title: Timed wake-up anaesthesia in hand: A modification to wide awake surgery of hand.
abstract: BACKGROUND
  Wide awake surgery of the hand (WASH) is a well-accepted technique in hand surgery which allows the surgeon to identify and rectify on the table of some of the inadvertent shortcomings in the surgical procedures to optimise the final outcome. The advantage, however, precludes the use of tourniquet. We describe a modified method which preserves all the advantages of WASH and allows the surgeon to use tourniquet.
  
  
  METHODS
  Thirty-one cases of hand surgeries were carried out using the modified technique where a wrist block was supplemented with the ultra-short acting intravenous propofol which allowed the surgeon to use the upper arm tourniquet. The propofol infusion was stopped, and the tourniquet was released after the important surgical step. Within an average of 10 min of stoppage of the infusion, all the patients were awake for active intraoperative painless movements to aid the surgeon to identify, rectify and fine tune the procedure to optimise the results.
  
  
  RESULTS
  Five of the 31 patients needed correction based on the intraoperative movements. All the 31 patients were pain free at the surgical site during surgery. All the 31 patients were cooperative enough to perform full range of pain-free intraoperative movements. No patient experienced significant tourniquet pain during the procedure. Patient's and surgeon's satisfaction at the end of the procedure has been quite satisfactory.
  
  
  CONCLUSIONS
  Timed wake-up anaesthesia, an improvement over the original WASH, has been suggested where the surgeon can add without subtracting the benefits of the procedure in the form of usage of the tourniquet providing the clear tissue plane and haemostasis during the surgery. However, an additional cost is incurred for the use of anaesthesia and equipment should be kept in mind.
authors.affiliation: Department of Orthopaedics, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India.
authors.forename: Jagannath
authors.initials: J
authors.lastname: Kamath
authors.affiliation: Department of Anesthesiology, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India.
authors.forename: Trivikram
authors.initials: T
authors.lastname: Shenoy
authors.affiliation: Department of Orthopaedics, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India.
authors.forename: Nikil
authors.initials: N
authors.lastname: Jayasheelan
authors.affiliation: Department of Orthopaedics, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India.
authors.forename: Naufal
authors.initials: N
authors.lastname: Rizwan
authors.affiliation: Department of Anesthesiology, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India.
authors.forename: Vartika
authors.initials: V
authors.lastname: Sachan
authors.affiliation: Department of Orthopaedics, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India.
authors.forename: Rajashekar
authors.initials: R
authors.lastname: Danda
keywords: Timed wake-up anaesthesia; tourniquet; wide awake surgery of the hand