Best Infiltration Practices - local analgesic techniques for abdominal and orthopedic surgery
Issue link: https://eguideline.guidelinecentral.com/i/73209
Key Points ÎThe origin of pain due to abdominal surgery is multifactorial. It includes a somatic component originating from the surgical incision and a visceral component originating from intra-abdominal structures.20 ÎThe ideal local analgesic infiltration technique would block all noxious stimuli that result from surgical insult — both somatic and visceral components. ÎInfiltration techniques vary from procedure to procedure, requiring knowledge of each surgical site and its anatomy to produce optimal results. ÎAdministration of local analgesic between the transversus abdominis and internal oblique muscles (TAP Block) can provide pain relief for a range of abdominal surgical procedures.21-25 ÎIt 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 ÎImproved infiltration techniques for subcutaneous tissue and the placement of local analgesic into deeper myofascial and peritoneal tissues where neurons are dissected and pain foci often arise are important to maximize the effect and duration of analgesia.16 ÎThe likelihood and intensity of a potential systemic local analgesic toxicity varies with the specific local analgesic used and is subject to cumulative local analgesic dosages administered (see Table).18 Technical Note ÎLocal 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. ÎIdeally use a 20-cc 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. ÎIn addition to generous administration to the dermis and subcutaneous areas of an abdominal incision, special attention should be given to provide adequate local analgesic deep to the anterior abdominal fascia/ into the subfascial plane 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 of the abdominal wall. 1