phalanges o the ngers. Only 1 ml is required in the volar
distal phalanx. I you inject too much volume o anesthetic in a n-
ger, the pure compression e ect o too much f uid can decrease blood
f ow. For nail bed work, a quarter-inch Penrose drain nger tourniquet
works better than epinephrine injected in the dorsal distal phalanx.
•
Always have at least 1 cm o visible or palpable subcutaneous local
anesthetic beyond the site where you plan to incise, dissect, insert su-
tures, manipulate ractures, or pass K-wires.
–
Do not cut or insert needles where the skin is pink. Never reinsert
a local anesthetic needle where the skin is not solidly white when
you reinsert needles to inject large areas. I there are not enough
epinephrine molecules there to produce good vasoconstriction,
there will likely not be enough unctioning lidocaine molecules
there either. The patient will eel the needles and scalpels in the
pinkish skin.
–
It is ideal to give the local anesthetic 30 minutes or more to work.
It takes an average o 26 minutes or maximal cutaneous vasocon-
striction to occur with 1:100,000 epinephrine.1 It takes a similar
amount o time or maximal numbness to occur with lidocaine. I
you inject the patient in the recovery room or on a stretcher out-
side the operating room, the anesthetic will have time to work by
the time you prep and drape the patient on the operating table.
–
For short procedures, inject the rst three patients and do the pa-
perwork be ore you operate on the rst patient. A ter you operate
on the rst one, inject the ourth patient while the nurse brings
the second injected patient into the room (see Chapter 14).
–
I your situation does not permit hal an hour or the tumescent
anesthetic to take e ect, hemostasis is usually reasonable at
15 minutes a ter injection. The site will bleed a little more, but only
an acceptably small amount.

Ch apt er 4 ° Tu mes c en t Lo c al An est h esia
31
IF YOU ARE WORKIN G WITH AN AN ESTH ESIOLOGIST
•
Ask him or her to use only propo ol. Inject the lidocaine with epineph-
rine as soon as the propo ol permits pain- ree injection o local an-
esthetic. The anesthesiologist can then wake the patient right away
while you are scrubbing, prepping, and draping. This means you will
have the bene t o an alert patient intraoperatively who can under-
stand your teaching (see Chapter 8) and be ully cooperative with
pain- ree movement. This will also give the epinephrine a little time
to become more e ective. Suggest that the anesthesia provider avoid
administering opiates and amnestics to prevent nausea and allow the
patient to remember your intraoperative advice.
SAFE D OSAGE OF LID OCAIN E WITH EPIN EPH RIN E
•
The widely quoted maximal dose o lidocaine with epinephrine is
7 mg/kg. This number originated be ore 1950, at the dawn o lido-
caine use. Since then, Vasconez and others have reported sa e blood
levels o lidocaine when they injected 35 mg/kg or liposuction.2,3
•
Because we do not monitor most o our patients, we stay within the
very sa e dose o 7 mg/kg, which is all we need to per orm most hand
operations. In a 70 kg adult, this means the ollowing:
7 mg/kg × 70 kg = 490 mg or 49 ml o 1% lidocaine
with 1:100,000 epinephrine
Ta b le 4-1 Sa e Dosage or an Average Adult
Volume Needed (ml)
< 50
We use commercially available 1% lidocaine with 1:100,000 epinephrine
(always bu ered with 10 ml local anesthetic to 1 ml o 8.4% sodium
bicarbonate to decrease the pain o injection4).
50-100
We dilute bu ered 50 ml o commercially available 1% lidocaine with
1:100,000 epinephrine with 50 ml o saline solution to produce 100 ml o
0.5% lidocaine with 1:200,000 epinephrine.
100-200
We dilute bu ered 50 ml o commercially available 1% lidocaine with
1:100,000 epinephrine with 150 ml o saline solution to produce 200 ml
o 0.25% lidocaine with 1:400,000 epinephrine, which is clinically very
e ective both or local anesthesia and or vasoconstriction. The lower
concentration just takes longer to work and does not last as long.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
32
•
In the average adult:
–
I we need less than 50 ml o volume, we use commercially avail-
able 1% lidocaine with 1:100,000 epinephrine (always bu ered
with 10 ml local anesthetic to 1 ml o 8.4% sodium bicarbonate to
decrease the pain o injection 4).
–
I we need 50 to 100 ml o volume, we dilute bu ered 50 ml o
commercially available 1% lidocaine with 1:100,000 epinephrine
with 50 ml o saline solution to get 100 ml o 0.5% lidocaine with
1:200,000 epinephrine.
–
I we need 100 to 200 ml o volume, we dilute bu ered 50 ml o
commercially available 1% lidocaine with 1:100,000 epinephrine
with 150 ml o saline solution to get 200 ml o 0.25% lidocaine
with 1:400,000 epinephrine, which is clinically very e ective both
or local anesthesia and or vasoconstriction. The lower concentra-
tion just takes longer to work and does not last as long.
•
You can nish most hand operations in the anesthesia time provided
by lidocaine with epinephrine (5 hours in the wrist,5 10 hours in the
nger6). We only use bupivacaine in operations that may last more
than 21⁄2 to 3 hours. We add 10 ml o 0.5% bupivacaine with 1:200,000
epinephrine to the total injection mixture in these cases.
TH E GREATER TH E CON CEN TRATION OF
EPIN EPH RIN E, TH E LON GER AN D MORE IN TEN SE
TH E VASOCON STRICTION
One investigator had three fingers simultaneously
injected with 0.5 ml of different concentrations
of epinephrine in three fingers.1 The small finger
(injected with epinephrine 1:100,000) pinked up
completely after 6 hours. It took 10 hours for
vasoconstriction to reverse in the ring finger after
injection of 1:10,000 epinephrine. The long finger
took 14 hours for the pink color to completely return
after injection of 1:1000 epinephrine.

Ch apt er 4 ° Tu mes c en t Lo c al An est h esia
33
•
Some surgeons use 1:1,000,000 epinephrine or WALANT7 with
good clinical results, but the epinephrine may not last as long as the
1:100,000 or 1:200,000 that most surgeons use.
•
The designation 1:100,000 epinephrine means 1 g (1,000,000 µg) o
epinephrine in 100,000 ml o saline solution, or 10 µg/ml.
•
The designation 1:200,000 epinephrine means 1 g (1,000,000 µg) o
epinephrine in 200,000 ml o saline solution, or 5 µg/ml.
D IFFEREN T CON CEN TRATION S OF EPIN EPH RIN E
PREMIXED WITH LID OCAIN E IN D IFFEREN T
COUN TRIES
•
In Canada and the United States, the anesthetic comes premixed as
1% lidocaine with 1:100,000 epinephrine.
•
At this writing, 1% lidocaine with 1:200,000 epinephrine is available as
a premixed solution with lidocaine in many European countries, and
this works very well or those surgeons. In Israel, premixed lidocaine
with epinephrine is not available, and surgeons have to mix their own.
In Hong Kong and Brazil, premixed 2% lidocaine with 1:200,000 epi-
nephrine is used. Egypt has premixed 2% lidocaine with 1:100,000 o
epinephrine. Indonesia has 2% lidocaine with 1:80,000 epinephrine.
Clearly, published evidence is not yet guiding the worldwide availabil-
ity o a single optimal combination.
•
You can mix lidocaine and epinephrine with saline solution in the
small 50 or 100 ml bags that saline comes in. I you remove 10 ml o
saline rom a 50 ml bag and then add 40 ml o 1% lidocaine with
1:100,000 epinephrine, you now have 80 ml o 0.5% lidocaine with
1:200,000 epinephrine.
Insulin syringe
Epinephrine 1:1000
Another method (as recommended by Marco
Felipe F.H. de Barros of Brazil) is to take one bottle
of 20 ml of 2% plain lidocaine, add 0.4 ml of
epinephrine 1:1000 (1 mg/ml), which produces
2% lidocaine with 1:50,000 epinephrine. You can
mix 20 ml of this 2% lidocaine with 1:50,000 epi-
nephrine with an equal volume of 20 ml of saline
solution to produce 40 ml of 1% lidocaine with
1:100,000 epinephrine.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
34
SCARS, CREASES, AN D PALMAR/ D ORSAL BORD ERS:
TH REE N ATURAL BARRIERS TO D IFFUSION OF LOCAL
AN ESTH ETIC SOLUTION
•
Local anesthetic does not di use well across scars. You will most o ten
need to inject local anesthetic on both sides o a linear scar, starting
in unscarred healthy subcutaneous at. For widely scarred areas, try
to start proximal to distal injecting in healthy subcutaneous tissue all
around the scarred area, then nishing under the scar i necessary.
•
All skin creases in the hand and wrist, such as the crease between the
ngers and palm, have ligaments that bind the skin to deeper struc-
tures, such as the f exor sheath. These can slow the di usion o tumes-
cent local anesthetic to the other side o the crease. Local anesthetic
will cross below a skin crease, but only slowly and i under pressure
with large volumes. It is wisest to inject on both sides o creases, start-
ing rom proximal to distal, to decrease the pain o injection.
•
Where palmar glabrous skin meets dorsal nonglabrous skin, there are
cutaneous ligaments that act as a third barrier to di usion o local an-
esthesia. This zone is also a natural embryologic “largely nerve- ree ter-
ritory” line between the palm and dorsum o the hand, where the dor-
sal sensory system meets the palmar sensory system. It is a line where
you can make incisions with less likelihood o neuroma ormation.8
IN FECTED H AN D S
•
In in ected hands, injecting directly into inf amed tissues does not
work very well because (1) it is pain ul, (2) the swollen tissues do not
easily accept the extra local anesthetic volume, and (3) the hyperemia
washes out lidocaine quickly, even with epinephrine.
•
Instead o injecting into the in ected area, inject tumescent local an-
esthetic rst proximally and then around the a ected site, and accept
the act that a little more bleeding will occur.
•
In the clinic or emergency department in countries that regulate wa-
ter cleanliness, you can wash a numbed in ected draining hand in the
sink, where a aucet delivers large volumes o clean water to wash out
the pus rom the wound (see Chapter 2). This also avoids contaminat-
ing clean main operating room theaters with pus.
PERSPECTIVE ON LOCAL AN ESTH ESIA
Duncan McGrouther
•
My personal approach to administration o local anesthetic in the
hand is to apply our knowledge o anatomy to capitalize on the glid-
ing planes around the digital nerves. In ormer times, my personal
success with axillary and supraclavicular nerve blocks was always less

