Improved Resource Utilization Using WALANT Hand Surgery in Adolescents

Abstract

Background:

Cost, efficiency, patient preference, and safety have driven utilization of wide awake, local anesthesia, no tourniquet (WALANT) in hand surgery. This is not well documented in adolescents. We hypothesize that the use of WALANT with adolescents reduced time spent in the operating room (OR) and in the hospital when compared with patients who underwent surgery with traditional anesthesia (TA).

Methods:

After institutional review board approval, we performed a retrospective review of patients aged 10 to 17 who underwent surgery at a regional hospital system including the level 1 pediatric trauma hospital. Operative notes were assessed for use of WALANT. We excluded those operations not traditionally amenable to WALANT. Using a propensity matched cohort, hospital time, OR time, and perioperative complications were recorded and compared to evaluate efficiency and perioperative safety.

Results:

There were 28 cases in the WALANT group and 28 cases in the TA group after excluding cases not amenable to WALANT, and cases were propensity matched. Although the operative time (incision to closure) was similar, for WALANT patients, the in-room to procedure time (15 vs 22 minutes), procedure end to out-room time (5 vs 10 minutes), total room time (52.81 vs 63.68), and length of hospital stay (222 vs 342 minutes) were shorter than patients in the TA group.

Conclusion:

Our case series demonstrates time-savings both in the OR and in the hospital overall. Avoiding TA when WALANT is feasible may result in significant savings to hospital systems, patients, and payers while also freeing up anesthesia staff and perioperative nurses.

Introduction

Wide-awake hand surgery using local anesthesia and no tourniquet (WALANT) continues to gain popularity among hand surgeons and patients worldwide. For example, there is a Canadian study showing a majority of their surgeon cohort using WALANT in carpal tunnel surgery to acceptance of WALANT in South America.^1,2 There have been multiple studies documenting cost savings, efficiency, safety, and patient satisfaction.^{3 -6} However, in the pediatric and adolescent patient population, acceptance has been much slower, and there are little data regarding its use, outcomes, and satisfaction in this younger cohort. In a time when resource management, shorter hospital stays, and decreased costs are increasingly important in America and also the world, it is paramount that we investigate that use of WALANT in pediatric hand surgeries. ⁷ The purpose of this study was to evaluate a cohort of adolescent patients during the implementation phase of the WALANT technique to provide perioperative safety and compare time spent in each phase of the surgical experience.

Materials and Methods

After obtaining institutional review board approval, a data query was used to identify all patients between the ages of 10 and 17 who underwent surgical intervention by the senior author in an operative suite at a level 1 pediatric academic hospital or within part of a regional hospital system between 2016 and 2020. A priori non-inferiority sample size calculation at α = 0.05, β = 0.80, with a large effect size (Cohen d ≥ 0.80) was 26 cases in each group. This is based on institutional historical data on adult patients undergoing traditional anesthesia (TA) for hand surgeries showing a mean total length of hospital stay of 6 hours with a standard deviation of 2 hours.

Medical records were reviewed, and the following data were collected: age, sex, height, weight, procedure performed, operative time, anesthesia, and length of hospital stay. Cases who underwent WALANT were propensity matched to patients who did not based on age, sex, body mass index (BMI), procedure performed, and whether they were admitted from the emergency department (ED) or not. Cases not traditionally amenable to WALANT included carpal fractures, wrist fractures, and complex high energy wounds with possible need for artery repair. Cases traditionally amenable to WALANT surgery included fractures of the metacarpal and phalanges, tendon repair of the wrist hand and finger, and hand/finger infections. Length of operative time and length of stay were compared. Metrics regarding length of stay and perioperative times were recorded by nursing staff and automatically calculated in EPIC EMR (electronic medical records). Notes were reviewed for intraoperative or perioperative complications. All analysis was performed using IBM SPSS v27.0 (Armonk, New York). Continuous variables were compared using unpaired independent t tests, and categorical variables were compared using χ² tests.

As part of implementation of WALANT within this age group, patients and their families were offered both traditional (general or regional) and wide-awake surgical options when technically feasible. Patients who underwent WALANT surgery received an injection of 1% lidocaine with 1:100 000 epinephrine in the preoperative area. Those undergoing WALANT were encouraged to bring headphones or a tablet/phone to use during the procedure or a tablet was provided. For digital work, a block was performed with a subcutaneous injection in the middle of the phalanx with lidocaine and epinephrine (The SIMPLE block).^8,9 For interventions of the palmar hand, a median nerve block was performed first at the wrist and then more lidocaine with epinephrine was injected at the surgical site once the palm was anesthetized. A gentle pinch in the proximal forearm elicited by the patient was also used as a sensory disturbance to minimize injection pain. ¹⁰

Results

On initial query, there were 151 patients between the ages of 10 and 17 years old who underwent surgery by the senior author over 4 years. Eighty patients were excluded because their procedure was not amenable to wide-awake surgery. There were 28 cases in the WALANT group and 43 cases in the TA group. All 28 cases in the WALANT group were propensity matched to 28 cases in the TA group. As expected with propensity matching, the 2 groups were similar in age, sex distribution, BMI, number of cases admitted from the ED, and procedure performed. Although the operative time (incision to close) was similar in both groups, the in-room to procedure time (15.25 vs 21.93 minutes, P < .001), procedure end to out-room time (5.19 vs 10.00 minutes, P < .001), total room time (52.81 vs 63.68 minutes, P = .050), and length of hospital stay (222.14 vs 342.37 minutes, P = .005) were shorter in the WALANT cases compared with the TA cases (Table 1). It is important to note that all procedures were performed in the hospital setting. No surgeries took place in an ambulatory surgery setting or in the office. The data collected reflect EPIC EMR data collection regarding hospital stay and more. No patients in the WALANT group required conversion to TA, and no patients in either group had any intraoperative or perioperative complications. During WALANT surgery, no anesthesia provider was present or was asked to come to the room because of complication. Within the TA group, 6 patients had a regional block, 3 patients had local anesthesia with intravenous sedation, and the remaining 19 had general anesthesia.

