Local anaesthetic with adrenaline (LAWA) is commonly used in clinical practice for a variety of interventions and minor surgeries including the excision of skin lesions, hand surgery and tooth extractions. The inclusion of adrenaline offers several additional benefits, such as reducing intraoperative bleeding through vasoconstriction and extending the duration of anesthesia (1). In the early 20th century, Braun first reported the additional benefit of mixing adrenaline with procaine, a commonly used vasodilatory LA agent at the time (2). Traditionally, the injection of adrenaline into anatomical sites with end-arteries (e.g. fingers, penis) has been denounced due to the theoretical risk of irreversible vasospasm-induced ischaemic necrosis, with a number of earlier textbooks rejecting its use for this very reason (3-5). In fact, even the British National Formulary (BNF) states that “it is not advisable to give adrenaline/epinephrine with a local anaesthetic in digits or appendages because of the risk of ischaemic necrosis.”(6) Despite this, there is a lack of evidence underpinning these recommendations. For instance, a recent Cochrane review indicated that, when administered correctly, adrenaline did not lead to any reported adverse events, such as distal ischemia, in the reported trials (7). Observational data substantiates these claims. For instance, a review by Finsen (2013) found that there have been over a quarter of a million reports of LAWA injection into hands, fingers and toes without resulting necrosis (8). The literature reveals that cases of ischaemic necrosis usually occurred in patients when the LAWA is injected with the improper technique/quantity (9) – as was frequently the case in the early 20th century (8, 9). Multiple studies have established that when injected correctly and safely in regions with terminal arteries, the reduction in digital blood flow is temporary, resulting in a negligible risk of necrosis (9,10).

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First described by Lalonde et al. (2003), ‘Wide awake local anaesthetic no tourniquet’ (WALANT) surgery describes delivery of a local anaesthetic and adrenaline directly into the operative site, in the absence of a tourniquet (11). Since, its rise in popularity can be attributed to the range of benefits it offers over alternatives involving tourniquet use or general anaesthetic (GA). Notably, there is not a requirement for any preoperative clearance or fasting, administration of sedation or intraoperative monitoring. This allows patients with multiple comorbidities to benefit from WALANT (12) whilst minimising the financial strain placed on the National Health Service (NHS) as anaesthetist’s and auxiliary theatre staff are no longer necessary (13). In addition, WALANT has shown to improve patient safety and comfort over tourniquet use. For instance, Ruxasagulwong et al. (2015) (14) demonstrated significantly lower intraoperative pain and bleeding in WALANT patients compared to conventional tourniquet patients. Crucially, the WALANT technique facilitates intraoperative assessment of the strength and function of repairs through patient participation, which has been shown to reduce the post-operative tendon rupture (15). During the COVID-19 pandemic, a relative shortage of NHS resources and anaesthetic teams has resulted in a further rise in the popularity of WALANT. Its implementation has allowed multiple centres across the UK to streamline services, enabling patients to be safely and successfully treated in a timely manner whilst minimising patient admissions and subsequent virus transmission potential (16,17).

The BNF currently advises that when administering adrenaline/epinephrine with a local anesthetic, low concentrations should be used and the maximum safe dose of the local anesthetic must be carefully calculated (18). A recent meta-analysis stated that the WALANT technique carries a low complication rate of 1.7%, with no significant temporal variation and a significant reduction in complications (19).

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The aim of this study is to describe the clinical education and practice in the United Kingdom and Ireland with regards the use of LAWA. This will inform initiatives to support a greater uptake of LAWA. In turn, this will improve patient safety and clinical effectiveness of local anaesthetic usage.