Wide-Awake Local Anesthesia and No Tourniquet (WALANT) in open thumb fracture under antithrombotic therapy: overcoming an impasse

Performing digital blocks with epinephrine is a matter of debate,¹ but there is considerable evidence that supports the tenet that properly used epinephrine in the fingers is not unsafe.² We report a case where a digital block with epinephrine helped us to overcome an “impasse”.

A 53 years old patient had an occupational accident. He presented an open fracture of the distal phalanx of the thumb with a large dorsal linear wound next to the distal interphalangeal joint. Just before entering the OR he presented a chest pain and an acute myocardial infarction was diagnosed. The operation was postponed and a transradial coronary angiography immediately performed under dual platelet therapy (ticagrelor, acetylsalicylic acid) and enoxaparin. The mid right coronary artery was approximately 90% blocked and was treated by thromboaspiration, dilatation and intracoronary injection of eptifibatide. Unfortunately 6 h later he relapsed and a stent was then inserted. The triple antithrombotic therapy was continued in the ICU and as a result a permanent bleeding was observed leading to blood transfusions. The operation was performed 24 h later under WALANT technique with the patient's consent. Were injected 10mL of 2% lidocaine with 1:200.000 epinephrine at the root of the thumb in the volar aspect and 5 more in the proximal vicinity the dorsal wound. Bleeding stopped promptly and percutaneous pinning and suture were then performed. No rebleeding was observed and analgesia lasted 10 h. No further complication occurred under dual platelet therapy.

WALANT is spreading worldwide and is a new concept of regional anesthesia in hand surgery.³ Its corner stone is the use of epinephrine associated with lidocaine injected subcutaneously in the surgical field and in the fingers if needed. It provides locally efficient exsanguination and makes it possible to perform the surgical procedures without using a pneumatic tourniquet, in addition the hand motricity is respected unlike brachial plexus block.

In case of surgery the decision regarding whether or not to interrupt or even reverse antithrombotic treatment will depend on the specific clinical situation, but also on the indication for the antithrombotic treatment. Current recommendations concerning the perioperative management of patients with coronary stents indicates that non-urgent surgery should be postponed until the end of the period of susceptibility to stent thrombosis. There are no guidelines concerning the management in case of recent infarction and limited data concerning bleeding in the setting of antiplatelet therapy. Administration of platelet concentrate is probably the best way to correct the hemostatic defect.⁴ Furthermore epinephrine could potentiated ADP-induced platelet aggregation and activation in ticagrelor-treated patients.⁵

Thus we hypothesise that the transient vasoconstriction and the local action of epinephrine on the platelet aggregation were sufficient to achieve durable hemostasis. WALANT technique is certainly a safer alternative than general or regional anesthesia in the setting of acute myocardial infarction, and makes it possible to cope with a local bleeding without modifying a mandatory antithrombotic therapy.

References

• ¹
  dos Reis Júnior A, Quinto D. Digital block with or without the addition of epinephrine in the anesthetic solution. Braz J Anesthesiol. 2016;66:63-71.
• ²
  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.
• ³
  Lalonde DH. Conceptual origins, current practice, and views of wide-awake hand surgery. J Hand Surg Eur Vol. 2017;42:886-95.
• ⁴
  Hansson EC, Shams Hakimi C, Åström-Olsson K, et al. Effects of ex vivo platelet supplementation on platelet aggregability in blood samples from patients treated with acetylsalicylic acid, clopidogrel, or ticagrelor. Br J Anaesth. 2014;112:570-5.
• ⁵
  Singh S, Malm CJ, Ramström S, et al. Adrenaline enhances in vitro platelet activation and aggregation in blood samples from ticagrelor-treated patients. Res Pract Thromb Haemost. 2018;2:718-25.

Publication Dates

• Publication in this collection
  10 Oct 2019
• Date of issue
  Jul-Aug 2019

History

• Published
  21 May 2019