***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Open carpal tunnel release is one of the commonest performed procedures in h and surgery . We performed a prospect i ve r and omised control trial to compare the efficacy and patient satisfaction of the traditional arm tourniquet versus infiltration of adrenaline and local anaesthetic solution to achieve haemostasis during the procedure . Using a combination of objective and subjective measures we concluded that infiltration of local anaesthetic and adrenaline not only provided adequate haemostasis but also provided a significantly more tolerable experience for the patient during the procedure We studied the presence and extent of upper extremity denervation in limb muscles after surgical release of the carpal tunnel . Sixty consecutive patients were r and omly assigned to have the procedure performed with ( 31 patients ) or without ( 29 patients ) tourniquet application . Cervical paraspinal and upper extremity muscles were examined electromyographically 3 weeks before and 3 weeks after carpal tunnel release . Three weeks after the operation 77 % of the patients in the tourniquet group had denervation in other than thenar muscles . Only one patient in the control ( no tourniquet ) group had similar electromyographic abnormalities after surgery . Tourniquet time and pressure did not vary significantly between those patients with or without postoperative forearm denervation . Mean operative time for the tourniquet and control groups was nearly identical . These findings indicate that upper extremity tourniquet application results in sub clinical , temporary changes in the muscles of the forearm , probably on the basis of nerve changes and denervation Background : Because of specific method ological difficulties in conducting r and omized trials , surgical research remains dependent predominantly on observational or non‐r and omized studies . Few vali date d instruments are available to determine the method ological quality of such studies either from the reader 's perspective or for the purpose of meta‐ analysis . The aim of the present study was to develop and vali date such an instrument Purpose : Minor h and surgeries can be done under field sterility in procedure rooms . Surgeons are still sceptical about the usage of wide awake local anaesthesia no tourniquet ( WALANT ) technique . They perceive that patients can tolerate tourniquet for a brief period while they perform minor surgeries under local anaesthesia ( LA ) . We compared the perceived comfort experienced by patients during minor h and surgeries with WALANT and LA/tourniquet .  We investigated the difference in preoperative preparation time , operating time and blood loss between the two groups . Methods : Between July and October 2016 , a total of 72 patients were diagnosed with carpal tunnel syndrome , trigger finger or ganglion , at the University Malaya Medical Centre . Forty patients consented to participate in this study and were r and omized into WALANT and LA/tourniquet groups . Anaesthesia was administered accordingly and tourniquet was applied . The time taken for preoperative preparation and surgery was recorded . Each surgeon estimated the blood loss . The perceived comfort level of each patient was quantified using a visual analogue score ( VAS ) . Data were analysed using SPSS . Results : The mean VAS for the WALANT group was 2.33 ± 1.94 , whereas it was 4.72 ± 3.05 for the LA/tourniquet group , and the difference was statistically significant ( p < 0.05 ) . The mean time for preoperative preparation  in WALANT group was 19.17 ± 12.61 min and LA/tourniquet group was 7.05 ± 3.44 min . The difference between these groups was statistically significant ( p < 0.01 ) . There was no significant difference in operating time and blood loss . Conclusion : WALANT technique was associated with better patient comfort . Tourniquet was the main reason for discomfort during surgeries . WALANT is an alternative in minor h and surgeries for a bloodless surgical field without the discomfort of tourniquet application A r and omized controlled comparison of tourniquet and local adrenaline infiltration for control of bleeding was performed in patients undergoing bilateral carpal tunnel release under local anaesthesia .  Visual analogue scores for intra-operative pain were substantially greater for tourniquet ( mean score 4.7 ) than for adrenaline ( 2.2 ) . Incomplete control of bleeding was responsible for longer operating time and for the surgeons ’ perception of slightly greater operative difficulty with the use of adrenaline . There were no complications attributable to the use of adrenaline . The use of adrenaline-containing local anaesthesia for carpal tunnel release avoids tourniquet pain and is preferred by patients Background In our experience , for all surgeries in the h and , the optimal epinephrine effect from local anesthesia — producing maximal vasoconstriction and visualization — is achieved by waiting significantly longer than the traditionally quoted 7 min from the time of injection . Methods In this prospect i ve comparative study , healthy patients undergoing unilateral carpal tunnel surgery waited either 7 min or roughly 30 min , between the time of injection of 1 % lidocaine with 1:100,000 epinephrine and the time of incision . A st and ardized incision was made through dermis and into the subcutaneous tissue followed by exactly 60 s of measuring the quantity of blood loss using sterile micropipettes . Results There was a statistically significant reduction in the mean quantity of bleeding in the group that waited roughly 30 min after injection and before incision compared to the group that waited only 7 min ( 95 % confidence intervals of 0.06 + −0.03 ml/cm of incision , compared to 0.17 + −0.08 ml/cm , respectively ) ( P = 0.03 ) . Conclusions Waiting roughly 30 min after injection of local anesthesia with epinephrine as oppose to the traditionally taught 7 min , achieves an optimal epinephrine effect and vasoconstriction . In the h and , this will result in roughly a threefold reduction in bleeding — making wide awake local anesthesia without tourniquet ( WALANT ) possible . This knowledge has allowed our team to exp and the h and procedures that we can offer using WALANT . The benefits of WALANT h and surgery include reduced cost and waste , improved patient safety , and the ability to perform active intraoperative movement examinations