Table 1.

Propensity Matched Cohort Demonstrating Statistically Significant Difference in In-Room to Procedure Start Time, Procedure End to Out-Room Time, Total Room Time, and Hospital Length of Stay Between WALANT and Non-WALANT Cases.

Characteristics, procedures, and operative time	Non-WALANT	WALANT	P value
Total	28	28
Sex, n (%)			.718
Female	4 (14%)	5 (18%)
Male	24 (86%%	23 (82%)
Age, years, mean (SD)	13.29 (2.18)	14.39 (2.11)	.029
Body mass index, kg/m2, mean (SD)	23.01 (5.87)	24.9 (6.28)	.129
Admit from ED	4 (14%)	2 (7%)	.669
Procedure			.453
Finger amputation	2 (7%)	0
Irrigation and debridement	4 (14%)	1 (4%)
Implant removal	2 (7%)	3 (11%)
Open reduction internal fixation	14 (50%)	15 (54%)
Scar revision	1 (4%)	2 (7%)
Tendon repair	5 (18%)	7 (25%)
Operative time	61.75 (38.88)	43.92 (29.43)	.111
InRoom to ProcedureStart, min, mean (SD)	21.93 (6.39)	15.25 (3.69)	< .001
ProcedureEnd to OutRoom, min, mean (SD)	10.00 (7.12)	5.19 (2.62)	< .001
Room time, min, mean (SD)	63.68 (27.74)	52.81 (23.16)	.050
Hospital length of stay, min, mean (SD)	342.37 (203.75)	222.14 (109.89)	.005

Note. ED = emergency department; WALANT = wide-awake hand surgery using local anesthesia and no tourniquet.

Discussion

At a time when staffing shortages and increasing costs are challenging an already stressed health care system, effective use of time and resources is critical. Previous studies in adults have highlighted the economic benefits of WALANT surgery. Comparing trigger release using WALANT versus monitored anesthesia care (MAC), Codding et al ¹¹ demonstrated 42 minutes more time spent in the recovery room for patients with MAC compared with those undergoing WALANT. In a study evaluating carpal tunnel release (CTR) in adults performed in a variety of settings, CTR with local in the operating room (OR) was shown to reduce both total direct costs and total combined payments compared with those patients undergoing surgery with other types of anesthesia in the OR. ¹² Although specific cost data were not available, we have demonstrated time-savings and thus possible decreased resource utilization in our adolescent cohort.

There is little published data representing a lack a utilization of WALANT in adolescent patients. This is likely multifactorial. Wide-awake surgery using lidocaine with epinephrine in the hand and finger represents a monumental shift for some in the OR setting, and this is often met with resistance from some OR staff. In our experience implementing a wide-awake hand surgery program, it was the dedicated pediatric hospitals that had a difficult time with adoption of this technique. Also, pediatric hospitals often operate as an “ouchless place” to mitigate anxiety and stress on those hospitalized. However, with modern WALANT techniques, injection pain is minimal. ¹³ There is also a paucity of clinical outcome data in the age group. A recent retrospective review was the first to report flexor tendon repair results in a pediatric population using only local anesthesia. ¹⁴ Hunyh et al showed surgical results to be equivocal in both local anesthetic and traditional groups in their study of 43 pediatric patients who underwent anesthesia with local only. Just 10 years ago, the idea of wide-awake surgery in a pediatric population for flexor tendon repair was not even mentioned as a possibility.^15,16 Finally, patients and their families also may have apprehension about the OR experience. Communication between the surgeon and the family is crucial in preparing pediatric patients for the wide-awake experience. Similar to our experience in adults, no patients required conversion to TA or requested anesthesia intervention during the surgery because of anxiety or insufficient anesthesia from the lidocaine with epinephrine. Likely, this lack of conversion does represent selection bias, as there are still patients who are best served with TA. Part of the WALANT procedure is screening; patients who had required some restraint from a parent for an immunization are not good candidates. If there is significant guarding, hesitancy, or crying during the initial examination, then TA is likely a more prudent option. And finally, a good conversation in the clinical setting prior to the OR with patient and family describing the “one little pinch” and then delivering on this promise builds confidence with the patient and their family. This allows the patient and family to relax and thus the surgeon to focus while in the operative suite.

Our study does have limitations. Actual cost data were not available to document savings, and our study was not randomized. Clinical outcome data were limited by patient follow-up, and there are no subjective measures of satisfaction. However, we hope and expect that utilization of WALANT in adolescents will continue to expand. It is our belief that studies aimed at outcomes, cost, and patient and family satisfaction with the surgical experience will help promote its adoption among pediatric patients.