Best Infiltration Practices - local analgesic techniques for abdominal and orthopedic surgery
Issue link: https://eguideline.guidelinecentral.com/i/319830
1 Î It is important to remember that the total local analgesic volume required to adequately cover a wound and systemic local analgesic levels are dependent on an interplay between total dosage administered, any additives, and the relative vascularity of the specific surgical site of injection. 18 Î Improved infiltration techniques for subcutaneous tissue and the placement of local analgesic into deeper myofascial tissues where neurons are dissected and pain foci often arise are important to maximize the effect and duration of analgesia. 13 Î The likelihood and intensity of systemic local analgesic toxicity varies with the specific local analgesic used and is subject to cumulative local analgesic dosages administered (see Table on last page). 18 Technical Notes Î Local analgesic should always be injected slowly into soft tissues of the surgical site with frequent aspiration to check for blood to minimize the risk of intravascular injection. • Aspirating while inserting the needle and injecting while withdrawing the needle further reduces risk. Î Ideally use a 20-30 mL syringe with a 1.5-3 inch, 22-25 gauge needle. • The use of a blunt tip needle may enhance the surgeon's ability to recognize the entry into, and exit from, the different fascial planes. • A 22-gauge needle is recommended since larger gauge needles allow more leakage of injectate into the wound. Choice of needle length depends on the anatomy being injected. This technique also avoids leaving large lakes of solution that swell tissues and increase pain. Î In addition to generous administration to the dermis and subcutaneous areas of the surgical incision, special attention should be given to provide adequate local analgesic in the deep tissues where many myofascial nerve endings reside. • Awareness of what myofascial plane the infiltrating needle tip is in during infiltration is important. In open cases, the surgeon has the advantage of direct visualization to place the needle directly into the desired soft tissues and subfascial planes. When direct visualization is not possible, the location of the needle tip may best be appreciated by the sensation of a "pop" or "feel" as the needle passes through the different layers. Recommended Injection Solutions Î 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.