Ch apt er 4 ° Tu mes c en t Lo c al An est h esia
35
than 100% , with a requent need to convert to general anesthesia. I
have moved toward using local anesthetic with epinephrine injected
directly into the hand.
•
At the wrist, I have always had concerns about all injections, because
there are many di erent planes and compartments where the needle
may land. There is a potential risk o damaging a nerve ascicle, which
can lead to ongoing symptoms o pain or paresthesias. For anesthe-
sia o the proximal palm, I tend to inject proximal to the carpal canal,
about 4 cm above the proximal wrist crease and through the deep as-
cia, where nerves are more mobile and damage is less likely. You can
augment this later by direct subcutaneous injection o the lignocaine
(lidocaine)/epinephrine mix in the palmar tissues to produce a dry op-
erative eld.
References
1. McKee DE, Lalonde DH, Thoma A, Glennie DL, Hayward JE. Optimal time delay between
epinephrine injection and incision to minimize bleeding. Plast Reconstr Surg 131:811,
2013.
2. Burk RW III, Guzman-Stein G, Vasconez LO. Lidocaine and epinephrine levels in tumes-
cent technique liposuction. Plast Reconstr Surg 97:1379, 1996.
3. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/
kg for liposuction. J Dermatol Surg Oncol 16:248, 1990.
4. Frank SG, Lalonde DH. How acidic is the lidocaine we are injecting, and how much bicar-
bonate should we add? Can J Plast Surg 20:71, 2012.
5. Chandran GJ, Chung B, Lalonde J, Lalonde DH. The hyperthermic effect of a distal volar
forearm nerve block: a possible treatment of acute digital frostbite injuries? Plast Recon-
str Surg 126:946, 2010.
6. Thomson CJ, Lalonde DH. Randomized double-blind comparison of duration of anes-
thesia among three commonly used agents in digital nerve block. Plast Reconstr Surg
118:429, 2006.
7. Prasetyono TO, Biben JA. “One-per-mil” tumescent technique for hand surgery. Plast Re-
constr Surg 132:1091e, 2013.
8. Ritchie J. A comparison of trapeziectomy via anterior and posterior approaches. J Hand
Surg Eur 33:137, 2008.

(Trang không có chữ)

37
LOCAL AN ESTH ESIA D OES N OT H AVE TO H URT
We easily teach all o our medical students and residents how to inject
local anesthetic or carpal tunnel surgery so that all the patient consis-
tently eels is the rst stick o a 27- or 30-gauge needle.1 Patients will
greatly appreciate the doctor who has invested the time required to learn
the ten simple rules listed below.2 The m ost im portant are rules 7, 8, 9,
and 10. Our patients are constantly amazed and delighted at how little
pain they eel rom our medical students’ and residents’ injections.
RULE 1. BUFFER 1% LID OCAIN E AN D 1:10 0 ,0 0 0
EPIN EPH RIN E WITH 10 :1 8.4 % SOD IUM BICARBON ATE
•
1% lidocaine with 1:100,000 epinephrine has an average pH o 4.2,
with a range o 3.3 to 5.5.3 This can be 1000 times more acidic than
the normal body pH o 7.4. This is one reason that it hurts when you
inject it unbu ered.
•
A bottle o 50 ml o 8.4% sodium bicarbonate costs less than $10.
Clip 5-1 How
to inject local
anesthetic with
minimal pain.
Clip 5-2 Patient’s
pain impressions
after a “hole-in-one”
local anesthetic
injection for carpal
tunnel surgery.
Clip 5-3 How and
why to buffer
lidocaine with
epinephrine.
Ch a P t e r 5
H o w t o In jec t Lo c al An est h et ic
Wit h Min imal Pain
Donald H. Lalonde, Nik Jagodzinski, Alistair Phillips

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
38
Conveniently, a 10 ml syringe
actually holds 11 ml, and a
20 ml syringe holds 22 ml. Sim-
ply add 1 ml of 8.4% bicarbon-
ate to 10 ml of 1% lidocaine and
1:100,000 epinephrine to make
the pH body neutral.1 Draw up
1 ml of sodium bicarbonate,
then fill the rest of the 10 ml
syringe to 11 ml with 1% lido-
caine with 1:100,000 epineph-
rine. (From Strazar AR, Leynes
PG, Lalonde DH. Minimizing
the pain of local anesthesia
injection. Plast Reconstr Surg
132:675, 2013.)
RULE 2. D O N OT USE REFRIGERATED LOCAL
AN ESTH ETIC
•
Re rigerated local anesthetic will result in a more uncom ortable injec-
tion or the patient than room-temperature local anesthetic.4 We store
our lidocaine with epinephrine at room temperature. Some centers
keep their lidocaine and epinephrine re rigerated so that it lasts lon-
ger. This is not necessary i you simply adhere to the expiration dates
on the bottle.
RULE 3. IN JECT LOCAL AN ESTH ESIA WITH SMALL-BORE
27- OR 30 -GAUGE N EED LES
•
Bigger needles hurt more. Stop using 25-gauge or larger needles.
•
Injecting large volumes quickly causes pressure pain. Use smaller
27-gauge needles, which will remind you to slow down, which will de-
crease injection pain.
•
Use 30-gauge needles or children or patients who are particularly sen-
sitive.
RULE 4 . CREATE SEN SORY N OISE IN TH E AREA
OF IN JECTION
•
Simply pressing rmly on the skin proximal to where you will insert
the needle can create sensory input “noise” that decreases the pain
elt by the patient. This is like hearing a baby cry in a crowd versus
hearing it cry in your room at 2 AM.
•
It may hurt the patient more i he or she watches the needle go in.5
Ask the patient to look away.

Ch apt er 5 ° H o w t o In jec t Lo c al An es t h et ic Wit h Min imal Pain
39
•
Icing the skin 6 or vibrating it 7 can decrease the pain o needle entry.
•
You can also move loose skin into the needle tip instead o moving the
needle into the skin.
If the skin is loose, it can be
gently pinched in the area into
which the fine needle will be in-
serted. You can also move loose
skin into the needle tip instead
of moving the needle into the
skin. These maneuvers provide
sensory noise distraction, which
decreases pain. (From Strazar AR,
Leynes PG, Lalonde DH. Minimiz-
ing the pain of local anesthesia
injection. Plast Reconstr Surg
132:675, 2013.)
RULE 5. STABILIZE TH E SYRIN GE WITH BOTH H AN D S
AN D H AVE YOUR TH UMB READ Y ON TH E PLUN GER TO
AVOID TH E PAIN OF A MOVIN G N EED LE
•
It can take up to a minute or the needle site to numb a ter you place
the needle under the skin, especially i you inject an insu cient bleb
right under the dermis. In this time, the patient will eel the sting with
every little wobble o the needle moving in the skin.
•
I you stabilize the syringe with two hands, and i your thumb is on
the plunger ready to inject be ore the needle penetrates, you will min-
imize pain ul needle movement in unanesthetized skin.
Stabilize the needle so it does not wobble un-
til the skin is numb. Hold it with two hands.
If the syringe-holding hand is free and is not
stabilized on the skin, the patient will feel
every little needle movement until the local
anesthetic has numbed the needle insertion
site. (From Strazar AR, Leynes PG, Lalonde
DH. Minimizing the pain of local anesthesia
injection. Plast Reconstr Surg 132:675,
2013.)

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
40
RULE 6. IN JECT 0 .5 ML WITH A PERPEN D ICULAR N EED LE
JUST UN D ER TH E D ERMIS AN D TH EN PAUSE UN TIL TH E
PATIEN T SAYS TH E N EED LE PAIN IS GON E
•
Nerves in the dermis are like trees with sensitive leaves, and in the at
are like branches and trunks. Injections in the dermis hurt more than
in subcutaneous at, because you irritate more “leaves” with the pres-
sure o intradermal injection.8 Inject just under the dermis instead o
in the dermis.
•
Inserting the needle perpendicular (90 degrees) to the skin hurts less
than i you come in parallel to it, because you pierce ewer nerve end-
ings with the sharp needle tip on the way to the subcutaneous at.9
•
Begin by injecting a visible bleb (0.5 ml) just under the dermis, then
pause until the patient tells you the pain is all gone. You will be able
to start to count the number o subsequent times the patient eels
pain. You can then score yoursel as per rule 9 and improve your injec-
tion technique, because you will be able to count the total number o
times the patient eels pain during the injection process.
•
When the patient tells you the sting o the needle site is gone, inject
an additional 1.5 ml very slowly without moving the needle.
•
I you start to inject quickly or move the needle tip out o the numb
zone, the patient will eel pain. A ter you have injected the initial
2 ml o anesthetic, you can change the angle rom 90 perpendicular
degrees to parallel to the skin without causing pain.
As soon as the needle is inserted, blow
in a visible bleb of 0.5 ml under the
dermis, not in the dermis. The needle
should be inserted at 90 degrees so
that fewer nerves are pierced. At a
90-degree angle, the patient will feel
less pain than if the needle is inserted
at a 45-degree angle. (From Strazar
AR, Leynes PG, Lalonde DH. Minimiz-
ing the pain of local anesthesia injec-
tion. Plast Reconstr Surg 132:675,
2013.)

