What is the procedure for a bedside deep wound closure with local anesthesia?

Procedure Note Template for Bedside Deep Wound Closure with Local Anesthesia

For optimal patient outcomes, bedside deep wound closure with local anesthesia should follow a systematic approach that includes proper anesthetic administration, wound preparation, and layered closure technique. 1

Pre-Procedure Assessment and Setup

• Patient identification: Verify patient identity and procedure site
• Wound assessment: Document size, depth, location, and time of injury
• Contraindications check: Assess for lidocaine allergy, significant contamination
• Equipment preparation:
  • Sterile field setup
  • Local anesthetic (typically 1% lidocaine with or without epinephrine)
  • Sterile gloves, drapes, gauze
  • Irrigation solution
  • Suture materials (absorbable for deep layers, non-absorbable for skin)
  • Instruments (needle driver, forceps, scissors)

Anesthetic Administration

1. Calculate maximum safe dose:

   • Adults: 4.5 mg/kg lidocaine without epinephrine or 7.0 mg/kg with epinephrine 1
   • Children: 1.5-2.0 mg/kg without epinephrine or 3.0-4.5 mg/kg with epinephrine 1

2. Anesthetic technique:

   • Use lowest effective dose of anesthetic
   • Aspirate before injection to avoid intravascular administration
   • Inject slowly with small-gauge needle
   • Consider buffering lidocaine with bicarbonate for less painful injection 1
   • Maintain communication with patient to monitor for early toxicity signs 1

3. Alternative options for lidocaine allergy:

   • Ester-type local anesthetics
   • 1% diphenhydramine (note: longer onset, limited efficacy)
   • Bacteriostatic normal saline (0.9% benzyl alcohol in normal saline) 1

Wound Preparation

1. Cleansing:

   • Irrigate wound with sterile saline or appropriate antiseptic solution
   • Remove foreign bodies and devitalized tissue
   • Debride wound edges if necessary for clean approximation

2. Exploration:

   • Assess for damage to underlying structures (tendons, nerves, vessels)
   • Determine depth and extent of wound

Closure Technique

1. Deep layer closure:

   • Use absorbable sutures (e.g., 3-0 or 4-0 Vicryl) for deep tissue layers
   • Close dead space to prevent hematoma formation
   • Approximate fascial layers if involved
   • Ensure meticulous hemostasis to prevent hematoma formation 2

2. Subcutaneous layer:

   • Use absorbable sutures (e.g., 4-0 or 5-0 Vicryl)
   • Place sutures to minimize tension on skin edges
   • Consider subcuticular technique for improved cosmesis 2

3. Skin closure:

   • Use non-absorbable sutures (e.g., 4-0 or 5-0 nylon or prolene)
   • Consider placement of incisions along Langer's lines for optimal cosmetic results 2
   • Alternative options: staples, tissue adhesives, or Steri-Strips for appropriate wounds

Post-Procedure Care

1. Dressing application:

   • Apply appropriate dressing based on wound location and characteristics
   • Consider antibiotic ointment if indicated

2. Patient instructions:

   • Wound care instructions
   • Signs of infection to monitor for
   • Pain management plan (consider longer-acting local anesthetic like bupivacaine for prolonged pain relief) 3
   • Follow-up appointment timing
   • Suture removal timing (if applicable)

Documentation

1. Procedure details:

   • Date and time
   • Indication for procedure
   • Wound characteristics (size, location, depth)
   • Anesthetic used (type, concentration, amount)
   • Closure technique (suture types and sizes)
   • Complications (if any)
   • Patient tolerance of procedure

2. Post-procedure plan:

   • Follow-up instructions
   • Wound care instructions
   • Pain management plan
   • Return precautions

Common Pitfalls and How to Avoid Them

• Anesthetic toxicity: Use appropriate dosing, aspirate before injection, administer incrementally, monitor for early signs (circumoral numbness, facial tingling) 1
• Inadequate anesthesia: Allow sufficient time for anesthetic to take effect (typically 5-10 minutes)
• Wound infection: Ensure thorough irrigation and debridement, consider prophylactic antibiotics for high-risk wounds
• Poor cosmetic outcome: Use appropriate suture technique, avoid excessive tension, consider anatomical location for incision placement 2
• Hematoma formation: Achieve meticulous hemostasis before closure 2

By following this systematic approach, clinicians can perform effective bedside deep wound closure with local anesthesia while minimizing complications and optimizing patient outcomes.