TAP blocks with Exparel?

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I thought this was for infiltration of soft tissue only. I dont think its been evaluated for regional or neuraxial use.
 
Correct, it hasn't been FDA approved for direct perineural use, only for infiltration. However I believe that trials for it's use in peripheral nerve blocks are underway.

Surgeons in my practice are using it routinely for hemorrhoidectomy, bunionectomy, inguinal hernias and VATS (intercostal).
 
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excalibur said:
Forget Dexamethasone. This guy on Youtube is going straight to the Exparel.

http://www.youtube.com/watch?v=_xLhtW5pPa4

Anyone else doing this? Very curious to hear thoughts
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Why? If or when there is a complication as a result of the nerve block who is going to testify on your behalf? Can you point to even one academic study in India or Egypt where they are doing this on their third world patients?

Did the patient consent for experimental treatment?
 
reanimatore said:
Correct, it hasn't been FDA approved for direct perineural use, only for infiltration. However I believe that trials for it's use in peripheral nerve blocks are underway.

Surgeons in my practice are using it routinely for hemorrhoidectomy, bunionectomy, inguinal hernias and VATS (intercostal).
Click to expand...

Well if it is being used for intercostal blocks, then why not for TAP? For an intercostal block you are trying to block anterior and lateral cutaneous branches for ventral rami of upper thoracic spinal nerves. For TAP block you are trying to block anterior and lateral cutaneous branches for ventral rami of lower thoracic spinal nerves.

What's the difference?

I know there may be a small motor component you block with TAP, like cremaster muscle, but couldn't the same be said about the intercostal nerves?

I also found this online. Take it for what it's worth. Dated 11/13/12

New Data Supporting Use of EXPAREL via Infiltration into the Transversus Abdominis Plane Presented at 11 th Annual American Society of Regional Anesthesia and Pain Medicine Meeting.
 
Exploring Additional Indications for EXPAREL: During the third quarter, Pacira initiated a Phase 2/3 study investigating the use of EXPAREL as a single-dose injection femoral nerve block for total knee arthroplasty surgery. Additionally, Pacira announced data from its first completed Phase 4 IMPROVE study in open colectomy patients, demonstrating that the EXPAREL-based multimodal regimen achieved a statistically significant reduction in each primary endpoint in the study, including a 60 percent reduction in hospital length of stay.
Fall Data Presentations and Publications: Through its ongoing Phase 4 and case studies, Pacira continues to generate strong data supporting both the clinical and economic benefits of EXPAREL use. Studies are ongoing in ileostomy reversal, open and laparoscopic colectomy procedures, as well as a wide range of plastic surgery uses and TAP (Transverse Abdominis Plane) infiltration. Over the next several months, Pacira expects data from these studies to be presented at the key society meetings and published in several top, peer-reviewed pain and surgical journals.
 
BLADEMDA said:
Why? If or when there is a complication as a result of the nerve block who is going to testify on your behalf? Can you point to even one academic study in India or Egypt where they are doing this on their third world patients?

Did the patient consent for experimental treatment?
Click to expand...

When I posted the video, I was somewhat shocked to see that the guy was using exparel for TAP blocks. I felt that it had only been approved for local infiltration. That is why I was asking if anyone else was doing this. Also in the video I noticed the guy say he mixed it with 0.25% plain Bupivacaine, when in the package insert it says not to administer other formulations of bupivacaine for 96 hours after using exparel. I believe that it can cause an immeidate release of bupivcaine. So I was surprised to see the guy was doing that as well.

But then I am just asking, if CT surgeons are doing intercostal nerve blocks with it, what is the difference in using it in a TAP block? Perhaps it really isn't approved for intercostal blocks??
 
BLADEMDA said:
Exploring Additional Indications for EXPAREL: During the third quarter, Pacira initiated a Phase 2/3 study investigating the use of EXPAREL as a single-dose injection femoral nerve block for total knee arthroplasty surgery. Additionally, Pacira announced data from its first completed Phase 4 IMPROVE study in open colectomy patients, demonstrating that the EXPAREL-based multimodal regimen achieved a statistically significant reduction in each primary endpoint in the study, including a 60 percent reduction in hospital length of stay.
Fall Data Presentations and Publications: Through its ongoing Phase 4 and case studies, Pacira continues to generate strong data supporting both the clinical and economic benefits of EXPAREL use. Studies are ongoing in ileostomy reversal, open and laparoscopic colectomy procedures, as well as a wide range of plastic surgery uses and TAP (Transverse Abdominis Plane) infiltration. Over the next several months, Pacira expects data from these studies to be presented at the key society meetings and published in several top, peer-reviewed pain and surgical journals.
Click to expand...