Ch apt er 5 ° H o w t o In jec t Lo c al An es t h et ic Wit h Min imal Pain

41
After you have injected 0.5 ml in the
subcutaneous fat, hold still at least
15 seconds. Ask the patient to tell
you when the sting of the needle is
all gone. The first subcutaneous bleb
or wheal must be visible or palpable
under the skin in order for the needle
insertion site to be properly numbed.
After the patient tells you the sting of
the needle is gone, inject an additional
1.5 ml very slowly without moving the
needle. (From Strazar AR, Leynes PG,
Lalonde DH. Minimizing the pain of lo-
cal anesthesia injection. Plast Reconstr
Surg 132:675, 2013.)
M O S T I M P O R T A N T R U L E S
RULE 7. N EVER LET TH E N EED LE GET AH EAD OF TH E
LOCAL AN ESTH ETIC AN D “BLOW SLOW BEFORE YOU GO”
•
Hitting live nerves with a sharp needle tip hurts! Never let your needle
tip hit nerves that are not numbed.
•
Instead, blow slow before you go.
Never let the needle get ahead of the local anesthetic. If this happens, the sharp needle tip will ir-
ritate nerve endings that have not been numbed. Inject the local anesthetic in an antegrade fashion
so the needle tip only enters numbed nerve territory. (From Strazar AR, Leynes PG, Lalonde DH.
Minimizing the pain of local anesthesia injection. Plast Reconstr Surg 132:675, 2013.)
0.5 ml
2.0 ml

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
42
Always repeat the phrase “blow slow before you go” in your head while you are injecting. It will
help you to slow down and be patient. If you inject in an antegrade direction while advancing very
slowly and steadily under the skin, the sharp needle tip will only enter numbed territory. There
should always be at least 1 cm of visible or palpable local anesthetic ahead of the sharp needle tip.
(From Strazar AR, Leynes PG, Lalonde DH. Minimizing the pain of local anesthesia injection. Plast
Reconstr Surg 132:675, 2013.)

Ch apt er 5 ° H o w t o In jec t Lo c al An es t h et ic Wit h Min imal Pain
43
RULE 8. REIN SERT N EED LES WITH IN 1 CM OF TH E
BLAN CH ED / UN BLAN CH ED BORD ER
•
Never reinsert the needle into unblanched skin. I there are not
enough epinephrine molecules working there to cause vasoconstric-
tion, chances are there is not enough lidocaine there or pain- ree
needle reinsertion.
•
When you are injecting a large area (extensor indicis to extensor pol-
licis longus tendon trans er, or example), and you need to reinsert the
injecting needle, reinsert the needle only into clearly blanched areas
that are tumesced with visible or palpable local anesthetic (slightly
rm to palpation). You should reinsert the needle 1 cm inside well-
blanched skin beyond the border o the blanched/unblanched skin
junction.
RULE 9. LEARN FROM EACH PATIEN T YOU IN JECT BY
ASKIN G H IM OR H ER TO GIVE YOU A SCORE
•
Ask each patient to score you every time you inject local anesthetic.
We have our patients score us and all our medical students and resi-
dents every time we inject so we can see that our scores continue to
improve.
•
Be ore you begin, ask the patient to tell you each time he or she eels
pain during the injection process.
•
I the patient does eel additional pain during the injection, stop mov-
ing the needle or back up a little and very, very slowly continue to in-
ject in that one place until the pain is completely gone.
–
I the patient only eels the sting o the rst needle stick, your pain
score is 1 (hole-in-one).
–
I he or she eels pain a second time during the injection process,
your pain score drops to 2 (eagle).
–
I the patient eels pain three times, you score a birdie, our times
a bogie, and so on.
•
Each patient you inject presents an opportunity or you to get better
and better at injection. Each time we do not ask the patient to score
us is a wasted opportunity to improve our technique.
•
The most common reason that medical students and residents do not
score a hole-in-one while injecting or carpal tunnel surgery is that
they inject too quickly.1 It takes about 5 minutes to consistently score a
hole-in-one or carpal tunnel injection.
•
The three m ost com m on causes o poor pain scores are (1) injecting
too quickly, (2) letting the sharp needle tip get ahead o the local an-
esthetic into unanesthetized areas, and (3) reinserting needles into
“live,” unanesthetized skin.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
44
RULE 10 . TOO MUCH LOCAL AN ESTH ETIC IS BETTER
TH AN N OT EN OUGH LOCAL AN ESTH ETIC
•
The more volume that you inject, the greater are the odds that the pa-
tient will eel no pain a ter you start to dissect. Try to avoid “top-ups”
o local anesthetic that give patients unnecessary bad memories. Your
patients do not want to eel pain during surgery any more than they
want to wake up during a procedure in which they have been given a
general anesthetic.
•
Patients seldom complain about being too numb but requently
complain about not being numb enough. Stay within sa e limits but
always provide a little more volume than you need, except or the n-
gers, where you need only 2 ml per phalanx per side in the proximal
and middle phalanges.
•
The tw o m ost com m on causes o needing a “top-up” are (1) not inject-
ing enough volum e o tum escent local anesthetic and (2) not giving
the local anesthetic enough tim e to w ork (w ait hal an hour).
OTH ER D ETAILS OF SH ARP N EED LE IN JECTION
•
Always inject rom proximal to distal to anesthetize nerves proximally.
The tumescent local anesthetic will create nerve blocks proximally.
•
I you are blocking a major nerve as part o tumescent local anesthe-
sia, never elicit paresthesias! I you do, you may have lacerated the
nerve with your needle. Remember that a 25-gauge needle is the
width o a human ascicle. You want to get near the nerve and inject a
large volume to make certain you surround the nerve with local anes-
thetic.
•
You may want to stage your injections or more time e ciency. For
example, start by injecting 10 ml in the palm. This blocks the digital
nerves o the ngers o interest. See or inject other patients while
this takes e ect. Come back 30 minutes later to per orm all your dis-
tal injections quickly in the distal palm and ngers now that the nerve
blocks have worked.
•
Don’t inject directly into a scar or skin crease. Scarred skin is tender
and does not distend easily with local anesthetic. Skin creases exist be-
cause structures such as the tendon sheath adhere to the skin at that
point with cutaneous ligaments, which are accompanied by sensitive
nerve branches that eel the sharp pain o needle insertion. See Chap-
ter 4 or details o injecting creased and scarred skin.

Ch apt er 5 ° H o w t o In jec t Lo c al An es t h et ic Wit h Min imal Pain
45
N EW BLUN T CAN N ULA IN JECTION OF LOCAL
AN ESTH ETIC
•
New technology lets you inject with blunt-tipped cannulas instead o
sharp needles. They are more expensive (about $5 to $10), but de -
nitely aster and less pain ul than sharp needle tips.10
•
See the clip in Chapter 18 or 37 mm blunt-tipped 27-gauge cannula
injection or carpal tunnel.
•
See the clip in Chapter 19 or 57 mm blunt-tipped 22-gauge cannula
injection o local anesthetic or cubital tunnel release.
•
See Chapter 27 clip or 40 mm long blunt-tipped 25-gauge cannula in
an injection site made with a 20-gauge needle or trapeziectomy.
•
The blunt needle tip can push quickly with no pain past “live,” un-
anesthetized nerves by gliding in the at. Sharp needle tips pierce
nerves and cause pain i the local anesthetic is not bathing the nerve
well ahead o the needle tip and i the operator is not moving slowly
enough to let the local anesthetic work be ore the needle tip reaches
the nerves.
•
You insert blunt-tipped cannulas into skin injection sites made with
sharp needles with a bore o larger diameter than that o the can-
nula so the cannula enters the injection site opening easily. For exam-
ple, you insert a 22-gauge (5.7 cm long) cannula into an injection site
opening made with a 20- or 21-gauge needle in anesthetized skin.
First insert a minimally painful 27-gauge sharp needle just under the dermis, and inject 1 to 2 ml
of buffered local anesthetic and create a hole for a 30-gauge blunt-tipped cannula insertion. Leave
the inserting needle in the skin for a few seconds to stretch the cannulation entry hole to make it
easier to find. Twirl the needle once or twice to help the hole stay open. Then insert a blunt-tipped
30-gauge cannula into the hole formed when you remove the sharp introducing 27-gauge needle.
You sometimes need to patiently wait several seconds for the red blood dot to appear in the needle
hole. Magnifying loupes are helpful to find the introducing needle hole. (From Lalonde D, Wong
A. Local anesthetics: what’s new in minimal pain injection and best evidence in pain control. Plast
Reconstr Surg 134(Suppl 2):40S, 2014.)
27-gauge sharp needle
30-gauge blunt-tipped cannula
Clip 5-4 Cannula
injection of
tumescent local
anesthetic for
synovectomy and
tendon transfer.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
46
Inject the local anesthetic ahead of the blunt cannula tip as you advance it in the low-resistance
fat. This remains painless as long as the injection rate is not too fast to cause pressure pain and as
long as the cannula does not encounter resistance from cutaneous ligaments.
Pause the advance of the cannula when you encounter resistance. The cannula is probably butt-
ing up against a neurovascular bundle–ligament complex. Skin dimpling occurs at the area of
resistance, and the patient may feel pain if that area is not numb. Inject solution at this barrier and
then try backing up and finding an alternate resistance-free path into the fat instead of just pushing
through the resisting tissue. Pushing through resistance areas that are not numb may be painful.
Redirect the cannula in a new path in resistance-free fat. When you encounter resistance, retreat
the cannula and then advance at a different angle to find another path of minimal resistance
through fat to avoid pain and bruising. (From Lalonde D, Wong A. Local anesthetics: what’s new in
minimal pain injection and best evidence in pain control. Plast Reconstr Surg 138(Suppl 2):40S,
2014.)
LEAST PAIN FUL D IGITAL BLOCK: TWO D ORSAL
IN JECTION BLOCK VERSUS SIMPLE BLOCK
•
The two dorsal injection block hurts more than the SIMPLE block,
which stands or single subcutaneous injection in the m iddle o the
proximal phalanx with lidocaine and epinephrine.11,12
Clip 5-5 How to
perform a SIMPLE
block.

