Life-threatening hypotension in the immediate postoperative period of cataract surgery under topical anesthesia: a report of two cases.

BACKGROUND: Cataract surgery is one of the most frequent surgeries in the world. It is a very safe procedure mostly performed under topical anesthesia in outpatients centers. Due to the growing lack of anesthesiologists, cataract surgeries are more frequently performed without an anesthesiologist present in the operating room. Although extremely rare, life-threatening complications may occur. CASES PRESENTATION: We report two cases of cataract surgery complicated by severe hypotension that required emergency resuscitation in the immediate postoperative period and hospitalization in intensive care unit. Anaphylactic shock was confirmed in the first case and suspected in the second. CONCLUSIONS AND IMPORTANCE: Even though cataract surgery is a very safe procedure, it is essential to ensure the presence of an anesthesiologist to manage potential, though extremely rare, life-threatening complications such as anaphylactic reactions.

WALANT as an Optimal Approach in Hand Surgery during Pandemics.

The emergence of the COVID-19 pandemic imposed fundamental changes in the field of surgery. Reorganization was made in order to adequately treat the patients during the pandemic. WALANT (Wide Awake Local Anesthesia No Tourniquet) approach was found to be a very convenient method in facilitating continuity in hand surgery with limited staff. A retrospective comparative study was performed between period of April 2020 till September 2021 at our clinic to evaluate advantages of WALANT approach. This study included 136 patients, from which 72 (53%) were operated with WALANT, compared to the control group of 64 (47%) patients without WALANT. Average hospital stay for the WALANT group was 2.2 days vs. 4.7 days for the control group. Average operating room personnel were 3.8 for WALANT and 6.2 for the control non-WALANT group. Intraoperative and postoperative VAS (visual analogue scale) score was evaluated. Due to its diversity, low cost and low complication rate, we recommend WALANT approach in acute and elective hand surgery.

WALANT technique versus locoregional anesthesia in the surgical management of metacarpal and phalangeal fractures: Lessons from the Covid-19 crisis.

Wide Awake Local Anesthesia No Tourniquet (WALANT) is an anesthetic method which uses a local injection of anesthetic and epinephrine, avoiding use of a tourniquet. During the COVID-19 pandemic, human and logistic resources had to be reorganized, and WALANT ensured resilience in our department to maintain access to surgical care. The objective of the present study was to compare hand function recovery 3 months after surgery for unstable metacarpal or phalangeal fracture under regional anesthesia versus WALANT. From November 2020 to May 2021, 36 patients presenting a metacarpal or phalangeal fracture requiring surgical treatment were included in a single-center study in a university hospital center. Nineteen patients underwent surgery under locoregional anesthesia with tourniquet, and 17 under WALANT. The main endpoint was functional recovery at 3 months on QuickDASH score. Need for complementary anesthesia, surgery duration, analgesic consumption, reintervention rate, and patient satisfaction were also assessed. There was no significant difference between groups in functional recovery at 3 months or on the secondary endpoints. In the COVID-19 context, WALANT proved to be a safe and effective method in hand fracture surgery, ensuring access to surgical care. It should be included in surgical training to optimize day-to-day surgical care and face future crises.

Wide-awake local anaesthesia no tourniquet (WALANT) procedures during COVID: a single centre experience.

Background and aim WALANT procedures are becoming more popular, and are particularly useful in the COVID-19 pandemic. Procedures can be performed without needing access to general theatres and anaesthetic support, minimising the number of patient-healthcare interactions and avoiding aerosolisation. Our unit has taken this approach and aim to present a case series that demonstrates the efficacy and safety of WALANT. Methods A prospective analysis of WALANT cases in a single plastic surgery centre during March-August 2020 was performed. All procedures using a WALANT approach were included, that would have otherwise required general anaesthetic or regional block. Data was collected on a number of variables, including patient satisfaction.  Results: 37 procedures were included in analysis. The majority of the injuries consisted of hand trauma. There were no cases of post-operative complications, although one required completion in main theatres due to technicality. No patients required additional anaesthetic during the procedure and all reported pain score as 0/10. Overall patient satisfaction was 10/10 for 26 patients, 9/10 for 10 patients and 7/10 for one patient. Conclusions Results show the use of WALANT can facilitate an effective plastic surgery trauma service during COVID-19. Most of the procedures were performed in the outpatient department setting, without the need for main operating theatres or anaesthetic support. All procedures were performed within 24 hours of initial presentation and were able to be discharged on the same day.  In addition, patient satisfaction remained high and post-operative complications were minimal. We propose that the use of WALANT should continue and increase beyond the current pandemic.

Local anaesthesia as a standard of care for penetrating keratoplasty?