I feel confident that it will be approved for TAP blocks. Until it comes out in the peer reviewed journals, it seems it is best to hold off.

I don't see why it would be a problem though
 
excalibur said:
I feel confident that it will be approved for TAP blocks. Until it comes out in the peer reviewed journals, it seems it is best to hold off.

I don't see why it would be a problem though
Click to expand...

I'm Totally PRO EXPAREL. I believe EXPAREL will change the way we practice in the USA in just 36 months. I fully expect to transition my practice from Bup with PF Decadron to some type of Exparel solution.

I agree that TAP blocks will be my first use of EXPAREL and I expect that to start in the Spring or Summer.

In about 3-5 years 80% of practices will replace catheters with EXPAREL.
 
excalibur said:
When I posted the video, I was somewhat shocked to see that the guy was using exparel for TAP blocks. I felt that it had only been approved for local infiltration. That is why I was asking if anyone else was doing this. Also in the video I noticed the guy say he mixed it with 0.25% plain Bupivacaine, when in the package insert it says not to administer other formulations of bupivacaine for 96 hours after using exparel. I believe that it can cause an immeidate release of bupivcaine. So I was surprised to see the guy was doing that as well.

But then I am just asking, if CT surgeons are doing intercostal nerve blocks with it, what is the difference in using it in a TAP block? Perhaps it really isn't approved for intercostal blocks??
Click to expand...

I don't believe that it is approved for intercostal blocks, I just don't think the surgeons care. Our podiatrists are also using it for ankle/mayo blocks, which you could classify as a peripheral nerve block as well as you are anesthetizing specific terminal branches of the sciatic/femoral nerves. It's a bit of a blurry line sometimes between infiltration and nerve block.

From what I've heard about the initial research/studies for exparel, and as Blade pointed out above, it seems that it will be ultimately approved for peripheral nerve blockade. If it is, it should obviate the need for local anesthetic adjuncts such as dexamethasone in many settings.
 
And, Pacira has big plans for EXPAREL. The current clinical trial for the nerve block indication is quite exciting. It would allow anesthesiologists to use the drug under the guidance of ultrasound – opening up the potential beyond post surgical pain.

Beyond EXPAREL, Pacira has two assets in pipeline. Pacira owns all commercialization rights to DepoNSAID (in preclinical development for acute pain) and DepoMethotrexate (in preclinical development for rheumatoid arthritis and oncology).

"In the future, we may pursue research and development and/or commercial partnerships for these compounds," the CFO concluded. "Both are exciting endeavors that could ultimately improve the standard of care for millions of patients."
 
Exparel= $285 for 20 ml vial

Bupivacaine 30 ml bottle of 0.5%= $1.85 plus $0.50 for PF Decadron (total of $2.35)

ObamaCare patients may still get the Bup with the Decadron
 
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Members don't see this ad :)
BLADEMDA said:
Exparel= $285 for 20 ml vial

Bupivacaine 30 ml bottle of 0.5%= $2.50 plus $0.50 for PF Decadron (total of $3.00)

ObamaCare patients may still get the Bup with the Decadron
Click to expand...

The math that will be trying to to sell is single shot Exparel v. Ropivicaine + On-Q pump.
 
I agree that something will replace catheters in the future, but it's hard to believe that it will be a liposomal preparation...
 
dr doze said:
The math that will be trying to to sell is single shot Exparel v. Ropivicaine + On-Q pump.
Click to expand...

I get it. A single bottle of Exparel which lasts for 72 hours is still cheaper than Ropivacane ($14 per bottle) plus On-Q with Ropivacaine (?$400 total).

Still, at $150 the Exparel will sell quite well vs over $250 per bottle.

Exparel would take 2 bottles to do a subcostal TAP bilaterally for a high abdominal incision ($570). I doubt ObamaCare will even pay me $570 for the entire case.
 
