Evaluation of the Impact of a Tourniquet Training Program: A Cross-Sectional Study.

Among the main preventable causes of death in the area of operations is external exsanguinating hemorrhage in the extremities, hence the importance of the tourniquet as a therapeutic tool in this type of injury and, therefore, of the training of personnel participating in international missions. The main objective of this study is to determine the impact of training in the application of this device. This is a quasi-experimental, prospective, cross-sectional study, carried out with 97 healthy volunteers, military personnel who perform their work in the Royal Guard barracks of El Pardo. The study was conducted between June 2019 and July 2021. The correct determination of the device placement site and the times of correct device placement were evaluated by determining whether there was blood flow using Doppler ultrasound measurements. Statistically significant results were obtained for application time (76.68 s to 58.06 s; p < 0.001), correct device placement (p < 0.001), and achievement of complete ischemia in the upper extremity (23.7% pretest vs. 24.7% post-test; p < 0.001). In the lower extremity, after training, longer application duration (43.33 s to 47.30 s) and lower ischemia achievement (59.8% pretest vs. 37.8% post-test) were obtained. Standardized and regulated training improves device application. More intensive training is necessary to obtain better results.

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.

Association of Use of Tourniquets During Total Knee Arthroplasty in the Elderly Patients With Post-operative Pain and Return to Function.

Objective: During total knee arthroplasty (TKA), tourniquet may negatively impact post-operative functional recovery. This study aimed at investigating the effects of tourniquet on pain and return to function. Methods: Pubmed, Embase, and Cochrane Library were comprehensively searched for randomized controlled trials (RCTs) published up to February 15th, 2020. Search terms included; total knee arthroplasty, tourniquet, and randomized controlled trial. RCTs evaluating the efficacies of tourniquet during and after operation were selected. Two reviewers independently extracted the data. Effect estimates with 95% CIs were pooled using the random-effects model. Dichotomous data were calculated as relative risks (RR) with 95% confidence intervals (CI). Mean differences (MD) with 95% CI were used to measure the impact of consecutive results. Primary outcomes were the range of motion (ROM) and visual analog scale (VAS) pain scores. Results: Thirty-three RCTs involving a total of 2,393 patients were included in this study. The mean age is 65.58 years old. Compared to no tourniquet group, the use of a tourniquet resulted in suppressed ROM on the 3rd post-operative day [MD, -4.67; (95% CI, -8.00 to -1.35)] and the 1st post-operative month [MD, -3.18; (95% CI, -5.92 to -0.44)]. Pain increased significantly when using tourniquets on the third day after surgery [MD, 0.39; (95% CI, -0.19 to 0.59)]. Moreover, tourniquets can reduce intra-operative blood loss [MD, -127.67; (95% CI, -186.83 to -68.50)], shorter operation time [MD, -3.73; (95% CI, -5.98 to -1.48)], lower transfusion rate [RR, 0.85; (95% CI, 0.73-1.00)], higher superficial wound infection rates RR, 2.43; [(5% CI, 1.04-5.67)] and higher all complication rates [RR, 1.98; (95% CI, 1.22-3.22)]. Conclusion: Moderate certainty evidence shows that the use of a tourniquet was associated with an increased risk of higher superficial wound infection rates and all complication rates. Therefore, the findings did not support the routine use of a tourniquet during TKA.

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.

The what, why and when of wide awake local anaesthesia no tourniquet surgery.

Wide awake local anaesthesia no tourniquet, also known as WALANT, is the practice of performing surgery under local anaesthetic in the absence of a tourniquet. This technique uses the vasoconstrictive effects of adrenaline and the local anaesthetic effects of lignocaine to establish a Bier block with haemostatic control. Permitting active patient participation intraoperatively, wide awake local anaesthesia no tourniquet surgery improves patient compliance with rehabilitation and yields higher patient satisfaction. With reduced cost and equipment requirements, this method improves accessibility for patients and productivity for healthcare institutions. This is of particular benefit within the current COVID-19 climate, as wide awake local anaesthesia no tourniquet technique provides a means of overcoming restrictions to theatre access and anaesthetic support. This review delves into the current uses of wide awake local anaesthesia no tourniquet surgery, outlining the initial conception of the practice by Canadian surgeons. The advantages and disadvantages are considered, and potential future applications of this technique are discussed.

