The Clinical Impact of Ambient Operating Room Temperature and Other Perioperative Factors on Patient Comfort during Wide-awake Hand Surgery Using Local Anesthesia

Document Type : RESEARCH PAPER


1 Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA

2 Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA

3 Rothman Orthopaedic Institute


Background: The prevalence of wide-awake hand surgery using local anesthesia has increased substantially. The full
influence of perioperative factors, namely operating room temperature, on patient comfort during these procedures is
presently underreported.
Methods: One hundred and fifty-eight patients undergoing wide-awake hand surgery using local anesthesia were
prospectively enrolled. Surveys with visual analog scale (VAS) were administered after surgery to assess overall
patient comfort (OPC) and patient comfort with temperature (TPC). Operating room temperature at the initiation of the
procedure, surgery type, duration of surgery, tourniquet use and local anesthetic use were all recorded and their impact
on patient comfort analyzed. The VAS used ranged from 1 (least comfortable) to 5 (most comfortable).
Results: Across all patients, the mean OPC was 4.7 (Range: 2 – 5, SD=0.6) and the mean TPC score was 4.7 (Range
2 – 5, SD=0.6). There were weakly negative correlations between room temperature and VAS score for OPC (rs =-0.2,
P=.038) and TPC (rs=-0.2, P=.051). The mean OPC score was lower with tourniquet use [4.6 (SD=0.7) versus 4.9
(SD=0.4), P=.002].
Conclusion: Patient comfort during surgery using local anesthesia is not substantially affected by operating room
temperature. Tourniquet use negatively impacts patient-reported comfort. Continued studies into the optimization of
patient comfort during wide-awake hand surgery are warranted.
Level of evidence: IV


1. Ahmad AA, Sabari SS, Ruslan SR, Abdullah S, Ahmad
AR. Wide-awake anesthesia for olecranon fracture
fixation. HAND. 2019:1558944719861706.
2. Hyatt BT, Rhee PC. Wide-awake surgical management
of hand fractures: Technical pearls and advanced
rehabilitation. Plastic and reconstructive surgery.
2019; 143(3):800-10.
3. Kazmers NH, Stephens AR, Presson AP, Yu Z, Tyser
AR. Cost implications of varying the surgical setting
and anesthesia type for trigger finger release surgery.
Plastic and Reconstructive Surgery Global Open.
2019; 7(5).
4. Xing SG, Mao T. Surgical excision of enchondromas
and osteochondromas in the hand under local
anaesthesia without tourniquet. Journal of Hand
Surgery (European Volume). 2019; 44(7):745-7.
5. Davison PG, Cobb T, Lalonde DH. The patient’s
perspective on carpal tunnel surgery related to the
type of anesthesia: a prospective cohort study. Hand.
2013; 8(1):47-53.
6. Rhee PC, Fischer MM, Rhee LS, McMillan H, Johnson
AE. Cost savings and patient experiences of a clinic- 
based, wide-awake hand surgery program at a
military medical center: a critical analysis of the first
100 procedures. The Journal of hand surgery. 2017;
7. Katz JD. Control of the environment in the operating
room. Anesthesia & Analgesia. 2017; 125(4):1214-8.
8. Dunn JC, Kusnezov N, Koehler LR, Orr JD. The sweaty
surgeon: raising ambient operating room temperature
benefits neither patient nor surgeon. JBJS. 2017;
9. Mills SJ, Holland DJ, Hardy AE. Operative field
contamination by the sweating surgeon. Australian
and New Zealand Journal of Surgery. 2000;
10. Sessler DI. Mild perioperative hypothermia. New
England Journal of Medicine. 1997; 336(24):1730-7.
11. Pellerin N, Deschuyteneer A, Candas V. Local thermal
unpleasantness and discomfort prediction in the
vicinity of thermoneutrality. European journal of
applied physiology. 2004; 92(6):717-20.
12. Romanovsky AA. Skin temperature: its role in
thermoregulation. Acta physiologica. 2014; 210(3): 
13. ANSI/ASHRAE/ASHE Standard 170-2017: Ventilation
of Health Care Facilities. 2017;
14. Gunasagaran J, Sean ES, Shivdas S, Amir S, Ahmad
TS. Perceived comfort during minor hand surgeries
with wide awake local anaesthesia no tourniquet
(WALANT) versus local anaesthesia (LA)/
tourniquet. Journal of Orthopaedic Surgery. 2017;
15. Koegst WH, Wölfle O, Thoele K, Sauerbier M. The” Wide
Awake Approach” in hand surgery: a comfortable
anaesthesia method without a tourniquet.
Handchirurgie, Mikrochirurgie, Plastische Chirurgie:
Organ der Deutschsprachigen Arbeitsgemeinschaft
fur Handchirurgie: Organ der Deutschsprachigen
Arbeitsgemeinschaft fur Mikrochirurgie der
Peripheren Nerven und Gefasse: Organ der V.... 2011;
16. Tulipan JE, Kim N, Abboudi J, Jones C, Liss F, Kirkpatrick
W, et al. Open carpal tunnel release outcomes:
performed wide awake versus with sedation. Journal
of hand and microsurgery. 2017; 9(2):74.
17. Kennedy W, Conway A. Temperature monitoring of
nonanaesthetised patients in a cardiac catheterisation
laboratory. Journal of Clinical Nursing. 2016; 25(11-
18. Dillon JP, Laing A, Hussain M, Macey A. Improved
tolerability of open carpal tunnel release under
local anaesthetic: a patient satisfaction survey.
Archives of Orthopaedic and Trauma Surgery. 2008;
19. Huang YC, Chen CY, Lin KC, Yang SW, Tarng YW, Chang
WN. Comparison of wide-awake local anesthesia no
tourniquet with general anesthesia with tourniquet
for volar plating of distal radius fracture. Orthopedics.
2018; 42(1):e93-8.
20. Sasor SE, Cook JA, Duquette SP, Lucich EA, Cohen AC,
Wooden WA, et al. Tourniquet use in wide-awake
carpal tunnel release. HAND. 2020; 15(1):59-63.
21. Lalonde D. Minimally invasive anesthesia in wide
awake hand surgery. Hand Clinics. 2014; 30(1):1-6.
22. Lalonde D. Wide awake local anaesthesia no
tourniquet technique (WALANT). InBMC proceedings
2015 (Vol. 9, No. S3, p. A81). BioMed Central.
23. Van Demark Jr RE, Becker HA, Anderson MC, Smith
VJ. Wide-awake anesthesia in the in-office procedure
room: lessons learned. Hand. 2018; 13(4):481-5.
24. Mckee DE, Lalonde DH, Thoma A, Dickson L. Achieving
the optimal epinephrine effect in wide awake hand
surgery using local anesthesia without a tourniquet.
Hand. 2015; 10(4):613-5.
25. Mohd Rashid MZ, Sapuan J, Abdullah S. A randomized
controlled trial of trigger finger release under
digital anesthesia with (WALANT) and without
adrenaline. Journal of Orthopaedic Surgery. 2019;
Volume 9, Issue 1
January 2021
Pages 110-115
  • Receive Date: 13 December 2019
  • Revise Date: 04 March 2020
  • Accept Date: 17 March 2020
  • First Publish Date: 01 January 2021