Discussion
Hematoma, bleeding, postoperative pain, ischemia, pain, infection, hematoma, vasovagal
HEMATOMA, BLEEDING, INFILTRATION, HAND ISCHEMIA, ADVERSE EVENTS, ISCHEMIA, DISEASE, ADVERSE EFFECTS, COMPLEX REGIONAL PAIN SYNDROME, ADVERSE EVENT, INFECTION, BLIND, EXSANGUINATION, HEMATOMA, DISEASES, COMPLICATIONS
The infiltration with local anesthetic with vasoconstrictor for hand surgery promoted analgesic effect similar to local anesthesia associated with sedation, without the increase in adverse effects and complications. In this study, all patients were evaluated preoperatively and operated on by the same surgeon, a board certified hand surgeon.The local anesthetic is acidic, causing pain during its administration, and the bicarbonate has the action of neutralizing the acidity, decreasing considerably the pain of the injection. The pain is mild to none as long as the infiltration is applied slowly and with pauses.Patients could feel discomfort when undergoing surgery without sedation, however, on the questionnaire, they reported no discomfort from being awake, and comfort during surgery was similar regardless of the anesthetic techniqueThere was no further need for anesthetic or analgesic complementation after the procedure in both groups. The volume of local anesthetic (10 mL) is in agreement with the literature as sufficient to perform all proposed surgeriesIn surgery with local anesthetic associated with sedation, bleeding is not observed through the use of pneumatic tourniquet. The WALANT technique must respect some principles, one of them is to wait for the vasoconstrictor to take effect before starting the surgery. According to one study, this time is between 25 to 30 minutesIn this study, the surgery was of short length, decreasing the time of tourniquet and ischemia of the sedation group. Also, the time to discomfort of the patient undergoing surgery without sedation was mild. In this study, the duration of surgery was not statistically significant, but it was longer in the WALANT group by a small margin. In a systematic review, the duration of surgical time was longerIn this study, 25 minutes were waited before the surgical incision in the WALANT group, as in the literatureThe duration of WALANT surgery in this research was slightly longer as in a systematic reviewThe intensity of postoperative pain in this study, with no difference between the groups, and the anesthesia used did not interfere with postoperative pain control, and opioid use was similar for conventional anesthesia and WALANT technique as in a study in the literatureIn this study, the most frequent adverse event was hematoma, but with no difference between the groups. Hematoma can be related to the lack of tourniquet in the WALANT technique, but we haven’t found any reports in which the end of the epinephrin effect could cause an increase in bleeding. We haven’t found any reports suggesting the end of the use of tourniquet caused an increase in bleeding and hematoma neither, even though the sedation group had similar cases of hematoma as the WALANT group. In one review, the authors reported no difference in patient complicationsThe adverse effects in this study were similar in the groups, and no serious adverse events such as ischemia associated with vasoconstrictor use were observed. After hand surgery, it is a frequent occurrence to develop complex regional pain syndrome, impairing rehabilitation. The Budapest criteria is used for the clinical diagnosis of complex regional pain syndromeThe comparison between adrenaline and non-adrenaline anesthesia without sedation cannot be done. Even though the expected surgery time for all diseases in the study is short, the non-adrenaline group need to exsanguinate the upper limb for surgery to be done. The exsanguination is painful for the non-sedated patient, and if surgery takes longer, the patient will feel a lot of discomfort. If exsanguination is not done, the surgery time of the non-adrenaline group would rise and with that the possibility of more complications, such as infection, hematoma and possibly others.One advantage of the WALANT technique is that it can be done as in office procedure, without the need of a complete surgical setting. Another one is that the patient is discharged right after surgery, which can potentially decrease cost, and since sedation is not performed the patient does not need to be fasting. One disadvantage is the possibility of vasovagal reflex, that is easily reversed by stopping the local anesthesia and elevating the patient legs until they feel better.As limitations of the study, it is not possible to blind the study completely. The sample was small compared to other similar studies, and, even though all illnesses had similarities with the surgery done, it is hard to compare different diseases that can have different outcomes postoperatively. A larger study with only one disease comparing the two techniques would be necessary.