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Pacira Pharmaceuticals, Inc. Announces Results from the First Improve Study to Complete its Prospective Phase 4 Clinical Program

Nov 20 12

Pacira Pharmaceuticals, Inc. announced that results from the first IMPROVE study to complete its prospective Phase 4 clinical program were published in the online version of the Journal of Pain Research. The IMPROVE studies compare the difference in opioid use, total hospital cost and length of stay (LOS) between patients receiving EXPAREL(R) (bupivacaine liposome injectable suspension) as the foundation of an opioid-sparing multimodal regimen versus a standard opioid-based postsurgical pain management regimen. Compared to patients undergoing open colectomy in the standard opioid-based treatment arm, patients undergoing the same procedure and receiving an EXPAREL-based multimodal regimen had: A 2.9-day reduction in median LOS (4.9 days in the hospital vs 2.0 days in the hospital, respectively; P=0.004); A $3,084 reduction in mean total hospital cost ($11,850 against $8,766, respectively; P=0.027); A 58 mg reduction in mean opioid consumption (115 mg vs 57 mg, respectively; P=0.025). The overall safety profile for EXPAREL was consistent with previous experiences in the Phase 3 program.


Pacira Pharmaceuticals, Inc. Announces the First Data Presentation Supporting the Use of EXPAREL Infiltrated into the Transversus Abdominis Plane for Postsurgical Pain Management

Nov 13 12

Pacira Pharmaceuticals, Inc. announced the first data presentation supporting the use of EXPAREL(R) (bupivacaine liposome injectable suspension) infiltrated into the transversus abdominis plane (TAP) for postsurgical pain management. TAP infiltration is being increasingly utilized for postsurgical analgesia in abdominal procedures as clinicians aim to maintain pain control while reducing reliance on opioid analgesics. Andrew Sternlicht, M.D., Assistant Clinical Professor of Anesthesiology at the Tufts University School of Medicine, is lead author on a poster presentation of the data, which will be presented at the 11(th) Annual American Society of Regional Anesthesia and Pain Medicine (ASRA) Meeting, taking place November 15-18, 2012 in Miami. Twenty-four patients undergoing robotic prostatectomy were enrolled in this open-label, prospective study to evaluate the efficacy and safety of EXPAREL via TAP infiltration. Key findings include patients required a mean of less than one oxycodone/acetaminophen tablet per day from their discharge until their day 10 visit; 100% of the available subjects reported being either satisfied or extremely satisfied with their postsurgical pain control at hospital discharge, at 72 hours and on day 10; and when retrospectively compared to a 2011 study of patients who received a TAP infiltration of bupivacaine HCl, patients administered EXPAREL in the same fashion had similar or better pain scores with a reduced requirement for opioids. There were no treatment-related adverse events in the study. EXPAREL is indicated for single-dose administration into the surgical site to produce postsurgical analgesia. Additionally at ASRA, Tong-Joo Gan, M.D., M.H.S., Professor and Vice Chair, Department of Anesthesiology at Duke University Medical Center, will present a poster that describes results from a 300-patient survey conducted to assess the current state of postsurgical pain management. Findings indicate that inadequately controlled postsurgical pain is ubiquitous more than 85% of the patients surveyed reported experiencing postsurgical pain; 75% of patients reporting pain characterized it as moderate, severe or extreme; and 79% of patients reported experiencing side effects from pain medications, with the majority of those side effects appearing to be opioid-related. Overall, the researchers found that postsurgical pain remains undermanaged; greater clinical adoption of multimodal therapy and novel non-opioid analgesics could potentially minimize opioid-related side effects and improve postsurgical pain management.
 
I'm on Board here. I expect to start using EXparel in 2013 for my TAP/Subcostal Tap blocks. Ditto for TPVB as that eliminates the need for catheter placement/misplacemt.

I'll be able to do 2-3 level TPVB blocks now using U/S and an echogenic needle. I expect 48-72 hrs of postop pain relief.
 
Wow, TPVB with exparel sounds awesome: open choles, thoractomies, mastectomies with LND...
 
Cool. Will be looking forward to it. I will post my interscalene + Decadron data soon once I have n = 10.

Was looking at US guided TPVB videos and genral paravertebral info online. I was deprived of this technique in residency as no attending did them. So I have never done one or seen one done.

Blade, is there a particular video on the internets that you think is good or demonstrates how you perform the procedure? Also, what are your most common operations where you are using paravertebrals? Why paravertebral block instead of epidural catheter? - Is it just to avoid the bilateral nature of epidurals and perhaps less need to follow up on the floor?
 
excalibur said:
Cool. Will be looking forward to it. I will post my interscalene + Decadron data soon once I have n = 10.

Was looking at US guided TPVB videos and genral paravertebral info online. I was deprived of this technique in residency as no attending did them. So I have never done one or seen one done.

