METHODS: We conducted a randomized controlled study on patients with closed fracture of the distal end of the radius requiring open reduction and plating from January 2019 till April 2020. We recruited 65 patients (33 patients in the WALANT group and 32 patients in the GA group). Randomization was done via block randomization. Data were collected to evaluate preoperative anxiety using the Amsterdam Preoperative Anxiety and Information Scale (APAIS) score, intraoperative pain score during injection (baseline) (V1), 10 minutes after injection (V2), during incision (V3), during gentle manipulation (V4), during aggressive manipulation (V5) and during first drilling of screw (V6), blood loss, duration of surgery and post-operative pain score. Additionally, intraoperative visual analog scale (VAS) score was obtained in the WALANT group. At three weeks, six weeks, three months and six months after operation, the Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) scores and range of motion (ROM) of the wrists were obtained.
RESULTS: The average age in the WALANT group was 47.19 (range, 36-64) years and GA group was 49.48 (range, 38-60) years. The mean APAIS score obtained was 7.78 (WALANT group) and 7.36 (GA group) with no statistical difference. For intraoperative VAS, only during V4 and V5 were the scores 1/10; otherwise at all other phases, the VAS score was 0. The average time for surgery was statistically longer in the WALANT group (61.22 minutes) compared to the GA group (55.33 minutes) (p = 0.003). There was no statistical difference in mean blood loss in both groups. The average post-operative VAS showed statistical significance only at 1 hour and 12 hours post-operation with no statistical difference at 2 and 24 hours post-operation. There was no difference in the post-operative ROM including wrist flexion, extension, supination and pronation for both groups up to six months' follow-up.
CONCLUSION: There was no statistically significant difference in terms of preoperative anxiety level, intraoperative and post-operative VAS score, amount of blood loss and clinical outcome in both groups for plating of the distal end radius. However, the operating time was slightly longer in the WALANT group. We conclude that distal radius plating under WALANT has similar outcomes to GA. In centres with limited resources, WALANT offers a safe, reliable and cheaper option, reserving GA time for head, abdominal and thoracic surgery.
Materials and methods: A systematic literature survey was adopted in this paper, involving the review of 25 relevant researched articles found in the databases Science Direct, EBSCO, MEDLINE, CINAHL and PubMed.
Result: The systematic literature survey reveals five variables to be core predictors of TQM, signifying how important these variables are in the successful implementation of TQM in the health-care context. Also, it is revealed that the identified core predictors have positive effects on an improved health-care system. However, the systematic survey of the literature reveals a dearth of studies on TQM in the health-care context.
Conclusion: As TQM has become an important management approach for advancing effectiveness in the health-care sector, this kind of research is of value to researchers and managers. Stakeholders in the health sectors should introduce and implement TQM in hospitals and clinics. Nevertheless, this study has limitations, including that the databases and search engines adopted for the literature search are not exhaustive.
METHODS: We report a case series of 16 patients who successfully underwent fixation of the clavicle under the wide-awake technique. The clavicle fractures were grouped under the AO Fracture Classification. The WALANT solution comprised 1% lidocaine, 1:100,000 epinephrine, and 10:1 sodium bicarbonate. A total of 40 mL was injected in each patient with 10 mL subcutaneously along the clavicle followed by 30 mL subperiosteally at multiple intervals and directions.
RESULTS: The Numerical Pain Rating Score was 0 during WALANT injection and during surgery except for 2 patients with Numerical Pain Rating Scores of 1 and 2, respectively, during reduction.
CONCLUSION: We conclude that clavicle plating under WALANT is a good alternative option of anesthesia.
STUDY DESIGN: Prospective, randomized, blinded clinical trial.
ANIMALS: A total of 40 adult wild common palm civets, 24 female and 16 male, weighing 1.5-3.4 kg.
METHODS: The civets were randomly assigned for anesthesia with butorphanol, azaperone and medetomidine (0.6, 0.6 and 0.2 mg kg-1, respectively; group BAM) or with butorphanol, midazolam and medetomidine (0.3, 0.4 and 0.1 mg kg-1, respectively; group BMM) intramuscularly (IM) in a squeeze cage. When adequately relaxed, the trachea was intubated for oxygen administration. Physiological variables were recorded every 5 minutes after intubation. Following morphometric measurements, sampling, microchipping and parasite treatment, medetomidine was reversed with atipamezole at 1.0 or 0.5 mg kg-1 IM to groups BAM and BMM, respectively. Physiological variables and times to reach the different stages of anesthesia were compared between groups.
