The Safety of Wide-Awake, Local Anesthesia, No Tourniquet Hand Surgery: Two Cases of Digital Ischemia

Abstract

PURPOSE: Wide-awake, local anesthesia, no tourniquet (WALANT) hand surgery has gained popularity in recent years. Lidocaine with low-dose epinephrine is used to minimize blood loss and improve patient comfort. WALANT surgery reduces the need for preoperative testing, avoids sedation requirements, allows for patient cooperation during surgery, and decreases cost and procedure time.1 Multiple studies show that local anesthesia with epinephrine is safe to use in the fingers;1,2 however, a few cases of ischemia have been reported.3,4 MATERIALS AND METHODS: We present 2 cases of digital ischemia after WALANT surgery that were successfully reversed with phentolamine. RESULTS: Case 1—A 31-year-old female with rheumatoid arthritis underwent nail plate removal for chronic paronychia performed under a digital block (5 ml of 1% lidocaine with 1:100,000 epinephrine). The patient presented to the emergency room 12 hours later with persistent ischemia and anesthesia. Topical nitroglycerin cream and a warm compress were applied with minimal improvement. Five milligrams of phentolamine in 1 ml of sterile saline was injected at the base of the proximal phalanx with complete resolution of ischemia within 2 hours. At 1-week follow-up, the patient’s finger was perfused. Case 2—A 76-year-old female with multiple medical comorbidities, including cardiac stents (on apixaban) and COPD (on 3 L of home oxygen), underwent trigger finger release under local anesthesia (6 ml of 1% lidocaine with 1:100,000 epinephrine mixed 1:1 with 0.25% plain bupivacaine). She returned to clinic 4 hours later with persistent ischemia. Topical nitroglycerin cream and a warm compress were applied without improvement. 1.5 mg of phentolamine in 1 ml of sterile saline was injected at the level of the A1 pulley. After 90 minutes, there was some improvement but the finger remained ischemic distal to the proximal interphalangeal joint. Another 1.5 mg of phentolamine in 1 ml of sterile saline was injected at the level of the proximal interphalangeal joint with significant improvement. At 10-day follow-up, the patient’s finger was perfused. CONCLUSION: Prolonged digital ischemia after WALANT surgery is rare, but surgeons should counsel patients on warning signs and be prepared for phentolamine rescue when needed. The incidence of epinephrine-induced digital ischemia may increase as WALANT surgery gains popularity. It is mandatory for surgeons performing WALANT procedures to have access to phentolamine. REFERENCES: 1. Al Youha S, Lalonde DH. Update/review: changing of use of local anesthesia in the hand. Plast Reconstr Surg Glob Open. 2014;2:e150. 2. Thomson CJ, Lalonde DH, Denkler KA, et al. A critical look at the evidence for and against elective epinephrine use in the finger. Plast Reconstr Surg. 2007;119:260–266. 3. Zhu AF, Hood BR, Morris MS, et al. Delayed-onset digital ischemia after local anesthetic with epinephrine injection requiring phentolamine reversal. J Hand Surg Am. 2017;42:479 e471–479 e474. 4. Zhang JX, Gray J, Lalonde DH, et al. Digital necrosis after lidocaine and epinephrine injection in the flexor tendon sheath without phentolamine rescue. J Hand Surg Am. 2017;42:e119–e123.