Archives of Plastic Surgery

Korean Society of Plastic and Reconstructive Surgeons (대한성형외과학회)
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Tourniquet-Free Hand Surgery Using the One-per-Mil Tumescent Technique

  • Prasetyono, Theddeus O.H. (Division of Plastic Surgery, Department of Surgery, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia)
  • Received : 2012.11.28
  • Accepted : 2013.01.19
  • Published : 2013.03.15
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Abstract

Background A pneumatic tourniquet is generally used to achieve a bloodless operation field in hand surgery. However, this has changed with tumescent solution-based wide-awake surgery. This study is a preliminary prospective case series study to elaborate the formula and indications of the tumescent technique in hand surgery without a tourniquet. Methods Seven patients (age range, 4 months to 37 years) underwent hand or upper extremity surgery for conditions such as nerve palsy, electric burn defect, fingertip injury, contracture, constriction ring syndrome, or acrosyndactyly. A "one-per-mil" tumescent solution (epinephrine 1:1,000,000+20 mg lidocaine/50 mL saline) was used to create a bloodless operating field without a tourniquet. Observation was performed to document the amount of solution injected, the operation field clarity, and the postoperative pain. Results The "one per mil" epinephrine solution showed an effective hemostatic effect. The tumescent technique resulted in an almost bloodless operation field in the tendon and in the constriction ring syndrome surgeries, minimal bleeding in the flap and contracture release surgeries, and acceptable bleeding in acrosyndactyly surgery. The amount of solution injected ranged from 5.3 to 60 mL. No patient expressed significant postoperative pain. Flap surgeries showed mixed results. One flap was lost, while the others survived. Conclusions Epinephrine 1:1,000,000 in saline solution is a potential replacement for a tourniquet in hand surgery. Further studies are needed to delineate its safety for flap survival.

Keywords

References

  1. Lalonde DH, Lalonde JF. Discussion. Do not use epinephrine in digital blocks: myth or truth? Part II. A retrospective review of 1111 cases. Plast Reconstr Surg 2010;126:2035-6. https://doi.org/10.1097/PRS.0b013e3181f52549
  2. Lalonde DH. "Hole-in-one" local anesthesia for wide-awake carpal tunnel surgery. Plast Reconstr Surg 2010;126:1642-4. https://doi.org/10.1097/PRS.0b013e3181f1c0ef
  3. Higgins A, Lalonde DH, Bell M, et al. Avoiding flexor tendon repair rupture with intraoperative total active movement examination. Plast Reconstr Surg 2010;126:941-5. https://doi.org/10.1097/PRS.0b013e3181e60489
  4. Bezuhly M, Sparkes GL, Higgins A, et al. Immediate thumb extension following extensor indicis proprius-to-extensor pollicis longus tendon transfer using the wide-awake approach. Plast Reconstr Surg 2007;119:1507-12. https://doi.org/10.1097/01.prs.0000256071.00235.d0
  5. Denkler K. Dupuytren's fasciectomies in 60 consecutive digits using lidocaine with epinephrine and no tourniquet. Plast Reconstr Surg 2005;115:802-10. https://doi.org/10.1097/01.PRS.0000152420.64842.B6
  6. Wilhelmi BJ, Blackwell SJ, Miller JH, et al. Do not use epinephrine in digital blocks: myth or truth? Plast Reconstr Surg 2001;107:393-7. https://doi.org/10.1097/00006534-200102000-00014
  7. Chowdhry S, Seidenstricker L, Cooney DS, et al. Do not use epinephrine in digital blocks: myth or truth? Part II. A retrospective review of 1111 cases. Plast Reconstr Surg 2010;126:2031-4. https://doi.org/10.1097/PRS.0b013e3181f44486
  8. Lalonde D, Bell M, Benoit P, et al. A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase. J Hand Surg Am 2005;30:1061-7. https://doi.org/10.1016/j.jhsa.2005.05.006
  9. Lalonde DH. An evidence-based approach to flexor tendon laceration repair. Plast Reconstr Surg 2011;127:885-90. https://doi.org/10.1097/PRS.0b013e31820467b6
  10. Ohnhaus EE, Adler R. Methodological problems in the measurement of pain: a comparison between the verbal rating scale and the visual analogue scale. Pain 1975;1:379-84. https://doi.org/10.1016/0304-3959(75)90075-5
  11. Merkel SI, Voepel-Lewis T, Shayevitz JR, et al. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs 1997;23:293-7.
  12. Luk KD, Pun WK. Unrecognised compartment syndrome in a patient with tourniquet palsy. J Bone Joint Surg Br 1987; 69:97-9.
  13. Hirvensalo E, Tuominen H, Lapinsuo M, et al. Compartment syndrome of the lower limb caused by a tourniquet: a report of two cases. J Orthop Trauma 1992;6:469-72. https://doi.org/10.1097/00005131-199212000-00014
  14. Knuttgen D, Reifenrath W, Autze W, et al. Massive rigor and compartment syndrome after tourniquet in a patient with suspected malignant hyperthermia. Acta Anaesthesiol Scand 1999;43:239-40. https://doi.org/10.1034/j.1399-6576.1999.430223.x
  15. Dove AF, Clifford RP. Ischaemia after use of finger tourniquet. Br Med J (Clin Res Ed) 1982;284:1162-3.
  16. Karabagli Y, Kose AA, Cetin C. Toe necrosis due to a neglected tourniquet. Plast Reconstr Surg 2005;116:2036-7. https://doi.org/10.1097/01.prs.0000192374.34135.51
  17. Selvan D, Harle D, Fischer J. Beware of finger tourniquets: a case report and update by the National Patient Safety Agency. Acta Orthop Belg 2011;77:15-7.
  18. Durrant C, Townley WA, Ramkumar S, et al. Forgotten digital tourniquet: salvage of an ischaemic finger by application of medicinal leeches. Ann R Coll Surg Engl 2006;88:462-4. https://doi.org/10.1308/003588406X117052
  19. Avci G, Akan M, Yildirim S, et al. Digital neurovascular compression due to a forgotten tourniquet. Hand Surg 2003;8: 133-6. https://doi.org/10.1142/S0218810403001595
  20. Hou SM, Liu TK. Salvage of tourniquet-induced thumb necrosis by a modified wraparound procedure. J Trauma 1987;27:803-5. https://doi.org/10.1097/00005373-198707000-00021
  21. Lalonde DH. Reconstruction of the hand with wide awake surgery. Clin Plast Surg 2011;38:761-9. https://doi.org/10.1016/j.cps.2011.07.005
  22. Fitzcharles-Bowe C, Denkler K, Lalonde D. Finger injection with high-dose (1:1,000) epinephrine: Does it cause finger necrosis and should it be treated? Hand (N Y) 2007;2:5-11. https://doi.org/10.1007/s11552-006-9012-4
  23. 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;119:260-6. https://doi.org/10.1097/01.prs.0000237039.71227.11

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