Ch apt er 5 ° H o w t o In jec t Lo c al An es t h et ic Wit h Min imal Pain
47
•
Injecting a SIMPLE block over 60 seconds hurts less than injecting it
over 10 seconds.13
•
Inject 2 ml o lidocaine and epinephrine in the at just beneath the
skin just past the palmar/digital crease between the two digital nerves.
References
1. Farhangkhoee H, Lalonde J, Lalonde DH. Teaching medical students and residents how
to inject local anesthesia almost painlessly. Can J Plast Surg 20:169, 2012.
2. Strazar AR, Leynes PG, Lalonde DH. Minimizing the pain of local anesthesia injection.
Plast Reconstr Surg 132:675, 2013.
3. Frank SG, Lalonde DH. How acidic is the lidocaine we are injecting, and how much bicar-
bonate should we add? Can J Plast Surg 20:71, 2012.
4. Hogan ME, vanderVaart S, Perampaladas K, Machado M, Einarson TR, Taddio A. Sys-
tematic review and meta-analysis of the effect of warming local anesthetics on injection
pain. Ann Emerg Med 58:86, 2011.
5. Höfle M, Hauck M, Engel AK, Senkowski D. Viewing a needle pricking a hand that you
perceive as yours enhances unpleasantness of pain. Pain 153:1074, 2012.
6. Aminabadi NA, Farahani RM. The effect of pre-cooling the injection site on pediatric pain
perception during the administration of local anesthesia. J Contemp Dent Pract 10:43,
2009.
7. Nanitsos E, Vartuli R, Forte A, Dennison PJ, Peck CC. The effect of vibration on pain dur-
ing local anaesthesia injections. Aust Dent J 54:94, 2009.
8. Arndt KA, Burton C, Noe JM. Minimizing the pain of local anesthesia. Plast Reconstr
Surg 72:676, 1983.
9. Martires KJ, Malbasa CL, Bordeaux JS. A randomized controlled crossover trial:
lidocaine injected at a 90-degree angle causes less pain than lidocaine injected at a
45-degree angle. J Am Acad Dermatol 65:1231, 2011.
10. Lalonde D, Wong A. Local anesthetics: what’s new in minimal pain injection and best evi-
dence in pain control. Plast Reconstr Surg 134(4 Suppl 2):40S, 2014.
11. Williams JG, Lalonde DH. Randomized comparison of the single-injection volar subcu-
taneous block and the two-injection dorsal block for digital anesthesia. Plast Reconstr
Surg 118:1195, 2006.
12. Wheelock ME, Leblanc M, Chung B, Williams J, Lalonde DH. Is it true that injecting
palmar finger skin hurts more than dorsal skin? New level I evidence. Hand (N Y) 6:47,
2011.
13. Hamelin ND, St-Amand H, Lalonde DH, Harris PG, Brutus JP. Decreasing the pain of fin-
ger block injection: level II evidence. Hand (N Y) 8:69, 2013.
Clip 5-6 A two dorsal
injection block hurts
more than a SIMPLE
block.

(Trang không có chữ)

49
TH E SAFETY OF SYSTEMIC LID OCAIN E AN D EPIN EPH RIN E
IN JECTION
•
The only drugs required or most hand surgery procedures are lido-
caine (also called lignocaine) and epinephrine.
•
Lidocaine was introduced in the late 1940s, and in the intervening
65 years, American dentists have injected lidocaine premixed with epi-
nephrine in an average o more than a million patients per day with
no monitoring, no intravenous insertion, and no preoperative testing
and have reported very ew adverse reactions.1,2 I there were com-
mon or serious problems with lidocaine and epinephrine injection, the
American legal community would have been seeking nancial com-
pensation or their clients rom dentists long ago.
•
The maximal dose o lidocaine with epinephrine, published be ore
1950, is 7 mg/kg. Since then, Vasconez and others have reported sa e
blood levels o lidocaine when they injected 35 mg/kg or liposuc-
tion.3,4
•
Lidocaine is much less cardiotoxic than other local anesthetics such as
bupivacaine or ropivacaine (see the section on longer-lasting local an-
esthetics). In act, internists commonly inject lidocaine to rescue ven-
tricular arrhythmias.5
•
A PubMed search or lidocaine anaphylaxis reveals six case reports in
the past 7 years. Two o the six cases had incomplete details,6,7 and the
remaining our had other con ounding variables, which made it hard
to attribute the anaphylaxis solely to the lidocaine.8-11 These reports
are rare when you consider the billions o lidocaine doses adminis-
tered in dental o ces in the world in six and a hal decades. I li e-
threatening anaphylaxis to lidocaine actually does exist, it is likely to
be extremely rare.12
•
Emergentologists inject lidocaine in 100 mg slow intravenous boluses
to treat various pain conditions.13 Anesthesiologists inject 1 mg/kg o
lidocaine intravenously or pain control in postoperative patients.14 In-
advertent intravenous small boluses o local anesthetic may occur with
antegrade injection, as described in Chapter 4. However, toxicity rom
these tiny intravascular doses is very unlikely.
Ch a P t e r 6
D eal in g Wit h Sys t emic Ad ver se
Reac t io n s t o Lid o c ain e
an d Epin eph r in e
Donald H. Lalonde

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
50
TREATMEN T OF SYSTEMIC AD VERSE REACTION S
TO LID OCAIN E AN D EPIN EPH RIN E
•
Lidocaine-induced seizures can occur with large intravenous doses
administered too quickly, or with excessive doses injected subcutane-
ously. With the doses and slow injection technique outlined in Chap-
ters 4 and 5, this complication is likely to be rare or nonexistent. The
treatment o lidocaine-induced seizures is conservative management.15
•
The antidote or lidocaine toxicity is the lipid emulsion Intralipid. It has
very limited use, because people rarely need it. It is not a per ect anti-
dote.16,17 The mechanism o action o lipid emulsion therapy or lido-
caine toxicity is not well de ned. It has been postulated that it works
by a “lipid sink,” decreasing circulating amounts o drugs to the pe-
riphery, or through a direct “energy source” to the myocardium.5
•
The antidote o epinephrine vasoconstriction is phentolamine. The
myth that epinephrine vasoconstriction is dangerous in ngers is ad-
dressed in Chapter 3. This chapter only deals with the systemic e ects.
•
The medical literature is almost devoid o reports o serious systemic
adverse reactions to the epinephrine that accompanies the lidocaine,
even in patients with cardiac disease.18 However, i there is a concern
about giving a patient with cardiac disease epinephrine-containing
local anesthetic, we can monitor these patients and give them lower
dosages o epinephrine.
•
Clip 6-1 shows an 84-year-old man with cardiac issues who was given a
lowered epinephrine concentration in the hospital with monitors dur-
ing WALANT surgery or EI to EPL tendon trans er, with a good result.
•
Epinephrine still provides good hemostasis in doses as low as 1:400,19
or 1:1,000,000.20 We routinely use 1:400,000 epinephrine when we
need 100 to 200 ml o volume or larger cases and nd the hemostasis
per ectly acceptable, as long as we give the epinephrine hal an hour
to work.
•
Epinephrine in a local anesthetic can cause transient elevation o the
heart rate and blood pressure, but the clinical importance o this e -
ect remains unclear.5,21 Adverse outcomes among hypertensive pa-
tients are in requent, and hemodynamic outcomes, which are possible
risk indicators, ref ect only minimal change.17
LON GER-LASTIN G LOCAL AN ESTH ETICS
•
Ropivacaine and bupivacaine both last longer than lidocaine, but they
have a lower sa ety pro le. In large doses, bupivacaine 22,23 and ropiva-
caine 24,25 can be cardiotoxic and atal. Lipid emulsion therapy has been
used or both bupivacaine 26 and lidocaine 27 rescue.
•
For digital blocks, bupivacaine-induced use ul numbness to pain lasts
only hal as long (15 hours) as the annoying pressure and touch numb-
Clip 6-1 Lowered
epinephrine
concentration for
cardiac issues.

Ch apt er 6 ° D eal in g Wit h Sys t emic Ad ver se Reac t io n s t o Lid o c ain e an d Epin eph r in e
51
ness (30 hours).28 That is why patients with bupivacaine digital blocks
complain that their injured nger is still numb, but it hurts.
•
Lidocaine pain and numbness to touch and pressure all come back at
the same time, like an on/o light switch.
•
You can nish most hand operations in the anesthesia time provided
by lidocaine with epinephrine (5 hours in the wrist,29 10 hours in the
nger30). We use bupivacaine only in operations that may last more
than 21⁄2 to 3 hours or in procedures such as a trapeziectomy, where
postoperative pain may be severe.
TH E EPIN EPH RIN E “RUSH ” AN D TH E VASOVAGAL
ATTACK (FAIN TIN G)
•
Although lidocaine and epinephrine are probably two o the sa est
drugs in use, injecting them can have two relatively common adverse
events. These are the epinephrine “rush” and the vasovagal attack in
response to receiving a needle injection.
t h e e pin eph r in e r u Sh
•
About one third o patients can eel an epinephrine “rush,” “jitter,”
“shakiness,” “nervousness” or a eeling “like you have had too much
co ee” or up to 20 to 30 minutes a ter an injection o local anes-
thetic.
•
Forewarned is orearmed. We warn all o our patients that they may
get this rushy eeling a ter we inject them. We tell them that this is
not an allergy; it is a normal reaction to the epinephrine we have
injected with the lidocaine, and the sensation will go away in 20 to
30 minutes.
•
Catecho-O-methyl trans erase and monoamine oxidase rapidly break
down epinephrine in plasma 31 so that its hal -li e inside blood vessels
is only 1.7 minutes.32 However, extravascular epinephrine degradation
is slower. The molecules must rst get into blood vessels either by di -
usion or through the lymphatics. You can requently see white lym-
phatic vasoconstriction tracks in the orearm when you inject epineph-
rine into the hand.
Av o iDin g t h e f Ain t
•
Loss o consciousness that occurs with a aint or vasovagal attack oc-
curs because there is not enough blood going to the brain. Nature’s
solution is to bring the head down by ainting to allow more blood to
get to the brain with gravity (see the box on p. 52).
•
A bandage change or cast removal can trigger ainting. Needles with
or without local anesthetic are another common trigger.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
52
Managing Fainting
Recognizing That Someone Is Going to Faint
Patients can aint even i you inject them lying down.
• The ollowing are signs that a patient is about to aint. The patient may say “I’m not eeling
well,” or “I think I’m going to be sick (vomit).” I you look at the patient, he or she may be
pale in the central upper ace (glabella, between the eyes, upper nose, or perioral skin).
When a Faint Is Impending
I your patient is showing signs that he or she is about to aint, get more blood to the brain with
the ollowing gravity-changing maneuvers.
• Have the patient lie down i he or she is sitting. (We do not recommend anesthetic injection
in the sitting position.)
• I the patient is lying down, put your hand beneath the knees and raise the knees up to f ex
the hips and knees so the thigh blood can run down toward the brain.
• Remove the pillow rom under the head and place it under the eet.
• Lower the head o the stretcher to the Trendelenburg position (head down, eet up).
m An Ag in g t h e f Ain t
•
I you inject patients in the lying-down position, ainting is less likely,
because gravity causes more blood to get to the brain when the head
is down.
•
Raise the knees, place a pillow under the eet, and lower the stretcher
to the Trendelenburg position.
TH E AN XIOUS PATIEN T
•
Most anxious patients can be reassured with a quiet, soothing voice
and manner. Most will tolerate wide awake hand surgery i they can
tolerate a dental procedure.
•
Music can be help ul to decrease anxiety.
•
Some anxious patients do better with sedation. You can give them
small oral doses o medication or provide ull main operating room se-
dation with an anesthesiologist. The downside is that the patient will
not be able to receive and remember intraoperative teaching and may
not be able to help you by cooperatively moving the hand to assess its
unction during surgery.
Clip 6-2 Managing
the vasovagal
fainting attack.