Blade, is there a particular video on the internets that you think is good or demonstrates how you perform the procedure? Also, what are your most common operations where you are using paravertebrals? Why paravertebral block instead of epidural catheter? - Is it just to avoid the bilateral nature of epidurals and perhaps less need to follow up on the floor?
Click to expand...

I'm wel over 250 blocks with Local plus Dexamethasone. Results are excellent so far with no complications. I'm sold.

Exparel is the next level. I'm planning on going full steam ahead with Exparel in all my blocks once FDA approval is granted. First, is TAP/SUBCOSTAL TAP/TPVB as they are approved.

I learned how to do every single one of these blocks on my own. U/S is a game changer and after several you tube videos these blocks are easy. For those with less technical skill BlockJocks.com offers courses in U/S. Or, go to an ASRA course.
 
To compare the outcomes of thoracic epidural block with thoracic paravertebral block for thoracotomy in pediatric patients. A prospective double-blind study. 60 pediatric patients aged 1-24 months, ASA II, III scheduled for thoracotomy were randomly allocated into two groups. After induction of general anesthesia, thoracic epidural catheter was inserted in group E (epidural) patients and thoracic paravertebral catheter was inserted in group P (paravertebral) patients. Post operative pain score was recorded hourly for 24 hours. Plasma cortisol level was recorded at three time points. Tidal breathing analysis was done preoperatively and 6 hours postoperatively. Analgesia, serum cortisol level, and pulmonary function parameters were comparable in the two groups. However, failure rate (incorrect placement of catheter) was significantly higher in epidural group than in paravertebral group (7% versus 0%, respectively). The complications were also significantly higher in epidural group (vomiting 14.8%, urine retention 11.1% and hypotension 14.8%) than paravertebral group (0%, 0%, and 3.6%, respectively). We conclude that both thoracic paravertebral block and thoracic epidural block results in comparable pain score and pulmonary function after thoracotomy in pediatric patients; the paravertebral block is associated with significantly less failure rate and side effects.
 
Either thoracic epidural analgesia with LA plus opioid or continuous paravertebral block with LA can be recommended. Where these techniques are not possible, or are contraindicated, intrathecal opioid or intercostal nerve block are recommended despite insufficient duration of analgesia, which requires the use of supplementary systemic analgesia. Quantitative meta-analyses were limited by heterogeneity in study design, and subject numbers were small. Further well designed studies are required to investigate the optimum components of the epidural solution and to rigorously evaluate the risks/benefits of continuous infusion paravertebral and intercostal techniques compared with thoracic epidural analgesia.


http://www.anesthesia-analgesia.org/content/107/3/1026
 
Br J Anaesth. 2006 Apr;96(4):418-26. Epub 2006 Feb 13.

A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy--a systematic review and meta-analysis of randomized trials.

Davies RG, Myles PS, Graham JM.


Source

Department of Anaesthesia and Pain Management, Alfred Hospital Commercial Road, Melbourne, Victoria 3004, Australia.


Erratum in
Br J Anaesth. 2007 Nov;99(5):768.


Abstract

Epidural analgesia is considered by many to be the best method of pain relief after major surgery. It is used routinely in many thoracic surgery centres. Although effective, side-effects include hypotension, urinary retention, incomplete (or failed) block, and, in rare cases, paraplegia. Paravertebral block (PVB) is an alternative technique that may offer comparable analgesic effectiveness and a better side-effect profile. We undertook a systematic review and meta-analysis of all relevant randomized trials comparing PVB with epidural analgesia in thoracic surgery. Data were abstracted and verified by both authors. Studies were tested for heterogeneity, and meta-analyses were done with random effects or fixed effects models. Weighted mean difference (WMD) was used for numerical outcomes and odds ratio (OR) for dichotomous outcomes, both with 95% CI. We identified 10 trials that had enrolled 520 thoracic surgery patients. All of the trials were small (n<130) and none were blinded. There was no significant difference between PVB and epidural groups for pain scores at 4-8, 24 or 48 h, WMD 0.37 (95% CI: -0.5, 121), 0.05 (-0.6, 0.7), -0.04 (-0.4, 0.3), respectively. Pulmonary complications occurred less often with PVB, OR 0.36 (0.14, 0.92). Urinary retention, OR 0.23 (0.10, 0.51), nausea and vomiting, OR 0.47 (0.24, 0.53), and hypotension, OR 0.23 (0.11, 0.48), were less common with PVB. Rates of failed block were lower in the PVB group, OR 0.28 (0.2, 0.6). PVB and epidural analgesia provide comparable pain relief after thoracic surgery, but PVB has a better side-effect profile and is associated with a reduction in pulmonary complications. PVB can be recommended for major thoracic surgery.
 
http://www.anesthesiologynews.com/download/NerveBlocks_AN0312_WM.pdf

PRINT OR SAVE PDF!

