title: Tourniquet-Free Hand Surgery Using the One-per-Mil Tumescent Technique.
abstract: BACKGROUND
  A pneumatic tourniquet is generally used to achieve a bloodless operation field in hand surgery. However, this has changed with tumescent solution-based wide-awake surgery. This study is a preliminary prospective case series study to elaborate the formula and indications of the tumescent technique in hand surgery without a tourniquet.
  
  
  METHODS
  Seven patients (age range, 4 months to 37 years) underwent hand or upper extremity surgery for conditions such as nerve palsy, electric burn defect, fingertip injury, contracture, constriction ring syndrome, or acrosyndactyly. A "one-per-mil" tumescent solution (epinephrine 1:1,000,000+20 mg lidocaine/50 mL saline) was used to create a bloodless operating field without a tourniquet. Observation was performed to document the amount of solution injected, the operation field clarity, and the postoperative pain.
  
  
  RESULTS
  The "one per mil" epinephrine solution showed an effective hemostatic effect. The tumescent technique resulted in an almost bloodless operation field in the tendon and in the constriction ring syndrome surgeries, minimal bleeding in the flap and contracture release surgeries, and acceptable bleeding in acrosyndactyly surgery. The amount of solution injected ranged from 5.3 to 60 mL. No patient expressed significant postoperative pain. Flap surgeries showed mixed results. One flap was lost, while the others survived.
  
  
  CONCLUSIONS
  Epinephrine 1:1,000,000 in saline solution is a potential replacement for a tourniquet in hand surgery. Further studies are needed to delineate its safety for flap survival.
authors.affiliation: Division of Plastic Surgery, Department of Surgery, Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia.
authors.forename: Theddeus O H
authors.initials: TO
authors.lastname: Prasetyono
keywords: Epinephrine; Lidocaine; Upper extremity