WEBVTT - Dr Cherot _ C-Section Infiltration _ PP-EX-US-7266 CC Transcript _ 08FEB22 1 00:00.499 --> 00:04.499 This video shares instructions and visualization on performing 2 00:04.500 --> 00:08.000 the infiltration of EXPAREL at the time of closure of a 3 00:08.001 --> 00:11.000 pfannenstiel incision, most commonly used at the time of 4 00:11.001 --> 00:14.499 cesarean section. This video will review the steps of local 5 00:14.500 --> 00:16.499 infiltration.   6 00:16.500 --> 00:20.000 In this procedure Dr. Cherot determined a total volume of 7 00:20.001 --> 00:23.499 80 mLs would be needed to cover the surgical site. She 8 00:23.500 --> 00:28.499 admixed 20 mLs of EXPAREL with 24 mLs of half percent 9 00:28.500 --> 00:32.499 bupivacaine HCL to provide early onset analgesia and 10 00:32.500 --> 00:36.000 bridge the time to onset of the long-acting local analgesia 11 00:36.001 --> 00:39.499 provided by EXPAREL, and further expanded the volume 12 00:39.500 --> 00:45.000 with 36 mLs of normal saline. Dr. Cherot used a 22-gauge 13 00:45.001 --> 00:50.000 needle and four 20 mL syringes to complete these injections. 14 00:50.001 --> 00:54.499 Dr. Cherot infiltrates 40 mLs of the EXPAREL admixture 15 00:54.500 --> 00:58.499 bilaterally into the interior rectus abdominis muscle and rectus 16 00:58.500 --> 01:03.499 sheath. She infiltrated 20 mLs of the admixture on each side, 17 01:03.500 --> 01:07.499 injecting parallel to the surgical plane in a fan-like pattern. 18 01:07.500 --> 01:11.000 Dr. Cherot delivered approximately 5 mLs deep into 19 01:11.001 --> 01:14.499 the tissue with each injection to ensure optimal coverage of the 20 01:14.500 --> 01:18.000 area. She infiltrated as she moved the needle to optimize 21 01:18.001 --> 01:21.499 coverage with the admixture. She then re-approximated the 22 01:21.500 --> 01:25.499 fascia before continuing with the remaining infiltration steps. 23 01:25.500 --> 01:30.000 This woman, unfortunately has got a little fat pad there, but the 24 01:30.001 --> 01:32.499 lipid layer is not where you want to be, but you truly want to see 25 01:32.500 --> 01:36.000 and you can see it starting to swell nicely. And it looks almost 26 01:36.001 --> 01:39.000 dilute, right? Like her rectus muscle is just getting infiltrated, 27 01:39.001 --> 01:42.499 which is exactly what you want. And again, going as lateral and 28 01:42.500 --> 01:50.499 trying to go south to get into the ilioinguinal nerve, which is 29 01:50.500 --> 01:54.000 further south, right? So again, withdrawing. And I’m not going 30 01:54.001 --> 01:57.000 into the abdomen, I’m staying in the rectus muscle. Really 31 01:57.001 --> 02:00.000 important to distinguish that. See that swell up? Beautiful! 32 02:00.001 --> 02:08.499 Love that plane. Nice. That was awesome. Lateral, right? 33 02:08.500 --> 02:15.499 Withdraw, stay in the rectus muscle and inject. There you go, 34 02:15.500 --> 02:17.499 that actually infiltrated nicely. Starts to leak, you’ve 35 02:17.500 --> 02:21.000 know you got to redirect. The same idea, withdraw. NOTE CC break --- 36 02:23.000 --> 02:31.000 Plane. You're not parallel to the tissue itself. Same idea. Hoping 37 02:31.001 --> 02:34.499 that this starts to swell. That it will, and you're not in the 38 02:34.500 --> 02:40.000 abdomen, you’re really parallel. Dr. Cherot infiltrated 20 mLs of 39 02:40.001 --> 02:43.499 the EXPAREL admixture bilaterally from the corners of 40 02:43.500 --> 02:47.000 the fascial incision site. She infiltrated in a fan-like 41 02:47.001 --> 02:51.499 pattern, delivering 3 to 4 mLs of the admixture with each 42 02:51.500 --> 02:56.499 injection for a total of 10 mLs on each side. Dr. Cherot infiltrated 43 02:56.500 --> 03:00.000 above and below the fascia and into the subcutaneous tissue, 44 03:00.001 --> 03:04.499 parallel and along the natural, lateral descending curvature of 45 03:04.500 --> 03:09.000 the fascial plane. She infiltrated out toward the iliohypogastric 46 03:09.001 --> 03:13.000 and ilioinguinal nerves as well as the obliques or aponeurosis 47 03:13.001 --> 03:15.000 begins to form the rectus sheath.   