Unive. of Pittsburgh uses TPVB for Breast and Lung Surgeries. Thousands and thousands of TPVB performed at Pitt over the past 20 years. They are the Mecca of TPVB in the USA.

They have maintained TPVB catheters in patients who are on Lovenox. Several hundred patients so far. No complications.
 
Great stuff. Yeah had read that one in Pitt.

So now your thoughts then. I can learn the block as I have seen video. Right now I can only do thoracic epidurals.

You can do both.

Do you do paravertebrals instead of thoracic epidurals for your thoracotomies to obtain less of a side effect profile? Do you generally favor PVB over epidurals then? Are there instances where you feel an epidural would be favored over PVB?

Regarding the actual US technique, I have seen a couple. That Anes News article described three. A "Classic" approach where the probe is more vertical on the back parallel with the spinous processes and the needle comes from above. Online videos demonstrate an approach where the probe is on the back over the transverse approaches where the probe is diagonally placed. One side of probe pointing to contralateral shoulder and other end pointing to ipsilateral hip. The view on US screen from here appears to be what I have seen in other videos. On screen you will see transverse proces, the IIM or costo-transverse ligament, the parietal pleura, and the wedge shaped paravertebral space which is the target.

Is it the latter technique that you use?

Also the angle seems fairly steep and I imagine should only be done with an echogenic needle. We have none at my institution. Recommendations? Tough to see my needle on infraclvicular blocks. Wouldn't want to use my hard to visualize Stimuplex needles as I aim to pleura
 
excalibur said:
Great stuff. Yeah had read that one in Pitt.

So now your thoughts then. I can learn the block as I have seen video. Right now I can only do thoracic epidurals.

You can do both.

Do you do paravertebrals instead of thoracic epidurals for your thoracotomies to obtain less of a side effect profile? Do you generally favor PVB over epidurals then? Are there instances where you feel an epidural would be favored over PVB?

Regarding the actual US technique, I have seen a couple. That Anes News article described three. A "Classic" approach where the probe is more vertical on the back parallel with the spinous processes and the needle comes from above. Online videos demonstrate an approach where the probe is on the back over the transverse approaches where the probe is diagonally placed. One side of probe pointing to contralateral shoulder and other end pointing to ipsilateral hip. The view on US screen from here appears to be what I have seen in other videos. On screen you will see transverse proces, the IIM or costo-transverse ligament, the parietal pleura, and the wedge shaped paravertebral space which is the target.

Is it the latter technique that you use?

Also the angle seems fairly steep and I imagine should only be done with an echogenic needle. We have none at my institution. Recommendations? Tough to see my needle on infraclvicular blocks. Wouldn't want to use my hard to visualize Stimuplex needles as I aim to pleura
Click to expand...

The Best needle on the market is Pajunk. Next is the Braun Echogenic. I like the Pajunk for this block as the needle is EASILY visualized up to 70-75 degrees (almost vertical).

I'm sorry to hear your institution won't allow you to spend an extra $10 on a needle so patients can avoid complications and get great care.
 
I think they will spend the money. It's just that the only ones who use US for blocks are one other partner and me. The Dept just got a decent US about a year and a half ago. I am sure if we ask for it, they will get it for us.
 
excalibur said:
I think they will spend the money. It's just that the only ones who use US for blocks are one other partner and me. The Dept just got a decent US about a year and a half ago. I am sure if we ask for it, they will get it for us.
Click to expand...



http://forums.studentdoctor.net/showthread.php?t=924585&highlight=paravertebral+blocks

Read the thread. See post number 20 for my technique as recommend by the experts at Pitt. You can insert the needle from the bottom or the top (if using the cranial insertion the probe is rotated the other direction with the cranial portion more oblique to the midline)
 
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http://www.youtube.com/watch?feature=player_embedded&v=QgGXnaxGNk0

Braun Stimuplex Ultra is a good needle. You must keep the black,etched markings which are only on one side of the needle facing the probe. Beginners have trouble with keeping the black marks facing the probe (they keep turning the needle so the non etched faces the probe and that non etched side is non echogenic). Pajunk has 100% echogenicity on all aspects of the needle.

