IC56-R: Tips on How to Introduce WALANT into Your Practice Moderator(s): Alison F. Kitay, MD Faculty: MD, Steven M. Koehler, MD, Donald H. Lalonde, MD, and Robert E. Van Demark, Jr., MD Session Handouts 75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1-3, 2020 822 West Washington Blvd Chicago, IL 60607 Phone: (312) 880-1900 Web: www.assh.org Email: [email protected] All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain. 7/23/2020 IC56-R: Tips on How to Introduce WALANT into Your Practice Moderator: Alison F. Kitay, MD Faculty: Steven M. Koehler, MD, Donald H. Lalonde, MD, Robert E. Van Demark, Jr., MD 1 Alison F. Kitay, MD Speaker has no relevant financial relationships with commercial interest to disclose. 2 Why and How WALANT is Performed Alison Kitay, MD Summit Orthopedics, Washington, DC 3 1 7/23/2020 WALANT • Wide Awake Local Anesthesia No Tourniquet • Don Lalonde • Saint John, Canada 4 WALANT • Lidocaine with epinephrine injected wherever you will dissect 5 No Tourniquet- epinephrine • Epinephrine in finger is safe • Myth: • *1920-1945, Procaine (Novocaine) • *Procaine: only safely injectable local anesthetic until lidocaine introduction in 1948 • *Procaine pH 3.6, became more acidic on the shelf • *1948: FDA warning in JAMA, found batches of procaine with pH of 1 prior to injection • *More fingers necrosed from procaine alone than from procaine with epinephrine Lalond, Wide Awake Hand Surgery, 2016 Denkler er al. Plast Reconstr Surg. 2001 6 2 7/23/2020 Lidocaine with Epinephrine • 1% lidocaine with epi: pH 4.2 • Lidocaine with epi is safe in the finger • *Prospective study: 9 surgeons, 3110 consecutive cases no lost fingers, no phentolamine rescue required* • Large volumes safe • *Tumescent lidocaine and epinephrine: form of extravascular Bier block without painful tourniquet • *Up to 50 cc of 1% lidocaine with 1:100,000 epi is safe in adults (7 mg/kg) *Nodwell et al, Can J Plast Surg, 2003 Lalonde, Wide Awake Hand Surgery, 2016 7 White finger? 8 Phentolamine • Alpha-adrenergic blocking agent • Inject 1 mg phentolamine in 1 cc saline where there is “severe epinephrine pallor” in the skin • Extravascular dose does not affect BP • Finger pinks up within 1-2 hours • Dalhousie Project* • 85 min for normal color after phentolamine rescue • 320 min for normal color after saline “rescue” *Nodwell et al, Can J Plast Surg, 2003 9 3 7/23/2020 Why not bupivacaine? • Lower safety profile (cardiotoxic and fatal) • Numbness to pain lasts only 15 hours vs numbess to pressure/touch (~30 hours) • Lidocaine pain/pressure/touch numbness all comes back at same time • Lidocaine with epi lasts about 5 hours in wrist and 10 hours in finger 10 Injection Technique • Supine • Distraction techniques • 27 or 30 g needle 11 Injection Technique • Subdermal (not intradermal) • 90 degrees Lalonde, Wide Awake Hand Surgery, 2016 12 4 7/23/2020 Injection Technique • “Blow slow before you go” • Inject 1 cm ahead of needle tip Lalonde, Wide Awake Hand Surgery, 2016 13 “Blow slow before you go” Lalonde, Wide Awake Hand Surgery, 2016 14 Buffer lidocaine for less pain • 1: 100,000 1% lidocaine with epi: pH 4.2 • Add 1 cc 8.4% sodium bicarbonate for every 10 cc of lidocaine/epi increases pH to 7.4 (normal body pH) • Less pain during initial injection 15 5 7/23/2020 Adverse Effects • Pain • Epinephrine “rush” • Shakiness, “too much coffee” for ~20 minutes • Vasovagal • Transient elevation of BP and heart rate • Anxiety 16 Injection Technique- Common Mistakes • Too quick • Sharp needle tip gets ahead of local anesthestic • Reinserting needles into un-anesthetized skin • Avoid eliciting paresthesias- nerve laceration • Avoid injection tendon sheath- more pain, white finger (stay subQ) • Wait about 30 minutes prior to surgery 17 Patient Benefits • No pre-operative testing • No pre-operative physical • No IV • No fasting • Can drive home • No nausea/vomiting • No tourniquet pain • Education from surgeon during case • Can participate in surgery 18 6 7/23/2020 Surgical benefits • Improved results in flexor tendon repair surgery • Pulley • Gapping • *Tenolysis • *Rupture *Lalonde et al, Wide‐awake flexor tendon repair. Plast Reconstr Surg. 2009 19 Surgical benefits Tendon transfers- setting tension Bezuhly M et al, Plast Reconstr Surg. 2007 20 Field Sterility- cost savings • Localized sterile field • Minor procedure room • Surgeon: mask and sterile gloves (no gown) • No laminar airflow required 21 7 7/23/2020 Field Sterility • CTR with field sterility safe? Multicenter study (6 surgeons)* • 0.39% infection rate (6/1504 patients developed superficial infections) • None required I&D or IV abx or hospital admission • Only 4 required oral abx • None had pre-op abx *Leblanc et al, Hand 2011 