BACKGROUND/OBJECTIVES: To determine preferences in the use of local anaesthesia (LA) versus general anaesthesia (GA) for penetrating keratoplasty (PK), and to examine the safety of LA for PK. SUBJECTS/METHODS: A retrospective analysis of PKs performed at an ophthalmology department in Canada from 01/01/2008 to 01/01/2020 was conducted to investigate rate of major complications. A questionnaire was also sent out to cornea specialists in the United Kingdom (UK) and Canada to determine trends in anaesthesia use for PK. Data on anaesthesia use in keratoplasty data was also obtained from the National Health Service Blood and Tissue (NHSBT) register. RESULTS: The retrospective study found that 2143 PKs were performed under LA by 4 surgeons. The following complications were revealed: 1 acute anxiety attack with tachycardia, 3 extraocular myotoxicity cases requiring squint surgery, 1 expulsive suprachoroidal haemorrhage and 1 retrobulbar haemorrhage. The survey revealed 92% of cornea specialists in Canada preferred LA to GA. In the UK, 4.5% of specialists preferred LA, with most preferring GA due to suprachoroidal haemorrhage risk. NHSBT data revealed that 86.6% of 6181 PKs performed in UK between 01/04/2015 and 31/03/2020 were done under GA. CONCLUSIONS: LA is preferred for PK in Canada, in contrast to the UK where GA is preferred. Our retrospective study suggests a low incidence of LA-related complications. We suggest that LA should be considered for most cornea transplant techniques, including optical penetrating keratoplasty. Rising worldwide keratoplasty numbers, ageing populations and risks of pandemics (e.g. COVID-19) give more reason for reduced reliance on GA.

WALANT Protocol: Stop before you block.

The use of Wide Awake Local Anaesthetic No Tourniquet (WALANT) amongst Plastic and Orthopaedic Hand Surgeons has been accelerated by the impact of the COVID-19 pandemic and associated risks of general anaesthesia. Benefits of WALANT include a bloodless field, improved recovery, on-table testing, as well as cost and time savings. Whilst more clinical trials are underway to fully elucidate safety-profile and outcomes, there is a lack of consensus and clarity over contraindications to WALANT. A survey of trainees identified that only one-in-five were aware of the appropriate reversal agent in the event of inadequate perfusion. We feel that a WALANT checklist should be developed and implemented for use immediately prior to administration of local anaesthetic with adrenaline to an extremity, building on the successes of the World Health Organisation (WHO) and the Royal College of Anaesthetists checklists. Such a checklist should include contraindications to WALANT and make the operator aware of the availability, dose and location of Phentolamine as a reversal agent. Introducing this checklist will help to facilitate safer and more effective use of WALANT within Hand Surgery.

Development of a Low-Resource Operating Room and a Wide-Awake Orthopedic Surgery Program During the COVID-19 Pandemic.

Introduction. The COVID-19 pandemic resulted in significant medication, supply and equipment, and provider shortages, limiting the resources available for provision of surgical care. In response to mandates restricting surgery to high-acuity procedures during this period, our institution developed a multidisciplinary Low-Resource Operating Room (LROR) Taskforce in April 2020. This study describes our institutional experience developing an LROR to maintain access to urgent surgical procedures during the peak of the COVID-19 pandemic. Methods. A delineation of available resources and resource replacement strategies was conducted, and a final institution-wide plan for operationalizing the LROR was formed. Specialty-specific subgroups then convened to determine best practices and opportunities for LROR utilization. Orthopedic surgery performed in the LROR using wide-awake local anesthesia no tourniquet (WALANT) is presented as a use case. Results. Overall, 19 limited resources were identified, spanning across the domains of physical space, drugs, devices and equipment, and personnel. Based on the assessment, the decision to proceed with creation of an LROR was made. Sixteen urgent orthopedic surgeries were successfully performed using WALANT without conversion to general anesthesia. Conclusion. In response to the COVID-19 pandemic, a LROR was successfully designed and operationalized. The process for development of a LROR and recommended strategies for operating in a resource-constrained environment may serve as a model for other institutions and facilitate rapid implementation of this care model should the need arise in future pandemic or disaster situations.

Maintaining Access to Orthopaedic Surgery During Periods of Operating Room Resource Constraint: Expanded Use of Wide-Awake Surgery During the COVID-19 Pandemic.