The Braun is a good needle up to 60 degrees from the skin. The pajunk can do 70-75 degrees from the skin due to its enhanced echogenicity. This means I can do Infraclavicular without ever moving the shoulder on a severly injured patient. All I need to do is place the probe over the proper location then put my Pajunk needle right next to the probe and get ready to go 70-75 degrees in my approach to the Axillary Artery (below the level of the first rib the Subclavian Artery becomes the Axillary Artery). You can't do this type of Infraclavicular block with any other needle and maintain good visualization. 70 degrees is badass.
 
You use Pajunk for all your blocks or just steep angle? I read a while ago that certain echogenic needles don't work well in 10-15 degree angles
 
Parasaggital (vertical) approach seems to need a steep needle angle, compared to the intercostal approach (not so much diagonal as parallel to ribs). That's the main reason I use the intercostal approach. Consider saving money by using a la carte 18g or 20g Tuohy needles. They are thick and well imaged on ultrasound. The tip is pretty easy to see. And the Tuohy tip can be aimed away from the pleura. We have Sonoplex stim needles 21g x 100mm, but I it's a waste to use them if youre not stimming.
 
Downside of the lateral to medial intercostal approach is that you might be too close to the surgery site (thoracotomy) for placing a catheter.
 
excalibur said:
You use Pajunk for all your blocks or just steep angle? I read a while ago that certain echogenic needles don't work well in 10-15 degree angles
Click to expand...

Echogenic needles work in all situations. Whoever told you they don't work at 10-15 degrees is full of crap. Are they needed at 15degrees? No.

You need to exceed 30 degrees before an echogenic needle begins to have a significant impact on needle visualization. At 50-60 degrees the echogenic needles are a huge advantage over the standard needle.

As for Ogg claiming that a cheap needle will work that is also true. But, considering the overall cost of the procedure and surgery I'd rather use that extra $10 for an echogenic needle in order to facilitate quick and easy placement of my blocks.

Those who work in academia have the luxury of doing 20 minute nerve blocks while I must complete the task in 10 minutes or less.
 
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excalibur said:
You use Pajunk for all your blocks or just steep angle? I read a while ago that certain echogenic needles don't work well in 10-15 degree angles
Click to expand...

Pajunk needles work in all situations. But, they make you lazy with your probe skills (P.A.R.T.). I'd recommend you use a basic needle or Braun Echogenic needle to keep up your probe skills so when you get handed that cheap Tuohy needle it won't cause your BP to rise.

You don't NEED a Pajunk Needle for any block except a 70 degree ICB. But, I like them on my TPVB, SubCostal TAP and ICB. That said, the Braun Echogenic needle is more than adequate for all those blocks as well (it just takes a few extra minutes).
 
When dealing with US probe manipulation, the mnemonic PART (Pressure, Alignment, Rotation and Tilt) is useful [Figure 7]. It is important to understand that by manipulating the US probe, we primarily manipulate the direction of the beam, and, by changing the direction of the beam, slightly different US images of the same structures can be obtained.



Figure 7

US probe manipulation maneuvers "PART" mnemonic for Pressure, Alignment, Rotation and Tilt as fundamental probe manipulation maneuvers
 
Agree with echogenic for TAP blocks. I would use them there for sure. It would cut down time tremendously in a bilateral TAP in my opinion
 
Morbidly obese patients are hard to TAP Block even with a Sonoplex or an 18g Tuohy.
 
Oggg said:
Morbidly obese patients are hard to TAP Block even with a Sonoplex or an 18g Tuohy.
Click to expand...

I do morbidly obese routinely for tap. I use a Pajunk echogenic needle. The super morbidly obese like for gastric bypass is another story entirely.

BMI of 30. No problem.

BMI of 35. Tough but I can do it.

BMI of 40. I'd rather pass on the TAP
 
Blade, I am gathering info to present to our supplies dept for possible order. I read you recommended the 80 mm needles. Do you use the Sprotte or the Facet needle? The differences are illustrated on the Pajunk website.
 
excalibur said:
Blade, I am gathering info to present to our supplies dept for possible order. I read you recommended the 80 mm needles. Do you use the Sprotte or the Facet needle? The differences are illustrated on the Pajunk website.
Click to expand...

Why not get the samples? They will send you at least ten block needles. Call them. Ask for each type and get 80 mm and the next size up. Try them. Pick one you like. They sent me 20. Block needles after I spoke with them
 
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