WALANT在门诊“小手术”中是必不可少的吗？

IF 0.9 4区医学 Q4 ORTHOPEDICS

Hand Surgery & Rehabilitation Pub Date : 2024-12-01 DOI:10.1016/j.hansur.2024.101859

Silvia Pietramala, Camillo Fulchignoni, Lorenzo Rocchi

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引用次数: 0

摘要

广角清醒局部麻醉（WALANT）是一种替代全身或区域麻醉的方法，在手外科医生中很流行，因为它是肌腱修复的理想选择，在这种情况下，患者的合作是至关重要的，避免了使用止血带，也给了患者更多的安慰。另一方面，对于外科医生来说，学习曲线很长，注射必须在手术开始前至少30分钟进行，这增加了每次手术所需的时间。与WALANT相关的并发症包括手指缺血和肾上腺素相关性心脏缺血。考虑到接受CTR的人大多是老年人，并且在没有麻醉师在场的情况下接受门诊服务，我们无法正确估计不良事件的风险。从2023年2月到2023年11月，我们选择了300例门诊手部手术（腕管松解术和扳机指）。每位患者均给予利多卡因局部麻醉，并在整个手术过程中在手臂处使用止血带。收集手术时间、手术类型、止血带期间患者疼痛不适情况等人口统计学资料（采用VAS评价）。手术平均时间为12分钟。最常见的手术是腕管松解。根据VAS，平均值为3.2。此外，我们注意到老年患者的VAS更高，手术时间更长。只有3例因患者不适而不得不在手术结束前松开止血带。尽管WALANT在一些手部手术（如创伤后肌腱松解或肌腱修复）中有帮助和关键作用，但风险-收益比并不能证明其在短期门诊手部手术中的应用是合理的。考虑到患者的平均年龄和可能干扰WALANT使用的合并症，本研究的一个局限性是缺乏对照组来验证在时间和低估并发症方面的有效劣势。

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Est-ce que la WALANT est indispensable dans la « petite chirurgie » de la main ambulatoire ?

Wide Awake Local Anesthesia (WALANT) is an alternative to general or regional anesthesia that became popular among hand surgeons for being ideal for tendon repair in which the cooperation of the patients is crucial, avoiding the use of the tourniquet, also giving more comfort to the patients. On the other hand, the learning curve is long for the surgeon and the injection must take place at least 30 minutes before starting the procedure, increasing the time needed to perform each surgery. Among the complications related to WALANT are digital ischemia and epinephrine-related-cardiac ischemia. Considering people undergoing CTR are mostly elderly and admitted to an outpatient service without the presence of an anesthesiologist, we cannot properly estimate the risk of adverse events.

From February 2023 to November 2023, we selected 300 patients who underwent outpatients hand surgery (carpal tunnel release and trigger finger). Each patient was administered local anesthesia with lidocaine and a tourniquet at the arm was applied for the whole length of the surgery. Demographic data were collected as long as the time of the surgery, the type of the surgery and the pain and discomfort felt by the patients during the tourniquet on period (evaluated with VAS).

Average length of the surgery was 12 minutes. The most common surgery performed was carpal tunnel release. The mean value, according to VAS, was of 3.2. Furthermore, we noted that the VAS was higher in older patients and longer surgeries. In only 3 cases, the tourniquet had to be released before end of surgery because of patient discomfort.

Despite WALANT being helpful and crucial to perform some hand surgeries, such as post-traumatic tenolysis or tendon repairs, the risk-benefit ratio doesn’t justify its use in short outpatient hand surgery. A limitation of our study is the lack of a control group to validate the effective disadvantage in terms of time and underestimated complications, considering the mean age of patients and the possible comorbidity that could interfere with the use of WALANT.

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来源期刊

Hand Surgery & Rehabilitation Medicine-Surgery

CiteScore

1.70

自引率

27.30%

发文量

审稿时长

49 days

期刊介绍： As the official publication of the French, Belgian and Swiss Societies for Surgery of the Hand, as well as of the French Society of Rehabilitation of the Hand & Upper Limb, ''Hand Surgery and Rehabilitation'' - formerly named "Chirurgie de la Main" - publishes original articles, literature reviews, technical notes, and clinical cases. It is indexed in the main international databases (including Medline). Initially a platform for French-speaking hand surgeons, the journal will now publish its articles in English to disseminate its author''s scientific findings more widely. The journal also includes a biannual supplement in French, the monograph of the French Society for Surgery of the Hand, where comprehensive reviews in the fields of hand, peripheral nerve and upper limb surgery are presented. Organe officiel de la Société française de chirurgie de la main, de la Société française de Rééducation de la main (SFRM-GEMMSOR), de la Société suisse de chirurgie de la main et du Belgian Hand Group, indexée dans les grandes bases de données internationales (Medline, Embase, Pascal, Scopus), Hand Surgery and Rehabilitation - anciennement titrée Chirurgie de la main - publie des articles originaux, des revues de la littérature, des notes techniques, des cas clinique. Initialement plateforme d''expression francophone de la spécialité, la revue s''oriente désormais vers l''anglais pour devenir une référence scientifique et de formation de la spécialité en France et en Europe. Avec 6 publications en anglais par an, la revue comprend également un supplément biannuel, la monographie du GEM, où sont présentées en français, des mises au point complètes dans les domaines de la chirurgie de la main, des nerfs périphériques et du membre supérieur.