Ch apt er 6 ° D eal in g Wit h Sys t emic Ad ver se Reac t io n s t o Lid o c ain e an d Epin eph r in e
53
References
1. Gaffen AS, Haas DA. Survey of local anesthetic use by Ontario dentists. J Can Dent As-
soc 75:649, 2009.
2. Jeske AH. Xylocaine: 50 years of clinical service to dentistry. Tex Dent J 115:9, 1998.
3. Burk RW III, Guzman-Stein G, Vasconez LO. Lidocaine and epinephrine levels in tumes-
cent technique liposuction. Plast Reconstr Surg 97:1379, 1996.
4. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/
kg for liposuction. J Dermatol Surg Oncol 16:248, 1990.
5. Dogru K, Duygulu F, Yildiz K, Kotanoglu MS, Madenoglu H, Boyaci A. Hemodynamic and
blockade effects of high/low epinephrine doses during axillary brachial plexus blockade
with lidocaine 1.5%: a randomized, double-blinded study. Reg Anesth Pain Med 28:401,
2003.
6. Al-Dosary K, Al-Qahtani A, Alangari A. Anaphylaxis to lidocaine with tolerance to articaine
in a 12 year old girl. Saudi Pharm J 22:280, 2014.
7. Khokhlov VD, Krut′ MI, Sashko Slu. [Anaphylactic shock following administration of li-
docaine after negative skin test] Klin Med (Mosk) 90:62, 2012.
8. Lee MY, Park KA, Yeo SJ, Kim SH, Goong HJ, Jang AS, Park CS. Bronchospasm and
anaphylactic shock following lidocaine aerosol inhalation in a patient with butane inhala-
tion lung injury. Allergy Asthma Immunol Res 3:280, 2011.
9. Soong WJ, Lee YS, Soong YH, Yang CF, Jeng MJ, Peng YY. Life-threatening anaphylac-
tic reaction after the administration of airway topical lidocaine. Pediatr Pulmonol 46:505,
2011.
10. Sinha M, Sinha R. Anaphylactic shock following intraurethral lidocaine administration
during transurethral resection of the prostate. Indian J Urol 24:114, 2008.
11. Culp JA, Palis RI, Castells MC, Lucas SR, Borish L. Perioperative anaphylaxis in a
44-year-old man. Allergy Asthma Proc 28:602, 2007.
12. Specjalski K, Kita-Milczarska K, Jassem E. The negative predictive value of typing safe lo-
cal anesthetics. Int Arch Allergy Immunol 162:86, 2013.
13. Tanen DA, Shimada M, Danish DC, Dos Santos F, Makela M, Riffenburgh RH. Intrave-
nous lidocaine for the emergency department treatment of acute radicular low back pain,
a randomized controlled trial. J Emerg Med 47:119, 2014.
14. Barreveld A, Witte J, Chahal H, Durieux ME, Strichartz G. Preventive analgesia by local
anesthetics: the reduction of postoperative pain by peripheral nerve blocks and intrave-
nous drugs. Anesth Analg 116:1141, 2013.
15. Aminiahidashti H, Laali A, Nosrati N, Jahani F. Recurrent seizures after lidocaine inges-
tion. J Adv Pharm Technol Res 6:35, 2015.
16. Heinonen JA, Litonius E, Salmi T, Haasio J, Tarkkila P, Backman JT, Rosenberg PH. Intra-
venous lipid emulsion given to volunteers does not affect symptoms of lidocaine brain
toxicity. Basic Clin Pharmacol Toxicol 116:378, 2015.
17. Agency for Healthcare Research and Quality. Cardiovascular effects of epinephrine in hy-
pertensive dental patients. Summary, evidence report/technology assessment: Number
48. AHRQ Publication Number 02-E005. Rockville, MD: The Agency, Mar 2002. Available
at epc&dbname= ephysum.
18. Sanatkar M, Sadeghi M, Esmaeili N, Naseri MH, Sadrossadat H, Shoroughi M, Fathi HR,
Ghazizadeh S. The evaluation of perioperative safety of local anesthesia with lidocaine
containing epinephrine in patients with ischemic heart disease. Acta Med Iran 51:537,
2013.
19. Kämmerer PW, Krämer N, Esch J, Pfau H, Uhlemann U, Piehlmeier L, Daubländer M.
Epinephrine-reduced articaine solution (1:400,000) in paediatric dentistry: a multicentre
non-interventional clinical trial. Eur Arch Paediatr Dent 14:89, 2013.
20. Prasetyono TO, Biben JA. One-per-mil tumescent technique for upper extremity surger-
ies: broadening the indication. J Hand Surg Am 39:3, 2014.

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21. Abu-Mostafa N, Aldawssary A, Assari A, Alnujaidy S, Almutlaq A. A prospective random-
ized clinical trial compared the effect of various types of local anesthetics cartridges on
hypertensive patients during dental extraction. J Clin Exp Dent 7:e84, 2015.
22. Dudley MH, Fleming SW, Garg U, Edwards JM. Fatality involving complications of bupi-
vacaine toxicity and hypersensitivity reaction. J Forensic Sci 56:1376, 2011.
23. Cordell CL, Schubkegel T, Light TR, Ahmad F. Lipid infusion rescue for bupivacaine-
induced cardiac arrest after axillary block. J Hand Surg Am 35:144, 2010.
24. Gnaho A, Eyrieux S, Gentili M. Cardiac arrest during an ultrasound-guided sciatic nerve
block combined with nerve stimulation. Reg Anesth Pain Med 34:278, 2009.
25. Hübler M, Gäbler R, Ehm B, Oertel R, Gama de Abreu M, Koch T. Successful resuscita-
tion following ropivacaine-induced systemic toxicity in a neonate. Anaesthesia 65:1137,
2010.
26. Harvey M, Cave G, Chanwai G, Nicholson T. Successful resuscitation from bupivacaine-
induced cardiovascular collapse with intravenous lipid emulsion following femoral nerve
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Jr. Intractable cardiac arrest due to lidocaine toxicity successfully resuscitated with lipid
emulsion. Crit Care Med 39:872, 2011.
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pain relief and temperature elevation? Plast Reconstr Surg 131:1098, 2013.
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thesia among three commonly used agents in digital nerve block. Plast Reconstr Surg
118:429, 2006.
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humans: radiotracer methodology. J Clin Endocrinol Metab 69:753, 1989.

