Keeping the finger on the pulse - Cardiac arrhythmias in hand surgery using local anesthesia with adrenaline

Background: Wide Awake Local Anesthesia No Tourniquet (WALANT) in hand surgery is gaining popularity. We aimed to prospectively analyze the frequency and type of arrhythmias in patients undergoing hand surgery under local anesthesia and to examine whether the addition of adrenaline affects their incidence.

Methods: Adult patients undergoing hand surgery under local anesthesia were randomized into two groups: Group 1 - local anesthesia with lidocaine and tourniquet; Group 2 - local anesthesia with lidocaine and adrenaline (WALANT). Patients with history of arrhythmias were excluded. Patients were connected to electrocardiogram Holter monitoring before the surgery and up until discharge. The records were blindly compared between the groups regarding types of arrhythmias, frequency and timing relative to injection and tourniquet inflation.

Results: Hundred and two patients were included between 8/2018 and 8/2019 (age 59.7±13.6 years, 71% women, 51 in each group). No major arrhythmia (ventricular tachycardia, ventricular fibrillation, atrial fibrillation) or arrhythmias related symptoms were recorded for either group. Minor arrhythmias (including atrial premature beats, ventricular premature beats and atrial tachycardia) were recorded in 68 patients (66.6%) with no statistical difference between the groups. There were 3 patients with minor arrhythmias during inflation of the tourniquet. Patients in the adrenaline group had 2% sinus tachycardia during injection and 4% asymptomatic bradyarrhythmias. These findings do not require any further treatment.

Conclusions: Our results show that hand surgeries under WALANT in patients with no history of arrhythmia are safe and are not arrhythmogenic, therefore there is no need for routine peri-operative continuous ECG monitoring.