Chapter 13 Performing Your First Cases With Walant
SUGGESTIONS ON GETTING STARTED
There are a number of wonderful descriptions in this book about WALANT and its use in some very complex surgical procedures. Chapter 1 offers an atlas with clear descriptions of exactly where to place injections of local anesthetic, how much to inject, and the correct formulation of injectate. For someone who has not used WALANT techniques, getting started can seem formidable. Here are some lessons I learned that I hope are helpful.
Choose your first cases carefully. Start small: trigger fingers, carpal tunnel releases, first dorsal compartments, simple masses, and skin lesions. Even if you never use WALANT for larger cases, this will still encompass a significant percentage of your schedule.
Choose your first patients carefully. Let them know what you are planning, and tell them that they are the first on whom you are using the technique. You have used local anesthesia before, so it′s OK to tell them that, and explain that the addition of epinephrine means that you may not have to use a tourniquet.
Put a tourniquet on the arm for your first few cases. You won′t use it, but it′s comforting to have it in place until you see for yourself how well this works. As a corollary, you can place the tourniquet for more complex surgeries and only inflate it for very brief periods when needed.
I still use a Penrose drain as a digital tourniquet for digital mucous cysts and nail bed cases. Patients do not feel it with a good digital block. (See Chapters 1, 4, and 5.)
Stay in your comfort zone. It takes a while to get comfortable with WALANT for some cases. If you have any doubts about a particular case, have the appropriate anesthesia personnel available in case you need to convert to general anesthesia.
The Use of Walant Techniques in Conjunction With General Anesthesia
I still use general anesthesia for most large cases. However, injection of lidocaine and epinephrine improves results in these cases as well. I would like to acknowledge the work of David L. Nelson, MD, in Marin County, California on postoperative pain management for providing the basis of this practice. (See www.DavidLNelson.MD.)
We all witness observable responses to painful stimuli, such as pulse rate increases, blood pressure elevation, and limb withdrawal in patients under general anesthesia. These hard-wired events occur even when sedation alters consciousness. WALANT techniques stop pain impulses from the tourniquet and nerve stimulation. The brain never experiences the “attack” of surgery. Patients need fewer drugs during the operation. This makes waking up and recovery time faster and much easier. Patients need less postoperative opioids (which may induce nausea), particularly if these are combined with a perioperative regimen of acetaminophen and nonsteroidal antiinflammatory agents.
I inject local anesthetic in the holding area, just as for WALANT cases, or after induction of general anesthesia, before prepping and draping the patient. The advantage of injection in the holding area is that the tumescent fluid spreads in the tissues, and hemostasis improves because the epinephrine has longer to induce vasoconstriction. However, some patients will not tolerate the injections while conscious, or the condition of the limb may require induction of anesthesia before it is unwrapped or manipulated.
Although the use of bupivacaine is not a part of WALANT technique for smaller cases, I inject 0.5% bupivacaine with epinephrine in the deep layers as well as in the skin while closing larger cases, which helps with postoperative pain control. (See Chapter 6 for more information on longer-lasting local anesthetics.)
TAKING THE FIRST STEP
Perhaps the biggest obstacle to starting WALANT surgery is taking the first step. If you started practice before 2005, you probably weren′t exposed to the WALANT concept in your training. Like me, you probably have done most of your ambulatory surgery cases with a combination of intravenous regional anesthesia, local with sedation, and/or general anesthesia. Usually this has worked well, except for the patients who had tourniquet pain and narcotic hangovers with nausea and vomiting. That is no longer the case when you perform the surgery with local injection only of 1% lidocaine with 1:100,000 epinephrine.
Patients can have breakfast, take their medications, and drive to and from the hospital or surgery center for their procedure. One of my patients, an 85-year-old with diabetes, drove to the hospital, underwent a carpal tunnel release with WALANT, and drove himself home. (However, see Chapter 7 for the potential legal problems to be addressed with patients using this approach.)
Another advantage of this technique is that you get to spend some time with patients and their families while you perform the local anesthetic injection and the wide awake procedure. It provides a significant opportunity for patient education.
Patients express greater overall satisfaction when you perform their procedure with the minimal pain method outlined in Chapter 5.
It may seem like a giant leap of faith to perform your cases with local anesthetic only. I have several suggestions for you if you are interested in using this technique.
Do Some Homework
There are several excellent articles published describing the WALANT technique and medication dosages.1–4 They are well worth your time to read, but their material is contained in greater detail in this book.