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
Wide-Awake Local Anesthesia No Tourniquet
By:
Abdallah Jomaa El-Azanki
Orthopedic Surgery Resident – R3
At Mansoura Uni. Hospitals

2. INTRODUCTION ; WALANT
• The only medications given to the patient are subcutaneous “ lidocaine plus
epinephrine buffered with sodium bicarbonate” mixture .
• This mixture is infiltrated wherever : surgical dissection, K wire insertion, or
manipulation of fractured bones will occur.
• The concept behind this technique is that the local anesthetic results in an
extravascular Bier block but only where it is needed. The other term that is
frequently used to describe this approach is tumescent local anesthesia.

3. • Patient feels the first needle poke of a 25-27-gauge needle in the hand for most
hand operations.
• The lack of any sedation means there is no need for preoperative testing, intravenous
insertion, intraoperative monitoring, or the postoperative anesthetic care unit. The
procedure can be performed without sedation, because epinephrine is used for
hemostasis, which obviates the need of a painful tourniquet.

4. ANESTHETIC SOLUTION
• Local anesthetic (1% lidocaine with epinephrine, 1:100,000 ) is injected to the
patient in the waiting area .
• Starting 30 minutes before surgery for anesthesia. ( Waiting after injection allows
the epinephrine to take effect and provide an adequately dry working field.)
• Lidocaine with epinephrine buffered with 10:1 8.4% bicarbonate is used for all
injections.
• All the local anesthetic solution is warmed to body temperature.

5. • Total dose of infiltration is less than 7 mg/kg. Usually.
• Less than 50 mL is required for tendon surgery in the hand (including digits and
palm areas), Occasionally, 50 to 100 mL is required when surgery is involved in 3 or
4 digits or in the forearm; in these cases, we dilute with saline to a concentration of
0.5% lidocaine with 1:200,000 epinephrine.

6. TIPS FOR WALANT
• It has now been shown that the time to maximal vasoconstriction after injection of
lidocaine and epinephrine is 25 minutes, not the previously believed 7 minutes .
• The patients also like the opportunity to get their questions answered by the
surgeon. This improved communication decreases complication rate and increases
patient satisfaction rate.

7. • Inject 20 mL of 1% lidocaine with 1:100,000 epinephrine buffered for
carpal tunnel, 10 mL in the wrist between the median and ulnar nerves,
and 10 mL in the palm. This is considerably more than required, but we
also almost never need to add more local anesthetic because of patient
discomfort.

10. WALANT IN
FINGERS

11. TIME VALUE - POSTOPERATIVE:
• There is level II evidence that the duration of action of lidocaine with
epinephrine (10.4 hours) lasts about twice as long in digital blocks as
the action of lidocaine without epinephrine (average 4.9 hours).
• Lidocaine is like an on/off switch; when lidocaine wears off, pain, touch,
pressure, and temperature all come back at the same time.

12. WHY LIDOCAIN NOT BUPIVACAINE !!!
• Level I evidence that pain relief in digital blocks with bupivacaine lasts
only half as long (15 hours) as the return to normal sensation (30 hours).
This is the reason patients call surgeons after a digital bupivacaine block
to say that their finger hurts but still numb. Some patients also find the
prolonged numbness to touch annoying with bupivacaine blocks,
particularly after the pain has returned.

13. • Level I evidence that the addition of epinephrine to bupivacaine digital
blocks prolonged the duration of pain relief for only an additional 1.5
hours. The main purpose of adding epinephrine to bupivacaine digital
blocks is there- fore to provide hemostasis, not significant prolongation
of anesthesia.
• Bupivacaine does not come out like an on/off switch.

14. IS LONGER ANESTHESIA TIME PREFRERED !!!
• There is level III evidence that patients who had carpal tunnel
release with ropivacaine had longer pain relief than those who
received lidocaine alone. However, longer acting anesthesia
patients had a poorer rest night’s sleep.

15. FINALLY…TAKE HOME MESSAGE
• Hand surgery of a wide-awake patient is a safer, cheaper, and more enjoyable
experience for the patient.
• Improved intraoperative communication between the surgeon and the patient.
• Improved in the results, particularly in the cases of tendon repair-strength , tendon
transfer-checking , and finally faster life style returning.

16. THANK YOU