55
Ch a P t e r 7
Tips o n Tal kin g t o Yo u r Pat ien t s
Abo u t WALAN T
Nik Jagodzinski, Alistair Phillips, Donald H. Lalonde
MAN AGIN G PATIEN T EXPECTATION S BEFORE SURGERY
•
For patients, ear o the unknown and anxiety about pain are the two
biggest concerns about being awake during hand surgery. However, i
we explain the process to patients calmly, clearly, and with con dence,
we can quell the ear o the unknown so that most patients are reas-
sured. By gaining knowledge o the procedure, the patient can eel
more like an active participant in the treatment process, awake and
cooperating. I we inject local anesthetic thought ully, as described in
Chapter 5, it really does make the local anesthetic injection and sur-
gery pain ree, except or the initial pinch with a 27-gauge needle. The
patient will be amazed at how brie and minor the discom ort is.
TH IN GS TO TELL PATIEN TS D URIN G TH E CON SULTATION
SO TH EY UN D ERSTAN D TH E PROCED URE BETTER
•
Wide awake surgery is as simple as when you go to the dentist or a
lling. We put in the reezing/numbing medicine, we per orm the
surgery, and then you get up and go home. (When asked, most pa-
tients say that it is a more pleasant experience than going to the
dentist.)
•
You will not need to undergo any tests be ore surgery. That means you
do not need to leave work or pay a babysitter to go or tests on a day
be ore your surgery. You just need to arrive the day o surgery.
•
You do not have to stop taking any medication be ore surgery.
•
You do not have to ast be ore surgery or change any diabetic treat-
ment routine.
•
No intravenous line will be placed, so there will be no uncom ortable
needle in your unoperated hand.
•
You will be amazed at how little the reezing/numbing medicine hurts
when we put it in slowly with a tiny needle. Most people just eel one
little needle prick in the hand, and then they eel no pain at all (see
Chapter 5).
Clip 7-1 Explaining
WALANT to a
patient.
Clip 7-2 When
patients are unsure
about remaining
awake.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
56
20-gauge
27-gauge
30-gauge
Comparison of the relative size of needles for sedation and wide awake hand surgery. The
20-gauge cannula is used for sedation; a 20-gauge needle is used for preoperative testing. The
27-gauge or 30-gauge needles are used for WALANT.
•
The needle prick you will eel will be smaller than the sting o an in-
travenous insertion i we were using a general anesthetic, because we
use a much smaller needle.
•
For those w ho are especially a raid o needles and there ore request
sedation: I you have sedation, you will have two needle sticks with
bigger needles than the single prick you will eel i we numb you
with a local anesthetic. You get two bigger needles i you want to be
asleep: the rst larger one is or blood tests, then you get another one
with an intravenous line inserted to put you to sleep.
•
In Clip 7-3 a patient describes the impression o pain o a local anes-
thetic needle or trapeziectomy versus the pain o intravenous needle
insertion. This patient just had 40 ml o local anesthetic to numb up
the radial hand, as described in Chapters 5 and 27.
•
We will not be putting an uncom ortable tourniquet on your arm
( or those w ho have had experience w ith a tourniquet or have heard
about it).
•
For tendon or bone reconstruction: You will be able to help me get a
better result. A ter I x your tendon, you can move it to make sure it is
working properly. Sometimes I need to adjust what I have done, be-
cause your repaired tendon does not want to t in the tunnel it lives
in a ter I x it. I you move your broken nger a ter I x it, I can be
sure that I have it straight. We are more likely to get a good result i
you are awake to help me get it right. You cannot move it i you are
asleep or sedated during the procedure.
•
A ter the surgery, there is no need to wait around in the hospital to
recover. You just get up and go home.
•
You will not be nauseated and you will not vomit i you are not se-
dated.
•
You will not have trouble urinating a ter surgery i you do not receive
sedation.
•
Staying awake is sa er than sedation, because the sa est sedation is
no sedation. This is especially important or you because o your other
medical problems [such as your lung problem . . .].
•
You do not have to worry about what will happen to you. You can just
ask us anything at any time be ore as well as during the procedure i
you have concerns.
Clip 7-3 Patient
impression of pain
of a local anesthetic
needle versus an
intravenous needle.

Ch apt er 7 ° Tips o n Tal kin g t o Yo u r Pat ien t s Abo u t WALAN T
57
•
You can watch i you wish. Many patients do enjoy watching parts o
the surgery. Some tell their riends that watching the surgery should
be on their “bucket list.” However, you do not have to watch anything
i you do not want to.
•
You can bring headphones and listen to music during the surgery.
•
It is very uncommon or anyone to eel pain during the surgery, but i
you did, you would just tell me and I would add more local anesthetic.
•
I you have a sore shoulder or back, let us know and we will help you
adjust to a more com ortable position, such as on your side, during the
surgery.
•
Bring a book to read. A ter we inject the local anesthetic, you need to
wait at least a hal hour be ore we do the surgery. It is like putting a
cake in the oven: you need to let it bake.
•
You can ask me any questions during the surgery, and I will be happy
to answer all o them.
•
While I am operating, we can also discuss details about how you
should care or your hand a ter the surgery.
•
You do not need to get undressed ( or patients or whom eld sterility
will be used, see Chapter 10). You will simply roll up your sleeve and
have the surgery. You may want to wear short sleeves or a loose long-
sleeve shirt so the bandage ts in easily.
•
You will not need to have someone stay with you the evening o sur-
gery, because you will not have had sedation. It will be sa e or you to
be alone with your children or elderly parents the evening o surgery.
I you were to have sedation, the hospital would tell you that you
need to have someone stay with you at home the evening o surgery.
TH IN GS TO TELL PATIEN TS ABOUT TH E D AY
OF SURGERY
•
You may be in the hospital 1 to 4 hours at most. (Add 1 hour to the
surgery time to allow or a slow injection and hal an hour to allow
the local anesthetic to work.)
•
You will have time to talk to me be ore and while we inject the local
anesthetic. We inject it slowly so it will hurt less.
•
Occasionally, people become aint when they get a needle. Has this
ever happened to you? We numb people while they are lying down to
avoid this. I you tend to aint, we will tilt the stretcher so your head is
lower than your eet, and this will help to prevent your ainting.
•
A ter we nish the injection, you may eel a bit jittery, as i you have
had too much co ee, or like you are a little nervous. It is not your
nerves. It’s because there is a little adrenaline in the numbing medica-
tion, and these eelings are completely normal and not dangerous. I
it does happen, the shaky eeling wears o all by itsel in 5 to 30 min-
utes. It doesn’t mean anything is wrong.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
58
•
You will then go back to the waiting room to give the numbing medi-
cine time to work or at least a hal an hour. You can read, talk to your
riends, or listen to music.
•
All you will eel is the cold and wet o us washing your hand and
maybe a little pulling and tugging during the surgery.
•
A ter the surgery, you will just get up and go home with your hand
held higher than your heart. Your hand will be “on strike” or 2 or
3 days. We don’t want you to move your ngers in that time so you
do not bleed inside the wound. This will also allow the swelling to go
away and will decrease your pain.
•
Technically, you could drive a car because you did not get sedation.
However, also technically, you are “impaired,” since you will only have
one normally unctioning hand. Because you are not used to this situ-
ation, your driving may not be sa e. I you were in an accident and it
was your ault, it would be hard or you to justi y in court that you
were driving with one hand impaired, even i you were sedation ree
and pain ree while the local anesthetic was still working.

59
•
During the years when we per ormed hand surgery with sedation,
there was no point in educating patients during the surgery. They
would not remember what we told them because o amnestic medica-
tions. With each passing year o wide awake hand surgery, it is becom-
ing more and more apparent that patient education during surgery is
very help ul in m any w ays. You can educate your patients about post-
operative care and how to avoid complications while you are operat-
ing, and this is a better use o your time than chatting with the nurses
about the weather.
•
The time you spend talking to patients during the surgery is time you
do not need to spend with them in the o ce be ore or a ter the sur-
gery.
•
Investing time to educate the patient during the surgery will save the
time that would be lost on complications that occurred because the
patient did not know how to look a ter his or hand postoperatively.
Educated patients understand the importance o their rehabilitation
protocols, are more likely to be compliant with postoperative instruc-
tions, and may require ewer ollow-up appointments.
•
You o ten nd out important details about the patient’s li e and activi-
ties that you did not learn about in the initial consultation.
Talking to patients during surgery not only gives them something to think about and puts their
minds at ease, but also provides them with information about all aspects of their problem, the
likely course of recovery and rehabilitation, and gives you the opportunity to address any questions
they may have.
Clip 8-1 Advice to
patient during skin
cancer excision in
the hand.
Ch a P t e r 8
Tal kin g Wit h Pat ien t s D u r in g
Su r g er y Saves Time
Donald H. Lalonde, Duncan McGrouther

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
60
•
Patients love personal education in a nonrushed ashion rom their
surgeon. They are able to develop a one-on-one bond with you that
was not possible in the days when sedation meant they had no mem-
ory o the procedure, and they did not eel that they were an active
participant in the process.
•
Patients know exactly what their hand should look like. I you have
reduced a crooked nger, they can tell you i you have it right be ore
you leave the operating room.
•
Talking with patients during f exor tendon repair about how to look
a ter their hand a ter surgery can decrease your rupture and tenolysis
rates (see Chapter 32).
•
Talking with patients during nger racture repair about how to look
a ter their hand a ter surgery can decrease your sti nger rate.
•
In Clip 8-3 advice is given to a patient, while the nger racture is
K-wired, about how to look a ter the nger in the days a ter surgery.
Chapter 41 has a clip o this patient’s whole care, including advice
about early protected movement. Chapter 41 also has a clip on intra-
operative advice or nger racture patients.
•
With complicated procedures such as a f exor tendon repair or a
K-wired nger racture, patients leave the operating room with a ull
understanding o how to take good care o their hand a ter surgery
to get a better result. They understand that i they move the hand
too much, the repair will all apart. I they do not move it at all, every-
thing will become stuck.
•
A 10-year-old is given advice in Clip 8-4 during f exor tendon repair
about how to look a ter the nger in the days a ter surgery. Chapter 9
has a clip o this patient’s whole care.
•
For a clip o a surgeon and therapist explaining the Saint John postop-
erative f exor tendon repair protocol to a patient during surgery, see
Chapter 15.
TH IN GS N OT TO SAY AN D D O TO TH E PATIEN T
D URIN G SURGERY
•
Never say something like “Oops.” Create an atmosphere o calm, e -
ciency, and competence.
•
A silent surgeon can seem quite oreboding, while one who speaks
too much without listening can also ail to reassure. The modern ver-
sion o the “bedside manner” is the “operating table side manner.”
•
Do not ask the scrub nurse or a blade, scalpel, or skin hook. Use terms
like “a number 15” and “single hook.”
•
Do not pass bloody swabs or instruments in ront o the patient i you
can avoid it.
Clip 8-2 During
surgery the patient
can verify that the
deformity has been
corrected.
Clip 8-3 Advice
to a patient while
K-wiring a finger
fracture.
Clip 8-4 Advice to a
10-year-old during
flexor tendon repair.