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.

Wide-awake local anaesthesia no tourniquet (WALANT) vs regional or general anaesthesia for flexor tendon repair in adults: protocol for a systematic review and meta-analysis.

BACKGROUND: Flexor tendon injuries most commonly occur following a penetrating injury to the hand or wrist. These are challenging injuries and the standard treatment is surgical repair under general or regional anaesthesia. 'Wide-awake' surgery is an emerging technique in hand surgery where a conscious patient is operated on under local anaesthetic. The vasoconstrictive effect of adrenaline (epinephrine) creates a 'bloodless' operating field and a tourniquet is not required. The potential advantages include intra-operative testing of the repair; removal of the risks of general anaesthesia; reduced costs; no aerosol generation from intubation therefore reduced risk of COVID-19 spread to healthcare professionals. The aim of this study will be to systematically evaluate the evidence to determine if wide-awake surgery is superior to general/regional anaesthetic in adults who undergo flexor tendon repair. METHODS: We designed and registered a study protocol for a systematic review and meta-analysis of comparative and non-comparative studies. The primary outcome will be functional active range of motion. Secondary outcomes will be complications, resource use (operative time) and patient-reported outcome measures. A comprehensive literature search will be conducted (from 1946 to present) in MEDLINE, EMBASE, CINAHL, and Cochrane Library. Grey literature will be identified through Open Grey, dissertation databases and clinical trials registers. All studies on wide-awake surgery for flexor tendon repair will be included. The comparator will be general or regional anaesthesia. No limitations will be imposed on peer review status or language of publication. Two investigators will independently screen all citations, full-text articles and abstract data. Potential conflicts will be resolved through discussion or referral to a third author when necessary. The study methodological quality (or bias) will be appraised using an appropriate tool. If feasible, we will conduct a random effects meta-analysis. DISCUSSION: This systematic review will summarise the best available evidence and definitively establish if function, complications, cost, or patient-reported outcomes are improved when flexor tendons are repaired using wide-awake technique. It will determine if this novel approach is superior to general or regional anaesthesia. This knowledge will help guide hand surgeons by continuing to improve outcomes from flexor tendon injuries. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020182196.

A protocol for wide awake local anaesthetic no tourniquet (WALANT) hand surgery in the context of the coronavirus disease 2019 (COVID-19) pandemic.

There are new and unique challenges to emergency surgery service provision posed by the Coronavirus disease 2019 global pandemic. It is in the best interests of patients for care providers to streamline services where possible to maximise the number of cases that can be performed by limited surgical and anaesthetic teams, as well as minimising patient interactions and admission times to reduce potential spread of the virus. There is evidence that wide awake local anaesthetic no tourniquet (WALANT) hand and upper limb surgery can meet this need in a number of ways, including reduced pre-operative work up, the lack of a need for an anaesthetist or ventilator, shorter inpatient stays and improved cost efficiencies. Though updated national guidelines exist that advocate increased use of WALANT surgery in response to the pandemic there are not yet clear protocols to facilitate this. We outline a protocol being developed at one UK Major Trauma Centre tailored to the expansion of WALANT hand and upper limb emergency surgery with particular emphasis on facilitating timely surgical care while minimising healthcare encounters pre and post-operatively. This will serve to reduce potential transmission of the virus and create cost efficiencies to free funding for COVID-19 related care. Our protocol is easily replicable and may be of benefit to other centres dealing with emergency upper limb surgery in the new climate of COVID-19.