INTRODUCTION: Wide-awake local anesthesia no tourniquet (WALANT) presents a nonstandard anesthetic approach initially described for use in hand surgery that has gained interest and utilization across a variety of orthopaedic procedures. In response to operating room resource constraints imposed by the COVID-19 pandemic, our orthopaedic service rapidly adopted and expanded its use of WALANT. METHODS: A retrospective review of 16 consecutive cases performed by 7 surgeons was conducted. Patient demographics, surgical details, and perioperative outcomes were assessed. The primary end point was WALANT failure, defined as intraoperative conversion to general anesthesia. RESULTS: No instances of WALANT failure requiring conversion to general anesthesia occurred. In recovery, one patient (6%) required narcotics for pain control, and the average postoperative pain numeric rating scale was 0.6. The maximum pain score experienced was 4 in the patient requiring postoperative narcotics. The average time in recovery was 42 minutes and ranged from 8 to 118 minutes. CONCLUSION: The WALANT technique was safely and effectively used in 16 cases across multiple orthopaedic subspecialties, including three procedures not previously described in the literature. WALANT techniques hold promise for use in future disaster scenarios and should be evaluated for potential incorporation into routine orthopaedic surgical care.

How COVID-19 Changed Our Management of Nasal Bone Fractures and Its Impact on Patient Outcomes-A Retrospective Study.

OBJECTIVES: Nasal bone fractures are a common presentation to the Ear, Nose and Throat (ENT) surgeon. Simple, closed fractures are assessed and considered for closed manipulation under anesthesia (MUA #nasal bones). Most departments perform this under general anesthesia (GA). Our protocol changed in the face of COVID-19, where procedures were alternatively performed under local anesthesia (LA) in the clinic, to cope with lack of elective theater capacity during the pandemic, while still allowing a nasal fracture service to take place. We present postoperative patient outcomes on breathing and shape, comparing GA versus LA. METHODS: Patient records retrospectively analyzed (January 2020-August 2020), and patients undergoing MUA #nasal bones interviewed by telephone after one month. Exclusion criteria were open injuries or depressed nasal bones requiring elevation. Breathing and shape scores were evaluated subjectively using a Likert scale (1 = very unsatisfied, 5 = very satisfied). RESULTS: Two hundred five nasal injury referrals were made (21 MUA #nasal bones under GA and 27 under LA). Manipulation under anesthesia #nasal bones significantly improved both breathing satisfaction scores (GA; 2.88 ± 0.24 to 4.06 ± 0.23, P < 0.05; LA; 2.86 ± 0.22 to 3.77 ± 0.27, P < 0.05) and aesthetic scores (GA; 2.00 ± 0.21 to 3.94 ± 0.23, P < 0.05; LA; 1.64 ± 0.19 to 3.59 ± 0.28, P < 0.05) in both GA and LA groups. There was no statistically significant difference between LA and GA in postoperative outcomes. There was a trend toward greater satisfaction for GA, though this was not statistically significant and may be impacted by the rate of cartilaginous deformity in the LA group. Both techniques were well tolerated and most patients would repeat the procedure in hindsight. CONCLUSIONS: Local anesthesia could provide a safer, cheaper, and satisfactory alternative for performing MUA #nasal bones in the clinic for selected patients, particularly with reduction of elective theater capacity in the event of further COVID-19 surges. We recommend training junior ENT surgeons to perform this procedure under supervision with adequate protective measures.

The management of "fragile" and suspected COVID-19 surgical patients during pandemic: an Italian single-center experience.

BACKGROUND: During Coronavirus disease (COVID-19) pandemic entire countries rapidly ran out of intensive care beds, occupied by critically ill infected patients. Elective surgery was initially halted and acute non-deferrable surgical care drastically limited. The presence of COVID-19 patients into intensive care units (ICU) is currently decreasing but their congestion have restricted our therapeutic strategies during the last months. METHODS: In the COVID-19 era eighteen patients (8 men, 10 women) with a mean age of 80 years, needing undelayable abdominal surgery underwent awake open surgery at our Department. Prior to surgery, all patients underwent COVID-19 investigation. In all cases locoregional anesthesia (LA) was performed. Intraoperative and postoperative pain has been monitored and regularly assessed. A distinct pathway has been set up to keep patients of uncertain COVID-19 diagnosis separated from all other patients. RESULTS: Mean operative time was 104 minutes. In only one case conversion to general anesthesia was necessary. Postoperative pain was always well controlled. None of them required postoperative intensive care support. Only one perioperative complication occurred. Early readmissions after surgery were never observed. CONCLUSIONS: On the basis of our experience awake laparotomy under LA resulted feasible, safe, painless and, in specific cases, the only viable option. For patients presenting fragile cardiovascular and respiratory, reserves and in whom general anesthesia (GA) would presumably increase morbidity and mortality we encourage LA as an alternative to GA. In the COVID-19 era, it has become part of our ICU-preserving strategy allowing us to carry out undeferrable surgeries.

