WALANT Surgery: The Unseen Risks of Cost-Cutting in the OR

The appeal of WALANT anesthesia is clear—reduced facility costs, elimination of anesthesia fees, and increased efficiency for surgeons. But what happens when the unexpected occurs?

Read on!

Dear NYSORA Community,

The shift toward Wide-Awake Local Anesthesia No Tourniquet (WALANT) surgery has been gaining traction, especially in orthopedic and hand surgery. As anesthesiology professionals, we know that patient safety isn't just about what’s most cost-effective on paper—it’s about real-world preparedness. While the recent review by Ilyas and Clarkson focuses on the theoretical, potential financial advantages of WALANT, it misses a crucial point: The value of a dedicated anesthesia team extends far beyond just the “cost” of anesthesia.

Why This Matters: A Life-Saving Lesson from the OR

A few months ago, I received a STAT page to the eye surgery suite. A patient undergoing a routine procedure under local anesthesia suddenly developed severe anaphylaxis to the local anesthetic administered intraoperatively by the eye surgeon. Within seconds, the patient’s airway was compromised, blood pressure plummeted, and the patient went into cardiovascular collapse, followed by the arrest.

Fortunately, the case was happening in an OR in our hospital, near-main operating room section with anesthesia personal. Responding to the STAT call, we secured the airway within moments, placed an arterial line, gained large-bore venous access, initiated resuscitation, and performed transesophageal echocardiography (TEE) to confirm the diagnosis. This patient was saved by anesthesiology team and was discharged home without complications.

But this scenario I experienced keeps me thinking: Had this same patient been in an office-based setting—where there is no dedicated anesthesia team—the outcome could have been tragically different.

The Hidden Benefits of an Anesthesia Team

Surgeons advocating for WALANT often focus on efficiency, control, and cost savings. But let’s consider what they’re missing:

1. Management of Systemic Complications – Severe allergic reactions, local anesthetic systemic toxicity (LAST), and airway emergencies can occur even with “routine” local anesthesia. Having a team trained in crisis management can be the difference between life and death.

2. Reduction in Surgeon Distractions – In a well-organized regional anesthesia service, the anesthesiology team ensures patients are comfortable before the surgeon even enters the room. This means no lost OR time managing anxious patients, unexpected sedation issues, or dealing with complex medical comorbidities.

3. Safety Net for the Unpredictable – Not every patient reacts predictably to local anesthesia. Some may have vasovagal reactions, others may experience pain, and some may deteriorate rapidly from preexisting conditions. In a surgical setting with an anesthesia team, these challenges are met with immediate, expert care.

4. Optimized Efficiency in a High-Volume Practice – Contrary to popular belief, eliminating anesthesia services doesn’t necessarily translate to better efficiency. When anesthesiologists handle preoperative sedation, intraoperative management, and postoperative recovery, surgeons can focus exclusively on operating. A well-run regional anesthesia program can streamline patient flow better than a DIY anesthesia approach.

The Bigger Picture: What’s Overlooked in WALANT Cost Analyses

The paper by Ilyas and Clarksonhighlights how WALANT eliminates anesthesia fees and reduces facility costs. But is financial savings worth the risk of patient?safety?

• The study does not account for the cost of complications—a single emergency requiring resuscitation, transport, and critical care admission can offset years of “savings.”
• It does not measure the hidden time costs—surgeons performing their own anesthesia must spend extra time managing patient anxiety, troubleshooting inadequate anesthesia, and handling unexpected events.
• It does not consider patient selection limitations—while WALANT is excellent for healthy patients, it is not always suitable for those with significant medical comorbidities, anticoagulation concerns, or complex surgical needs.

The Takeaway: Think Beyond the Balance Sheet

WALANT has its place, but it is not a universal solution. The argument for wide-awake surgery should not hinge solely on financial metrics while ignoring the critical safety net that anesthesia teams provide.

Key Takeaways for Clinical Practice

• Surgeons should recognize the value of a well-organized anesthesia team. Regional anesthesia services can optimize efficiency and patient outcomes without compromising safety.
• Patient selection is key. WALANT may work well for minor procedures in healthy patients, but complex cases or patients with comorbidities should still be managed in an OR setting.
• Cost savings should never come at the expense of safety. The rare but catastrophic complications of local anesthesia are best managed in an environment where advanced resuscitation is immediately available.

To my orthopedic colleagues pushing for more WALANT conversions—remember, some benefits of anesthesia services cannot be crudely measured. When an emergency strikes, you’ll want the right team by your side.

Stay safe, stay vigilant, and thank you for subscribing to the NYSORA newsletter!

Warm regards,

Dr. Admir Hadzic

Citation: Ilyas AM, Clarkson JHW. Wide Awake Surgery: A Review of Cost Savings Potential. SurgiColl. 2024;2(4). doi:10.58616/001c.125563.