Ch apt er 8 ° Tal kin g Wit h Pat ien t s D u r in g Su r g er y Saves Time
61
ED UCATIN G TRAIN EES TO PERFORM WALAN T
•
I you are teaching residents or medical students during the surgery,
say things like “Well done! That was a per ect stitch,” and so on. You
may not normally be this complimentary to trainees, but patients are
reassured when you like what the trainee is doing. This attitude goes
a long way toward increasing patient con dence in the surgical teach-
ing event.
•
I you don’t like what the resident is doing, nonverbal communication
such as putting your hand between an instrument and his or her eyes
is very e ective.
•
Say things such as “I know that some surgeons like to use the scis-
sors this way when they do this part o the operation, but I like to use
them this way, because . . .” as you take over the surgery.
•
So tly saying, “Pause . . .” is also a good way to stop the action.
•
This is clearly not the time or the place to reprimand a resident.
TH IN GS TO SAY TO PATIEN TS WH EN YOU BEGIN TH E
IN JECTION OF LOCAL AN ESTH ETIC
•
It is good to begin with a calm, com ortable conversation about
weather, amily, or ootball be ore you inject the local anesthetic. Wait
to ocus on talking about the hand until the patient is as relaxed as
possible.
•
Your instructions to the patient should be polite and simply worded:
–
“Can you please lie down com ortably on your side? Would you
kindly place your hand f at on the stretcher?”
–
“Try not to move when I put the needle in. I you pull away (which
is normal when you get a little sting), the needle will come out
be ore the medicine goes in, and I will need to put the needle in
a second time. I you hold still, you will only eel one little stick
instead o two. I will help you by holding your hand. OK? At the
count o three, don’t move. . . .”
•
A ter you have started putting in the lidocaine and epinephrine, and
the pain is completely gone (see Chapter 5), tell the patient it will take
about 5 minutes or you to nish putting in the numbing medicine.
“I I do it slowly, you will only eel the very rst needle stick and that
is all.”
•
As you inject the local anesthetic and have con rmed that the pa-
tient will no longer be eeling pain during the injection process, ask
whether he or she has any questions about the surgery or about the
care o the hand, when to go back to work, and other postsurgery is-
sues. Take this 5-minute opportunity to answer questions and to tell
the patient how to look a ter the hand a ter surgery.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
62
TH IN GS TO TELL PATIEN TS D URIN G CARPAL TUN N EL
RELEASE (APPLICABLE TO MAN Y OPERATION S)
•
In Clip 8-5 a patient is given intraoperative advice during carpal tunnel
release. This is also applicable to most other minor hand operations,
such as trigger nger and f exor sheath ganglion. (See Chapter 18 or
another clip on patient education during carpal tunnel release.)
•
Instruct the patient: “Keep your hand higher than your heart or the
next day or two. Consider that it is ‘on strike.’ Don’t move your ngers
or put your hand down until all o the numbing medicine is gone and
until you are o all pain medications. I you keep your hand up and
quiet, it will swell less, hurt less, and bleed less inside. Internal bleed-
ing slows recovery. I you walk around with your hand dangling down,
it will swell more, bleed more inside, hurt more, and sti en more in
the days to come.”
•
Ask patients what they usually take or pain. We tell them they can
take up to 800 mg o Advil or Motrin (ibupro en) and up to 1 g o Ty-
lenol (acetaminophen) when the numbing medicine wears o . They
can take ibupro en and acetaminophen at the same time, because the
two medications work in di erent ways.
•
“There are two kinds o pain with any operation: (1) the pain o the
incision, and (2) the pain o ‘Gee, doctor, now it only hurts when I put
my hand down or when I move.’ The pain o the incision lasts a day or
two, and you can take Advil or Tylenol or that pain. Stop taking pain
medicine as soon as you get into the pain o ‘Gee, doctor, now it only
hurts when I put my hand down or when I move’ and listen to your
body. That pain is your riend. It is your body telling you, ‘Hey there, I
am not ready or that. I am trying to heal in here and you are screw-
ing it up! Stop that!’ That little voice inside your head is one that you
should listen to.”
•
“We did not spend 2 billion years evolving pain because it is bad or
us; it is our body’s only way o telling us how to behave so we can heal
aster.”
•
“You can remove your ‘Hollywood’ bandage (a 3-inch gauze roll so
named because it is mostly applied or its visual e ect) be ore you
take a shower tomorrow. There is no problem with getting your
wound wet in the shower. It’s a myth that you can’t wash resh
wounds; resh wounds love running water. A ter the shower, you can
gently pat the wound site dry with a towel. Put on a clean, dry Band-
Aid and reuse or recycle the Hollywood bandage over the Band-Aid.
The outer bandage does not need to be sterile, just clean. It is only
there or visual e ects to remind you and those around you that you
can’t do the things you normally do because you have had an opera-
tion. They will not shake your hand or ask you to do something that
may hurt your hand. Stop using the outer bandage in 3 to 7 days. I
your wound is dry and not oozing liquid any more, the germs cannot
enter the wound, and no bandage is required. You may want to keep
the bandage on or the Hollywood e ect or sympathy or to protect
yoursel rom small children and eager hand-shakers.”
Clip 8-5 Giving
intraoperative advice
during carpal tunnel
release.

Ch apt er 8 ° Tal kin g Wit h Pat ien t s D u r in g Su r g er y Saves Time
63
•
“Don’t baby your hand, but don’t do anything that hurts. I you try to
do something and it does hurt, don’t try it again that a ternoon. Do
not try it again or 2 or 3 days. Healing takes days and weeks, not min-
utes and hours. You will get better aster i you listen to your body.
It is very wise. It will tell you what you can and cannot do, but the
only language it speaks is pain, and you may not be able hear it when
you’ve taken Advil or Tylenol.”
•
“I you eel tingling or a small electrical shock sensation a ter surgery,
this is normal. It is your body’s natural healing mechanism at work.
Your nerve is waking up a ter it has been compressed and asleep.”
•
“Redness on or around the incision is normal; redness less than the
width o your thumb is healthy inf ammation. The redness means that
your body is bringing more blood to the wound edges to help with
healing. Bruising in your orearm can also be normal. In ection is un-
common a ter a carpal tunnel procedure. Signs o in ection include
redness that goes all over your palm and up your orearm, with more
and more pain in the incision instead o less and less pain, ever, chills,
and real pus coming out o the wound (as opposed to a little clear liq-
uid or blood in the rst 2 or 3 days, which is normal).”

(Trang không có chữ)

65
Ch a P t e r 9
WALAN T H an d Su r g er y in In f an t s
an d Ch il d r en
Donald H. Lalonde
H OW TO EXPLAIN WALAN T TO CH ILD REN BEFORE YOU
IN JECT TH E LOCAL AN ESTH ETIC
Children do very well with WALANT hand surgery. The key is to provide
good local anesthesia (see Chapter 5) with a skill ul injection so that all
they eel is the rst sting o a 30-gauge needle.
•
The most important actor in gaining the patient’s trust and coopera-
tion is how you talk to the child be ore you inject the local anesthetic.
Using a calm, so t-spoken voice with a gentle manner and engaging
conversation is very help ul. I you are not com ortable having a pro-
longed conversation with the child you are about to operate on, per-
haps you should plan on per orming the surgery with the patient
under general anesthesia.
•
The child must be old enough to understand your explanation and to
hold still while you insert the rst needle.
•
I you can get the child to hold still to tolerate the stick o a 30-gauge
needle in the nger or hand, you can per orm the surgery with
WALANT.
The ollowing approach works well with children: “Do you believe
in magic?”
Most children will say, “No.”
“Neither do I, but today I am going to show you some real magic. I
am going to put some magic medicine underneath your skin. A ter
I put it there, I will be able to x your nger and it WILL NOT HURT
AT ALL. I PROMISE YOU.
The only problem with putting in the magic medicine is that you
have to eel one tiny needle stick to get the medicine in there. All
you need to do is hold still and not move.
I will help you by holding your hand.
I you pull your hand away be ore the medicine goes in, the needle
will come out and I will have to stick it back in.
I you hold still, you will only eel one little sting. I you move, you
will eel two stings.
Do you think you can hold still?”
Clip 9-1 Flexor
tendon repair in a
6-year-old girl.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
66
•
I the child gets that panicked look in the eyes that indicates he or she
cannot hold still or the injection, general anesthesia is advisable.
•
You need to keep your promise by making certain that all the child
eels is the rst sting, as shown in Chapter 5. Be sure that you have
more than enough volume o anesthetic rather than not enough. Chil-
dren should not have to have “top-ups.”
•
I usually have my body between the patient’s eyes and her hands. Note
that in Clip 9-2 my body is in an awkward position on the wrong side
o the table or this video so you can see the patient and the injection.
•
A ter you inject the local anesthetic, this is what you can tell the pa-
tient:
“I told you all you would eel was one little stick and then no pain.
I was not lying, was I?”
They say, “No.”
“I am not lying now. The surgery will not hurt you one little bit
now that the magic medicine is in there.”
•
You can establish a wonder ul relationship with most children during
WALANT surgery.
•
You can avoid all the risks and inconveniences o pediatric sedation
and general anesthesia or many cases.
•
The same bene ts o the patient’s seeing active movement in an op-
eration such as f exor tendon repair or a nger racture holds true or
children as or adults.
WALAN T H AN D SURGERY FOR IN FAN TS
•
For accessory nger nubbins in a newborn, have the mother start to
eed the in ant or a minute be ore gently pinching the skin and in-
serting the 30-gauge needle under the nger nubbin at the same
time. Inject enough 1% lidocaine with 1:100,000 epinephrine with
10% by volume o 8.4% bicarbonate that you can see the tissue swell
up under the nubbin. The needle pain momentarily distracts the
baby rom drinking milk, but he or she usually just carries on eeding
quickly because the discom ort is brie and minor.
TIPS AN D TRICKS FOR PED IATRIC WALAN T H AN D
SURGERY
•
Start with a 30-gauge needle instead o a 27-gauge needle.
•
Have the local anesthetic in your pocket, out o sight and ready to
inject, without the child seeing the syringe. Have the child look away
be ore you take the syringe out o your pocket and while you insert
the needle.
Clip 9-2 Flexor
tendon repair in a
10-year-old girl.
Clip 9-3 Excision of a
fifth finger nubbin in
a 4-week-old infant.