RESULTS: Onset time of sedation and recumbency was similar in both groups; time to achieve complete relaxation and tracheal intubation was longer in group BAM. Supplementation with isoflurane was required to enable intubation in five civets in group BAM and one civet in group BMM. All civets in group BAM required topical lidocaine to facilitate intubation. End-tidal carbon dioxide partial pressure was lower in group BAM, but heart rate, respiratory rate, rectal temperature, peripheral hemoglobin oxygen saturation and mean arterial blood pressure were not different. All civets in both groups recovered well following administration of atipamezole.
CONCLUSIONS AND CLINICAL RELEVANCE: Both BAM and BMM combinations were effective for immobilizing wild common palm civets. The BMM combination had the advantage of producing complete relaxation that allowed intubation more rapidly.
METHODS: Sixty-one adult patients who underwent diaphyseal plating of the forearm under WALANT between the period of January 2019 and January 2021. It consists of 31 radius fractures, 15 ulna fractures and 15 ipsilateral radius and ulna fractures. Outcomes evaluated were duration of stay, peri-operative numerical pain rating scale, peri-operative blood pressure and heart rate, visual analogue scale for anxiety, blood loss, surgery duration, adverse effect, patient's satisfaction and any complications at 6 months follow up.
RESULTS: Fifty-four patients (88.5%) were male and 7 patients (11.5%) were female with a mean age of 31.7 years (SD = 13.564). Thirty-eight out of 61 patients were totally pain free throughout the surgery. Ten (13%) patients reported pain during muscle dissection, 14 (18%) patients reported pain during bone manipulation and 12 (16%) patients reported pain during bone drilling. There was no significant difference in pain score between radius and ulna bones (P > .05). There was a significant change in blood pressure after LA infiltration (P < .01). The mean estimated blood loss was 27.39 ml (SD = 11.44) and the mean duration of post-surgery hospital stay was 1 day (SD = 1.026). Fifty-six patients (92%) recommended diaphyseal plating of the forearm under WALANT. None of the patients required conversion to general anesthesia and had any adverse events or infection during 6 months follow up.
CONCLUSIONS: Diaphyseal plating of the forearm under WALANT is a feasible alternative anesthesia technique and is well tolerated by patients.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.
METHODS: This was a prospective study with patients divided into either the WALANT or GA cohort. The waiting time for surgery, Amsterdam Preoperative Anxiety and Information Scale, blood pressure, and heart rate were measured. Postsurgical questionnaires with the visual analog scale were completed. The surgeon's feedback on the ease of ganglion stalk visibility and usage of diathermy as a measure of a bloodless field was recorded. Patients reported the amount of analgesia consumed and overall satisfaction with the operation via the Surgical Satisfaction-8 questionnaire.
RESULTS: A total of 42 patients underwent wrist ganglion excision in 2 orthopedic centers over a period of 2 years, with 21 undergoing GA and 22 undergoing WALANT. The GA group was more anxious about anesthetic use with a higher demand for information about GA (P = .04). The duration of surgery was significantly shorter in the WALANT group and with a lower diathermy usage (P < .001). There was no difference in terms of surgical difficulty and stalk visualization. The visual analog scale pain score was significantly lower in the WALANT group than in the GA group immediately after surgery (P = .04) and on discharge (P = .004). While at home for 2 weeks, the WALANT group (mean = 2.91 tablets) consumed significantly fewer analgesic tablets than the GA group (mean = 6.25 tablets). However, both groups were satisfied with their experience.
CONCLUSIONS: Wide-awake local anesthesia no tourniquet technique in the excision of ganglions provides another option of anesthesia with painless experiences, and no pain rebound after surgery. Patients were less anxious about WALANT than GA. Excision can be performed without diathermy usage with similar visualization of the stalk.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.
METHODS: Twenty-four participants were randomly assigned to the therapeutic group (n = 19) (1% lidocaine in 1:100,000 adrenaline) and control group (n = 5) (2% lidocaine alone). Clinical parameters, including skin necrosis, duration of recovery of sensation, and lidocaine toxicity, were monitored. The serum lidocaine level was measured at different time intervals using a high-performance liquid chromatography reagent.
RESULTS: No lidocaine toxicity was recorded in any participant. The therapeutic group had a longer time for recovery of sensation. There was a significant difference in the serum lidocaine levels between both the groups at all time intervals up to 6 hours, with all participants exhibiting serum lidocaine levels below the mild toxicity level of 6.0 μg/mL.
CONCLUSIONS: Lidocaine used within a safe recommended dose in wide-awake local anesthesia no tourniquet for distal radius plating is clinically and biochemically safe.
CLINICAL RELEVANCE: Determining the clinical and biochemical safety profile of lidocaine with adrenaline in wide-awake local anesthesia no tourniquet can promote wider use of this technique.