Best Infiltration Practices - local analgesic techniques for abdominal and orthopedic surgery
Issue link: https://eguideline.guidelinecentral.com/i/319830
Infiltration Technique Descriptions 8 Primary or Revision Total Knee Injection solution includes bupivacaine liposomal injectable suspension (EXPAREL) 20 mL and 0.25% bupivacaine with epinephrine 30 mL. Normal saline 10-20 mL may be added if extra volume is needed. Notes: • The femoral, saphenous and posterior tibial nerves all innervate the knee with variable distributions. Therefore successful injection requires injecting all layers of the knee. • Extra medication can be injected into the quadriceps tendon and proximal perisoteum ( a source of considerable patient pain), the medial meniscosynovial junction and the patellar branch of the saphenous nerve. • Injecting the subcutaneous layer may be omitted if the skin is very thin. • A few mLs should be reserved for the drain site. Infiltration Technique Local Analgesic Volume Step 1: Deep Injection Aer exposing the knee joint and before the prostheses are in place, inject 10 mL into the deep structures: ▶ Inject into the anterior and posterior cruciate ligaments, the posterior capsule, the superficial and deep fibers of the medial and lateral collateral ligaments, the iliotibial band and its insertion on Gerdy's tubercle, the popliteus, the periosteum around the cut surfaces of the medial femur and tibia, the peri-articular synovial reflections, the suprepatellar pouch and the soft-tissue envelope. Inject 10 mL into the quadriceps tendon and muscles and peri-patellar so tissue. 20 mL Note: When injecting the posterior structures avoid the midline vascular bundle. Also avoid the peroneal nerve when injecting lateral structures. Step 2: Mid-layer Injection Aer the implants are in place and while the cement cures, inject 10 mL into the deep dermal tissue planes, targeting the femoral, saphenous and posterior tibial nerve distributions. 10 mL Step 3: Superficial Injection e remaining 20 mL is injected into the subcutaneous tissues and skin, more medially where the sensory nerves predominate. 20 mL Notes: • Remaining medication can be used in the quadriceps. • Reserve a few mLs for the drain wound. • For revisions: ▶ Extend the deep injections further up the femoral periosteum, further down the tibial periosteum, and further along the anterior tibial compartment. ▶ Extend the mid-layer injections further up the quadriceps tendon and capsule. ▶ Extend the superficial injections more broadly along the full length of the incision.