How to avoid intra-vascular injection of local anesthetic during subcutaneous hormone pellet insertion in the gluteal region?

From the Guidelines

To avoid intra-vascular injection of local anesthetic during subcutaneous hormone pellet insertion in the gluteal region, aspirate the needle prior to injection, as this is a crucial step in preventing systemic toxicity, as recommended by guidelines for the use of local anesthesia in office-based procedures 1. When performing subcutaneous hormone pellet insertion, it is essential to take steps to minimize the risk of local anesthetic systemic toxicity. The guidelines for the use of local anesthesia in office-based dermatologic surgery 1 provide valuable recommendations for decreasing this risk.

• Key steps include:
  • Using the lowest effective dose of local anesthetic
  • Aspirating the needle/catheter prior to each injection to avoid introducing the drug directly into a vessel
  • Using incremental injections of anesthetic
  • Continually assessing and communicating with the patient to monitor for signs of early toxicity Aspiration before injection is particularly critical in the gluteal region due to its significant vasculature, including the superior and inferior gluteal vessels.
• If blood appears in the syringe upon aspiration, it indicates that the needle has entered a blood vessel, and the needle should be withdrawn, repositioned, and aspirated again before proceeding with the injection. Additionally, injecting the anesthetic slowly while monitoring for signs of intravascular injection, such as dizziness, tinnitus, metallic taste, perioral numbness, or cardiac arrhythmias, is crucial for patient safety, as highlighted in the guidelines for local anesthesia use 1.

From the FDA Drug Label

To avoid intravascular injection, aspiration should be performed before the local anesthetic solution is injected The needle must be repositioned until no return of blood can be elicited by aspiration. It is essential that aspiration for blood or cerebrospinal fluid (where applicable) be done prior to injecting any local anesthetic, both the original dose and all subsequent doses, to avoid intravascular or subarachnoid injection.

To avoid intra-vascular injection of local anesthetic during subcutaneous hormone pellet insertion in the gluteal region, aspiration should be performed before injecting the local anesthetic solution. The needle must be repositioned until no return of blood can be elicited by aspiration. However, it is noted that a negative aspiration does not ensure against an intravascular injection 2 3.

• Aspiration is essential before injecting any local anesthetic.
• Reposition the needle until no blood return is observed.
• Be aware that a negative aspiration does not completely rule out intravascular injection.

From the Research

Avoiding Intra-Vascular Injection

To avoid intra-vascular injection of local anesthetic during subcutaneous hormone pellet insertion in the gluteal region, consider the following:

• Aspirate before injecting to check for blood return, as outlined in general subcutaneous injection techniques 4
• Use a small needle and inject slowly to minimize the risk of injecting into a blood vessel
• Choose an appropriate site for injection, avoiding areas with a high concentration of blood vessels

Local Anesthetic Administration

When administering local anesthetics, consider the following:

• Dilute the local anesthetic with normal saline to reduce pain and discomfort upon injection 5
• Use epinephrine in concentrations of 2.5 to 5 microg/mL to prolong the duration of analgesia and reduce the risk of systemic toxicity 6
• Be aware of the maximum recommended doses of local anesthetics and adjust according to patient-related factors such as age, organ dysfunctions, and pregnancy 6

Epinephrine Concentration

Epinephrine can prolong the duration of analgesia in a dose-related manner, with concentrations of 1:50,000 or 1:200,000 increasing duration by approximately 200% 7

• Use epinephrine concentrations from 1:200,000 to 1:3,200,000 for prolongation of analgesia after local infiltration 7

Injection Technique

The technique of injecting local anesthetic through the epidural needle before catheter insertion can improve the quality of anesthesia and reduce catheter-related complications 8

• Consider using a similar technique for subcutaneous injections to improve the quality of anesthesia and reduce complications