Treatment of hand infections using WALANT when the anesthesiologist is not available
A. Enechukwu1, A. Jokuszies1, S. Könneker1, P. Vogt1 1Medizinische Hochschule Hannover
Aim of this study was to determine, if Wide Awake Local Anesthesia No Tourniquet (WALANT) can be used as an alternative method of providing anesthesia in management of infections of the hand. Since the advent of WALANT in 2003 , infections of the hand have been regarded as contraindication to its use. Occasional shortage of anesthesiologic manpower, especially during busy call hours, can often lead to delay of treatment. In cases were swift surgery is needed, in order to prevent progress of an infection, this can result in severe morbidity.
Materials and methods:
In the period from 2015 to 2020, 16 patients with various infections of the hand were treated in 17 operations using WALANT. The solution used in our institution consists of 0,4ml of adrenaline (1:1000) mixed with 20ml of lidocaine and 20ml of 0,9% normal saline. We carried out a retrospective analysis of these patients and their operation reports, with emphasis on location of the infection, time and duration of the operation, as well as intraoperative occurrences. We also evaluated the need for revision surgery or necessity to convert to general anesthesia.
9 of the patients were men, 7 were women. The average age was 45,8 years. All but one patient, who was pregnant (33 weeks), were operated during call hours. The average duration of surgery was 29 minutes. With an average of 15,3 ml of WALANT solution injected. 52,9% of the operations were carried out by consultant surgeons, 47,1% were performed by surgical residents. There was bacterial growth in all wound swabs obtained from the surgical sites. In 2 (23,5%) of all cases 2 or more bacteria were identified. 10 patients received i.v. perioperative antibiotic treatment. All patients were commenced on postoperative oral antibiotics.The locations of the infection were as follows, dorsum of the hand 6, palm 4 while the digits were 7 times the focus of infection, with the thumb accounting for 2 of the 7. Etiologically 15 of the patients suffered form trauma to the hand. One patient had a planned 2nd look operation in general anesthesia. Two patients required revision surgery, because of persistent infection. We carried out preoperative radiological investigations using plane radiographs in 11 patients (70,6%). We discovered a foreign body as cause of the hand infection in one individual. There was no case of accompanying osteomyelitis. One patient had a fresh fracture. 4 patients had diabetes mellitus, one receiving additional oral steroids for keratosis pilaris. There was one smoker. Non of the aforementioned required revision surgery. All patients had a preoperative laboratory work-up. The mean CRP was 11,4mg/l (Reference CRP <5mg/l). Leukocyte mean count was 9,78Tsd/µl (SD 3,68). Post op the mean (n=7) CRP had risen to 23,9mg/l, while the leukocyte count had fallen to 7,87 Tsd/µl. The affected extremity was splinted in all cases. 10 patients were admitted, with a mean stay of 4,2 days, while the rest were treated as outpatients. The patients were discharged on non-opioid analgesics with 3 receiving a combination of 2. There was no documented case of inadequate analgesia or the need to convert to general anesthesia. Furthermore all but one patient, who had developed a panic attack, tolerated the procedure without documented intraoperative occurrences. No difficulties in carrying out the procedure without tourniquet were reported. S100 Abstracts – DGCH Annual Congress 2021 – via Livestream, April 12–16 • DOI 10.1515/iss-2021-2002 DE GRUYTER Innov Surg Sci 2021; 6, (Special Suppl 1): S81–S123.
The status of infection as an absolut contraindication to the use of WALANT should be revised. Especially when human resources are limited, it could serve as a means of enabling quick and quality treatment, in order to prevent the progression of infections of the hand.