48 03:15.001 --> 03:22.499 So again, same idea. So things I wouldn't want to see, for 49 03:22.500 --> 03:27.499 instance, would be, coming through the skin like that, which 50 03:27.500 --> 03:30.499 you can see this little poke here. Not what I want to do. I want to 51 03:30.500 --> 03:34.000 be a little deeper than that. Other things you don't want to do, 52 03:34.001 --> 03:35.499 would be going to deep.   53 03:35.500 --> 03:38.000 You don't need to be at that angle. Again it’s parallel with the 54 03:38.001 --> 03:41.499 incision itself, um and as lateral as you can. Because again, 55 03:41.500 --> 03:44.499 you’re trying to get those nerves and the branching point. 56 03:44.500 --> 03:49.000 So another 10 ccs being injected out in that fan-like. 57 03:49.001 --> 03:52.000 You will sometimes be so close to the skin, especially on 58 03:52.001 --> 03:55.000 somebody super skinny, that you might actually feel where 59 03:55.001 --> 03:58.499 you’ve injected a little, you know, just in the sub Q. That 60 03:58.500 --> 04:03.499 will, as it gets absorbed, go away. And is not a problem. 61 04:03.500 --> 04:06.499 And again, same thing, you want to be careful not to hit any 62 04:06.500 --> 04:09.500 vessels, you’re withdrawing back and injecting. NOTE CC break --- 63 04:20.500 --> 04:25.499 Same idea, going out lateral, withdrawing and then injecting. 64 04:25.500 --> 04:30.000 In this final step, Dr. Cherot performed bilateral field blocks, 65 04:30.001 --> 04:33.499 infiltrating two fingerbreadths superior or medial to the 66 04:33.500 --> 04:38.000 anterior superior iliac crest. She infiltrated 10 mLs of the 67 04:38.001 --> 04:42.000 EXPAREL admixture on the right and left side of the patient, 68 04:42.001 --> 04:45.499 perpendicular to the surgical plane, making sure to deliver 69 04:45.500 --> 04:49.000 the admixture deep into the abdominal wall. This step 70 04:49.001 --> 04:52.499 provides a field block of the ilioinguinal nerves, addressing 71 04:52.500 --> 04:57.000 pain from any innervation closer to the incision. If preferred, the 72 04:57.001 --> 05:00.499 surgeon can also choose to infiltrate the remaining 20 mLs 73 05:00.500 --> 05:04.000 of the admixture along the incision above and below the 74 05:04.001 --> 05:07.000 fascia and into the subcutaneous tissue. NOTE CC break --- 75 05:08.000 --> 05:12.000 So anterior iliac spine, right? Two fingerbreadths above, 76 05:12.001 --> 05:19.000 right? You’re going to realize this woman is not very thick. 77 05:19.001 --> 05:22.499 Average for New Jersey’s a little bigger than that. NOTE CC break --- 78 05:27.500 --> 05:32.000 Two fingerbreadths above. You want to do where you think you would 79 05:32.001 --> 05:37.000 put a port for a laparoscopic, right? The more medial, 80 05:37.001 --> 05:41.000 I’m worrying about my, um epigastric, so you want to be 81 05:41.001 --> 05:45.000 very careful of that. So, again, I’m not bearing this off but going 82 05:45.001 --> 05:50.000 halfway down, right? And I’m going to put about 5 ccs right there. NOTE CC break --- 83 05:52.500 --> 05:56.499 Can’t count upside down. And then I’m going to start to 84 05:56.500 --> 06:00.499 withdraw slightly, but continue to put another couple ccs. A little 85 06:00.500 --> 06:04.499 more. And again, the whole point is I'm really trying to get at 86 06:04.500 --> 06:10.000 nerve endings. And that’s it. And if you just want to, out lateral 87 06:10.001 --> 06:13.499 here was the major ones we did with 10 ccs. You could take 88 06:13.500 --> 06:17.499 another, you know, 5 to 10 up here. Another 5 to 10 even more 89 06:17.500 --> 06:21.499 medial or along the line of the, of the incision which I think 90 06:21.500 --> 06:23.500 I showed when I was doing that before.