Ch apt er 9 ° WALAN T H an d Su r g er y in In f an t s an d Ch il d r en
67
•
Simply pressing rmly on the skin proximal to where you will insert
the needle can create sensory input “noise” that decreases the pain
elt by the patient. (See Chapter 5 or a list o rules o how to inject
local anesthetic with minimal pain.)
N O TOURN IQ UET FOR CASES IN WH ICH A GEN ERAL
AN ESTH ETIC IS AD MIN ISTERED
•
The bene ts o epinephrine vasoconstriction and painless awakening
rom the lidocaine also apply when patients are asleep.
•
For pediatric repair o a trigger thumb per ormed under general anes-
thesia, inject under the skin at the center o the incision until you see
the tissues are a little swollen and rm. Usually no more than 1 ml is
required in these tiny thumbs.
•
For other operations in which children will be having general anesthe-
sia, you can still avoid the tourniquet and let-down bleeding. As soon
as the anesthesiologist has the child sa ely asleep and lets you pro-
ceed, inject the lidocaine with epinephrine wherever you will dissect.
Then you can go scrub, prep, and drape the patient. By the time you
make the rst incision, the epinephrine will have started to work.
COMMUN ICATION AN D IN JECTION SKILLS
With a little practice in communication and injection techniques, most
hand surgeons can easily provide almost pain- ree local anesthesia to chil-
dren to make their hand surgery experience and that o their parents a
sa e, pleasurable, and educational one.
Clip 9-4 Numbing
a proximal phalanx
fracture in a boy.

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69
Ch a P t e r 1 0
Fiel d St er il it y f o r Simpl e Cases
Makes Sen se
Donald H. Lalonde
FIELD STERILITY VERSUS FULL STERILITY
•
In this book, f eld sterility, as shown below, means creating a localized
sterile eld with our towels or a small 40 × 40 cm drape with a hole
in it. We only expose and sterilize the part we are operating on or
need to see move during the surgery. The surgeon has a mask and
sterile gloves, but no sterile gown. Laminar airf ow is not required.
Most carpal tunnel procedures in Canada are performed with field sterility in a minor procedure
room outside of the main operating room.
•
In this book, ull sterility means standard operating room ull draping
with the entire patient covered in sterile drapes, with surgeons and
nurses in sterile operating gowns, masks, and gloves.
Clip 10-1 Safety and
value of field sterility
for hand surgery.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
70
Full sterility for carpal tunnel surgery in the main operating room is half as efficient and four times
more expensive.3
FULL STERILITY VERSUS FIELD STERILITY FOR MIN OR
PROCED URES: WH AT IS TH E EVID EN CE?
•
Plastic surgeons all over the world have excised small skin cancers and
benign lesions with eld sterility outside the main operating room or
well over 80 years, with no red f ags o excessive incidence o in ec-
tion. The standard o care o Mohs surgery skin cancer excision every-
where in the United States is eld sterility outside the main operating
room. A recent prospective American cohort study o 20,871 cases o
Mohs surgery with eld sterility revealed an in ection rate o 0.37%
with only 78 in ections.1 This in ection rate is almost identical to the
1500-case series eld sterility carpal tunnel in ection rate discussed
next.
•
What is the evidence or eld sterility in ection in hand surgery? In a
prospective consecutive series o 1504 eld sterility carpal tunnel pro-
cedures in ve North American cities by six surgeons,2 only six patients
developed super cial in ections, none o which required incision and
drainage; no intravenous antibiotics were given, no reoperation was
necessary, and none o the patients required hospital admission. Two
in ections resolved with suture removal and no antibiotics, and only
our patients required oral antibiotics. None o these patients had
been given preoperative antibiotics. The in ection rate in that 1504-
case series was 0.39% , almost identical to the Mohs 20,871-case series
described earlier.
•
For many years, Canadian hand surgeons have been doing most carpal
tunnel and trigger nger operations with eld sterility in minor pro-
cedure rooms with very ew in ections.3 The patient doesn’t need to
su er the embarrassment o getting undressed and being transported
on a stretcher, although per ectly healthy. There is no monitoring. He
or she simply rolls up a sleeve, has the surgery, and then gets up and
goes home.

Ch apt er 10 ° Fiel d St er il it y f o r Simpl e Cases Makes Sen se
71
•
There is no evidence that outcomes in carpal tunnel surgery are better
with ull sterility than with eld sterility. However, the cost is at least
our times as much, the e ciency is hal as much, and the garbage
production is more than ten times greater.3
•
Most simple hand trauma operations in Calgary, Saskatoon, Ottawa,
Saint John, and other Canadian cities happen with eld sterility as
well. Those Canadian hand surgeons are repairing tendons and
K-wiring most ractures outside the main operating room in clinic pro-
cedure rooms Monday through Friday, 8 AM to 5 PM. Calgary has dedi-
cated eld sterility clinic trauma rooms on weekend daytime hours
as well. Patients may get a better tendon repair at 2 PM than at 2 AM
when surgeons and nurses are sleepy.
•
Just over a century ago, humans discovered how to sa ely administer
a local anesthetic or induce sedation and general anesthesia to make
surgery easier, less pain ul, and sa er. We now know that we don’t al-
ways need general anesthesia, especially i we are not hurting patients
when we inject a local anesthetic. More anesthetic is not always better
than less anesthetic. Likewise, more sterility is not necessarily always
better than less sterility.
•
I we were to ollow the premise that more sterility is always better
than less sterility, we would all be using “space-suit” sterility mea-
sures, as shown below, even or drawing blood or starting an intra-
venous line. A ter all, that little plastic intravenous catheter that has
contacted bacteria on the skin is placed in a vein with a direct line to
the heart! However, we all would agree that we don’t need that much
sterility or a venipuncture or starting an IV.
•
The human and nancial cost o an in ection a ter venipuncture or
intravenous insertion does not warrant the cost o space-suit steril-
ity, both in terms o human su ering and in dollars. In ections are not
common and are usually easily dealt with inexpensively.
“Space-suit” full operating room sterility is appropriate for insertion of an artificial knee. If a
patient’s implant becomes infected, the cost is massive both in patient morbidity and in dollars for
care. Optimal sterility is worth the investment for that type of operation. In comparison, the cost of
an infected carpal tunnel procedure is minimal both in terms of human cost and dollars.

Par t II ° Gen er al Pr in c ipl es o f Wid e Aw ake H an d Su r g er y
72
•
Where does trigger nger or carpal tunnel surgery t between draw-
ing blood and knee implant insertion? We need to look at the down-
side o in ection to learn the answer. What are the usual problems
associated with in ection a ter carpal tunnel surgery? Not many. Most
people respond to suture removal, oral antibiotics, elevation, and im-
mobilization. Very ew ever need incision and drainage plus admin-
istration o intravenous antibiotics. Most hand surgeons have never
seen devastating in ection a ter carpal tunnel surgery because it is so
rare. Is it reasonable to spend vast amounts o money or ull sterility
and millions o tons o medical waste every year to prevent a problem
that may not even exist? Probably not.
•
We need better evidence, such as the studies cited earlier, to guide the
appropriate amount o sterility or which we spend a lot o money.
We need to use solid evidence to help us make wise decisions as we
ne-tune how much sterility we really need to do each o the various
invasive procedures we per orm sa ely. Patients can’t a ord the cost,
surgeons and hospitals can’t a ord the cost, and the world does not
need the garbage produced unnecessarily by the alse assumption that
more sterility measures are always better.4
•
When ull sterility is required or a procedure such as inserting a per-
manent PIP joint implant, the wide awake hand operation can be
moved to the main operating room or theater with ull sterility and
laminar airf ow.
•
The blood supply to the hand is excellent, which is why most hand lac-
erations sutured in the emergency department do not develop in ec-
tion, despite the act that many o those lacerations occurred in se-
verely contaminated hands. Be ore such lacerations occur, no prepping
and draping is done, and no antibiotics are given.
•
Now that we no longer need the tourniquet and sedation or hand
surgery, eld sterility permits us to per orm minor hand surgery or
carpal tunnel release and minor hand trauma outside the main operat-
ing room, which greatly decreases the cost o the surgery3-6 (see Chap-
ter 11).
WH EN D O WE USE TH E MAIN OPERATIN G ROOM
WITH FULL STERILITY FOR H AN D SURGERY?
•
We per orm the vast majority o our hand surgeries in the clinic or o -
ce, because using the main operating room is much slower and much
more expensive; the only added bene t is absolute sterility. The only
time we per orm WALANT procedures in the main operating room is
when we want that ull sterility.
•
Examples o cases that we take to the main operating room are plat-
ing ractures, thumb basal joint arthroplasty, complex tendon trans-
ers, secondary tendon reconstruction procedures, and similar cases.
•
These cases all require either permanent implants or a prolonged op-
erating time in a relatively avascular space, which increases the risk o
in ection.

Ch apt er 10 ° Fiel d St er il it y f o r Simpl e Cases Makes Sen se
73
References
1. Alam M, Ibrahim O, Nodzenski M, et al. Adverse events associated with Mohs micro-
graphic surgery: multicenter prospective cohort study of 20,821 cases at 23 centers.
JAMA Dermatol 149:1378, 2013.
2. Leblanc MR, Lalonde DH, Thoma A, Bell M, Wells N, Allen M, Chang P, Mckee D, Lalonde
J. Is main operating room sterility really necessary in carpal tunnel surgery? A multicenter
prospective study of minor procedure room field sterility surgery. Hand (N Y) 6:60, 2011.
3. Leblanc MR, Lalonde J, Lalonde DH. A detailed cost and efficiency analysis of performing
carpal tunnel surgery in the main operating room versus the ambulatory setting in Can-
ada. Hand (N Y) 2:173, 2007.
4. Sieber D, Lacey A, Fletcher J, Kalliainen L. Cost savings using minimal draping for routine
hand procedures. Minn Med 97:49, 2014.
5. Bismil MS, Bismil QM, Harding D, Harris P, Lamyman E, Sansby L. Transition to total
one-stop wide-awake hand surgery service-audit: a retrospective review. JRSM Short Rep
3:23, 2012.
6. Chatterjee A, McCarthy JE, Montagne SA, Leong K, Kerrigan CL. A cost, profit, and ef-
ficiency analysis of performing carpal tunnel surgery in the operating room versus the
clinic setting in the United States. Ann Plast Surg 66:245, 2011.

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