22 Waste Garbage production > 10 times greater with main operating room sterility vs field sterility* *Leblanc et al, Hand 2007 23 Cost Savings • Military health system study: WALANT in clinic vs main operating room • 85% cost savings for CTR • 70% cost savings for trigger finger release • CTR, trigger, and de Quervain release: $393,100 in cost savings during study period (1/14-9/15). • No adverse events with WALANT Rhee et al, JHS, 2016 24 8 7/23/2020 WALANT • Huge benefits • Barriers to introducing WALANT to practice 25 9 7/23/2020 Steven M. Koehler, MD Consulting Fees: Integra LifeSciences, Inc. Speakers Bureau: TriMed, Inc. Ownership Interests: Reactiv, Inc. 1 Tips on How to Introduce WALANT into Your Office Steven Koehler, MD 2 Considerations • Procedure room set-up? • Waiting area? Separate space while allowing epi to set? • Sterilization/Tray Processing • Peel-packed instruments? • Billing - facility fee? • Bony procedures? • Implants? • Postop care? 3 1 7/23/2020 My Set-ups 4 Office 1 • Two small procedure rooms • I spend 1/2 day per week here (usually do ~6 cases but could do up to 9) • Install over-head light ($5-$15K) versus headlamp ($2K) • Mini C-arm available (run $50-75K new) • Sterilization agreement with nearby hospital. • Stock 9 trays, 2 TPS trays, 1 TPS box, 1 bovie machine 5 6 2 7/23/2020 7 8 Office 2 • Single procedure room • I use 1/2 day per week (typically do 4-5 cases) • Adapted from interventional pain management who use other days • No over-head light - use headlamp ($2K) • No mini C-arm available, but large available • Another sterilization agreement with nearby hospital. • Stock 6 trays, 1 cordless drill/driver, 1 bovie machine 9 3 7/23/2020 10 My universal trays for every procedure 11 12 4 7/23/2020 My workflow at both sites • 4 patients come at a time • Takes me 30 min to consent 4 patients, inject them, AND set up the room for the first case • By the time the fourth patient is consented and injected, the first patient is ready for surgery. • Patients undergoing bony procedures are injected first to ensure full anaesthetization and go last. • Patients are operated on in the order that they received an injection from the surgeon. • There is approximately a five-minute turnover time between cases • No room cleaning between cases • If operating on more than 4 patients, I consent and inject the next patients during turnover. 13 YOU matter more than ever • Be cognizant of your demeanor • ENGAGE the patient…partner with them • De-mystify surgery. show them and teach them. they will be better postoperative patients. They will appreciate you more. • It starts with the injection - make it painless and surgery will go well. Follow the steps Dr. Lalonde outlines. 14 Sterilization • Probably the hardest part • Easiest answer - have your local hospital do it for you! • Cheap and painless. Just need to transfer trays safely (wrap in heavy plastic) • Some unwilling, however • Options • Single use instruments • Not cheap, but easy. • Install own sterilization systems • LOTS of regulations • Easiest answer: visit your local dentist, oral surgeon. They all do this in their offices - replicate their setup. Also, many plastic surgeons also have procedure rooms in their offices and sterilize their own equipment. Can also replicate. 15 5 7/23/2020 Beyond carpal tunnels and trigger fingers 16 Wait longer than 27min after injection for a DRY field Dupuytren’s Example Multiple peri‐incisional injection points Proximal block 17 Use “tumescent” anesthesia The fallacy of 7mg/kg…1948 epidural dosing! No current actual FDA guidelines 28mg/kg has been shown to be safe* I inject about 80‐100cc of 1% lidocaine with epi in 70kg adult and comfortably use the 22mg/kg guideline *Anesth Analg. 2016;122(5):1350. LAST is not really an issue with lidocaine. 18 6 7/23/2020 19 Can be surprisingly dry – if you wait! Wait at least 60 min for a massive forearm case or bony cases. The longer you wait ‐ the drier the field. The local lasts a long time. I have done 4‐5 hour cases under local only without redosing. 20 abscesses 21 7 7/23/2020 Ulnar nerve 22 Propeller Flap 23 Expand your horizons - implants and bony work • Stock on the shelf? I don’t - reps bring what I need • How to bill? No facility fee associated...so how to bill implants? • Contact payors directly. Many will negotiate a fee. • Need to negotiate a contract with implant company. Smaller companies more willing to work with you. • Can charge an implant fee to the patient. • All else fails - move it to the ASC or Hospital. • Implant choices matter A LOT. • EASY, comprehensive, versatile AND affordable is important. • Don’t have shelves of options/backups available • I don’t have scrub tech - so I do it all myself.