BACKGROUND Most minor h and operations can be performed with local anesthesia and tourniquet . Some literature supports this concept based on the believe that the " patient can tolerate it " . Nowadays , the wide-awake technique with epinephrine- contained lidocaine is safe . This technique does not need a tourniquet because epinephrine provides local vasoconstriction . OBJECTIVE The present study was design ed to compare patients ' comfort and effectiveness of local anesthesia as well as bleeding at the surgical site between wide-awake anesthesia and local lidocaine with tourniquet application . MATERIAL AND METHOD Prospect i ve Clinical Trial was performed in 60 patients who received outpatient surgery for common h and problems at Maharaj Nakorn Chiang Mai Hospital . With r and omization , 30 patients were in wide-awake group , who received adrenaline-contained lidocaine as a local anesthetic agent , with tourniquet wrapping but with no pressure applied ( group 1 ) . The other 30 patients were in the conventional group that received lidocaine ( no adrenaline ) and a 250-mmHg tourniquet application ( group 2 ) . Operations were performed with st and ard methods . Visual analog scores , surgical field bleeding , amount of bleeding , any complications within 4 weeks were recorded . RESULTS There are no significant differences between the two groups in terms of patient profiles ( sex , age and diseases ) , injected site pain and surgeon 's opinion of surgical site bleeding . Tourniquet 's pain and the amount of blood loss in the conventional group were significantly higher than the wide-awake group . CONCLUSION Wide-awake technique ( no tourniquet applied ) offers better comfort for patients and less total blood loss while providing effective anesthesia and patient safety as with the conventional technique Purpose Distal blocks are not recommended even for a short procedure when a tourniquet is used . This study was design ed to evaluate the tolerance , effectiveness , patient acceptance and safety of distal blocks at the wrist . Methods Consecutive patients ( n=273 , mean age 53 ± 15 yr ) undergoing endoscopic carpal tunnel release with a pneumatic tourniquet were included in this study . The median nerve was blocked 6 cm above the wrist crease by injecting 10 mL of 2 % lidocaine and 0.5 % bupivacaine ( v/v ) . The ulnar nerve was blocked by injecting 8 mL ofthe same anesthetic mixture below the flexor carpi ulnaris tendon 6 cm above the wrist crease . Finally , 2 mL of local anesthetic were infiltratedsc and laterally below the crease to block the musculocutaneous nerve . The intensity of the block was evaluated after five , ten and 20 min . In addition , pain associated with block performance and tolerance of the tourniquet were evaluated . Finally , neurological complications associated with this technique were investigated . Data are presented as means ± SD . Results At ten minutes after the block was performed , 9 % and 32 % of patients required an additional injection to complete the block in the median and ulnar territories , respectively . In more than 75 % of patients , performance of the block was associated with either no or mild pain . The tourniquet was inflated for 12.6 ± 5.4 min and was well tolerated in 99 % of patients . Finally , neither transient nor permanent neurological deficit were recorded postoperatively . Conclusion Blocks at the wrist are effective , well accepted by the patient and safe when a pneumatic tourniquet is used for a short procedure . RésuméObjectifLes blocs distaux ne sont pas recomm and és , même pour des interventions de courte durée , qu and un garrot pneumatique est utilisé . Le but de cette étude était d’évaluer la tolérance , l’efficacité et la sécurité des blocs tronculaires au poignet . MéthodesDeux cent soixantetreize malades consécutifs , âgés de 53 ± 15 ans opérés d’un syndrome du canal carpien ont été inclus dans cette étude . Le nerf médian était bloqué 6 cm audessus du pli de flexion du poignet avec 10 mL d’un mélange de lidocaine 2 % et de bupivacaine 0,5 % ( 50/50 ) . Le nerf ulnaire était bloqué avec 8 mL du même mélange endessous du tendon fléchisseur ulnaire du carpe 6 cm audessus du pli de flexion du poignet . Enfin , 2 mL d’anesthésiques locaux étaient injectés latéralement et immédiatement endessous du pli de flexion pour bloquer le nerf musculocutané . L’intensité du bloc a été évaluée à cinq , dix et 20 min . La douleur lors de la réalisation du bloc et la tolérance du garrot étaient également évaluées . Enfin , les complications neurologiques associées à ces techniques ont été recherchées . Les résultats sont présentés en moyenne ± SD.RésultatsAprès dix minutes , 9 % et 32 % des patients ont nécessité un complément d’anesthésie au niveau des nerfs médian et ulnaire . Chez plus de 75 % des malades , la réalisation du bloc était associée à une douleur qui était , soit absente , soit modérée . Le garrot était gonflé en moyenne 12,6 ± 5,4 min et considéré comme supportable par 99 % des malades . Aucun déficit neurologique partiel ou total n’a été constaté en postopératoire . Conclusion Pour des interventions de courte durée , les blocs au poignet sont efficaces , sans risque et bien acceptés par le patient même qu and un garrot pneumatique est utilisé We conducted a prospect i ve r and omized controlled trial to investigate carpal tunnel decompression under local anaesthesia . Carpal tunnel decompression was performed in 37 wrists using local anaesthesia and an arm tourniquet and 36 without tourniquet but with a local anaesthetic mixture containing adrenaline . Patients who underwent  carpal tunnel decompression  using a tourniquet experienced a significantly greater degree of pain when compared with those who did not have a tourniquet .  Pain and h and function improved to a similar degree in both groups . We conclude that carpal tunnel decompression performed with a tourniquet causes patients unnecessary pain with no additional benefit as compared with the wide-awake carpal tunnel decompression without use of a tourniquet . Level of evidence : 
    Output:
    
There were no significant differences between groups in intraoperative blood loss , surgeon perceived difficulty , and complications .
Conclusion : This systematic review found that tourniquet use causes significantly more pain with no significant clinical benefit as compared with using a wide awake , no tourniquet approach in carpal tunnel decompression