Dilutional local anaesthetic techniques in oncoplastic breast surgery and potential benefits during the COVID-19 pandemic and beyond.

INTRODUCTION: COVID-19 has changed the approach to operating on breast cancer for the benefit of patients, staff and the general population. One approach involves the switch from operating under general to local anaesthetic. We assess whether diluational local anaesthetic is as effective as the current standard approach. METHODS: Postoperative pain was recorded in prospective, consecutive patients undergoing wide local excision under dilutional local anaesthetic (concentration < 1mg/ml). Pain scores were documented at 0, 30 and 60 minutes and compared to a control group consisting of combined general with local anaesthetic. RESULTS: Pain significantly increased in the control group during the postoperative recovery. This was not seen in the dilutional local anaesthetic group that was non-inferior to the standard approach at 0, 30 and 60 minutes. CONCLUSION: Dilutional local anaesthetic provides a safe and effective alternative approach to operating on breast cancer patients whilst avoiding risky general anaesthetic in a COVID-19 pandemic environment.

Paracervical blocks facilitate timely brachytherapy amidst COVID-19.

PURPOSE: The COVID-19 pandemic presents serious challenges for brachytherapists, and in the time-sensitive case of locally advanced cervical cancer, the need for curative brachytherapy (BT) is critical for survival. Given the high-volume of locally advanced cervical cancer in our safety-net hospital, we developed a strategy in close collaboration with our gynecology oncology and anesthesia colleagues to allow for completely clinic-based intracavitary brachytherapy (ICBT). METHODS AND MATERIALS: This technical report will highlight our experience with the use of paracervical blocks (PCBs) and oral multimodal analgesia (MMA) for appropriately selected cervical ICBT cases, allowing for completely clinic-based treatment. RESULTS: 18 of 19 (95%) screened patients were eligible for in-clinic ICBT. The excluded patient had significant vaginal fibrosis. 38 of 39 intracavitary implants were successfully transitioned for entirely in-clinic treatment utilizing PCBs and oral MMA (97% success rate). One case was aborted due to inadequate analgesia secondary to a significantly delayed case start time (PO medication effect diminished). 95% of patients reported no pain at the conclusion of the procedure. The median (IQR) D2cc for rectum and bladder were 64.8 (58.6-70.2) Gy and 84.1 (70.9-89.4) Gy, respectively. Median (IQR) CTV high-risk D90 was 88.0 (85.6-89.8) Gy. CONCLUSIONS: In a multidisciplinary effort, we have successfully transitioned many ICBT cases to the clinic with the use of PCB local anesthesia and oral multimodality therapy in direct response to the current pandemic, thereby mitigating exposure risk to patients and staff as well as reducing overall health care burden.

[Recommendations for local-regional anesthesia during the COVID-19 pandemic]. / Recomendações para realização de anestesia loco­regional durante a pandemia de COVID­19.

Since the beginning of the COVID-19 pandemic, many questions have come up regarding safe anesthesia management of patients with the disease. Regional anesthesia, whether peripheral nerve or neuraxial, is a safe alternative for managing patients with COVID-19, by choosing modalities that mitigate pulmonary function involvement. Adopting regional anesthesia mitigates adverse effects in the postoperative period and provides safety to pati ents and teams, as long as there is compliance with individual protection and interpersonal transmission care measures. Respecting contra-indications and judicial use of safety techniques and norms are essential. The present manuscript aims to review the evidence available on regional anesthesia for patients with COVID-19 and offer practical recommendations for safe and efficient performance.

Anesthetic and surgical management of tracheostomy in a patient with COVID-19.

OBJECTIVE: The ongoing pandemic coronavirus disease-2019 (COVID-19) infection causes severe respiratory dysfunction and has become an emergent issue for worldwide healthcare. Since COVID-19 spreads through contact and droplet infection routes, careful attention to infection control and surgical management is important to prevent cross-contamination of patients and medical staff. Tracheostomy is an effective method to treat severe respiratory dysfunction with prolonged respiratory management and should be performed as a high-risk procedure METHOD: The anesthetic and surgical considerations in this case involved difficult goals of the patient safety and the management of infection among health care workers. Our surgical procedure was developed based on the previous experiences of severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV). RESULTS: We described the management procedures for tracheostomy in a patient with COVID-19, including the anesthesia preparation, surgical procedures, required medical supplies (a N95 mask or powered air purifying respirator, goggles, face shield, cap, double gloves, and a water-resistant disposable gown), and appropriate consultation with an infection prevention team. CONCLUSION: Appropriate contact, airborne precautions, and sufficient use of muscle relaxants are essential for performing tracheostomy in a patient with COVID-19.