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Is "Wide Awake“ Hand Surgery Safe and Reliable? – Systematic Literature Review and Experience in 163 Own Patients
Andreas Gohritz, MD
Basel University Hospital, Basel, Switzerland
Introduction: In hand surgery controversy persists on the application of local anesthetics combined with epinephrine, instead of a tourniquet, due to the alleged risk of ischaemic complications. Objective: This systematic review and clinincal result analysis aimed at investigating the reliability, safety and complication rate of the ăwide-awakeŇ approach in hand surger, which combines lidocaine anesthesia with epinephrine for vasoconstriction to avoid tourniquet use.
Methods: A systematic literature review was conducted according to PRISMA (Preferred Items for Systematic Review and Meta-Analyses) guidelines, based on Pubmed hits between 1980 to 2016 . All studies reporting clinical outcome of ăwide awakeŇ hand surgery were included. Major complications were defined as severe systemic reaction and tissue ischemia requiring antidot (phentolamine) or resulting in necrosis. Minor complications included transient adverse events, like excessive bleeding or patient discomfort. Furthermore, the results of 163 own cases were analyzed.
Results: Overall, 31 studies met the inclusion criteria involving a total of 6115 patients. 23 studies used a 1:100 000 and 6 a 1:1 000 000 lidocaine/epinephrine dilution. Major complications were observed in 5 patients (0.08%), including one CRPS, two digital nerve injuries, one digital artery injury and one finger tip necrosis. This necrosis happened after 1:100 000 lidocaine/epinephrine anesthesia for trigger finger release in a 70-year old female with diabetes mellitus, previous ischemic stroke and severe arteriosclerosis. Minor complications were reported in 38 patients (0,62 %), mostly excessive bleeding in 15 cases. In 163 consecutive cases treated at our at our institution between 2014 and 2016 (21 % nerve decompressions, 20 % osteosyntheses and hardware removal, 15 % trigger finger release), no serious complication occured. Excessive bleeding as minor complication was observed only initially, before a 20 minutes latency phase was introduced between anesthesia injection and surgical incision. No serious complications occured.
Conclusion: The combination of local anaesthesia with epinephrine in hand surgery proves to be safe and reliable and offers many advantages for the patient and surgeon. Complications due to epinephrine-induced vasoconstriction are rare, if caution is taken to exclude risk factors for local ischaemia. Minor complications, e.g. a blood-blurred operative field can be reduced by a latency phase, until optimal epinephrine induced vasoconstriction is established.
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