TAP blocks with Exparel?

[BLADEMDA]

We have pajunk Sonoplex 21g x 100mm. Might as well go long.

Agreed. I like the 80 mm and 100 mm sizes the best.

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[excalibur]

Agreed. I like the 80 mm and 100 mm sizes the best.

Well, I might call and get the free Pajunk samples, but since our hospital already has a contract with Braun Stimuplex and we have the Braun nerve stimulator, our Supplies director went ahead and ordered some of the Braun Stimuplex Ultra 4 inch echogenic needles. They should be here by end of the week..

Although I guess I could get free samples of the Pajunk, if we wanted to order them, I was told it would take a whole bunch of paperwork, and they would not be here any time soon.

From reading the posts it seems the Braun are still a good echogenic needle up to about 60 degrees, but I won't get the awesome power of the Pajunk at 70 degrees. Still better than before I guess. Looking forward to doing infraclaviculars and TAPS with the echogenic needle

 

[bogatyr]

What CPT code do you guys use to bill for TAP block? Thanks

 

[yancantcook]

Bump, what is the status of exparel and tap blocks. Is there a "FDA" approval for this usage?

Is there any comparison of TAP catheters vs Exparel? I'm at an academic center and I'm trying to get it implemented for TAP blocks

 

[BLADEMDA]

Bump, what is the status of exparel and tap blocks. Is there a "FDA" approval for this usage?

Is there any comparison of TAP catheters vs Exparel? I'm at an academic center and I'm trying to get it implemented for TAP blocks

FDA has granted approval to use Exparel for Tap Blocks: http://www.fda.gov/downloads/Drugs/...etterstoPharmaceuticalCompanies/UCM477250.pdf

 

[BLADEMDA]

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0153675

 

[BLADEMDA]

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0153675

My experience with Exparel and TAP Blocks shows the following:

1. Exparel at 0.44% or 0.66% lasts about 40-48 hours postop
2. The addition of PF dexamethasone to the Exparel or regular Bupivacaine improves analgesia and extends the duration of the block (just slightly for the Exparel)
3. For Open procedures where there is visceral pain I recommend the addition of Buprenorphine (quality of analgesia postop is much better)


TAP block technique
The goal of the TAP block is to inject local anesthetic in the plane between the internal oblique and transversus abdominis muscles. This will interrupt innervation to the abdominal skin, muscles, and parietal peritoneum; however, it will not block visceral pain.

 

[BLADEMDA]

European Journal of Anaesthesiology:
November 2015 - Volume 32 - Issue 11 - p 797–804
doi: 10.1097/EJA.0000000000000345
Regional anaesthesia
Comparison of efficacy and safety of lateral-to-medial continuous transversus abdominis plane block with thoracic epidural analgesia in patients undergoing abdominal surgery: A randomised, open-label feasibility study
Ganapathy, Sugantha; Sondekoppam, Rakesh V.; Terlecki, Magdalena; Brookes, Jonathan; Adhikary, Sanjib Das; Subramanian, Lakshmimathy

Supplemental Author Material

Abstract

BACKGROUND: We recently described a lateral-to-medial approach for transversus abdominis plane (LM-TAP) block, which may permit preoperative initiation of the block.

OBJECTIVE: Our objective was to evaluate the feasibility of continuous LM-TAP blocks in clinical practice in comparison with thoracic epidural analgesia (TEA).

DESIGN: A randomised, open-label study.

SETTING: University Hospital, London Health Sciences Centre, London, Ontario, Canada from July 2008 to August 2012.

PATIENTS: Fifty adult patients undergoing open abdominal surgery via laparotomy were allocated randomly to receive preoperative catheter-congruent TEA or ultrasound-guided continuous bilateral LM-TAP block for 72 h postoperatively. Reasons for noninclusion were American Society of Anesthesiologists’ physical status more than 4, known allergy to study drugs, chronic pain/opioid dependence, spinal abnormalities or psychiatric illness.

INTERVENTIONS: In the TEA group (n = 24), patient-controlled epidural analgesia was maintained using bupivacaine 0.1% with hydromorphone 10 μg ml−1 after establishment of the initial block. In the LM-TAP group (n = 26), ultrasound-guided LM-TAP catheters were inserted on each side preoperatively after a bolus of 30 ml of ropivacaine 0.5% (20 ml subcostal and 10 ml subumbilical injections on both sides). Analgesia was maintained with an infusion of ropivacaine 0.35% at a rate of 2 to 2.5 ml h−1 through each catheter, along with rescue intravenous patient-controlled analgesia.

MAIN OUTCOME MEASURES: The primary outcome was pain score on coughing 24 h after the end of surgery. Secondary outcomes were pain scores from 24 to 72 h, intraoperative and postoperative opioid consumption, time to onset of bowel movement and side effect profiles.

RESULTS: Mean [95% confidence interval (95% CI)] pain scores at rest ranged from 1. 7 (0.9 to 2.5) to 2.3 (1.1 to 3.4) in TEA vs. 1.5 (0.7 to 2.2) to 2.2 (1.3 to 3.0) in LM-TAP (P = 0.829). The dynamic pain scores ranged from 2.9 (1.5 to 4.4) to 3.8 (2.8 to 4.8) in TEA vs. 3.3 (2.4 to 4.3) to 3.8 (2.7 to 4.9) in LM-TAP (P = 0.551). The variability in pain scores was lower in the LM-TAP group than in the TEA group in the first 24 h postoperatively. Patient satisfaction and other secondary outcomes were similar.

CONCLUSION: Continuous bilateral LM-TAP block can be initiated preoperatively and may provide comparable analgesia to TEA in patients undergoing laparotomy.

 

[Mman]

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0153675

isn't that graph the definition of not clinically relevant?

 

[BLADEMDA]

isn't that graph the definition of not clinically relevant?

Unless you are the patient that is. The combo of Exparel/Dexamethasone/Buprenorphine for TAP blocks is very effective for Open Abdominal surgeries. Have you tried it? Even 0.375% Bup/Dexamethasone/Buprenorphine is very effective for postop analgesia with a duration of 22-24 hours.


http://prc.coh.org/FF-TAPBlock01-11.pdf

 

[BLADEMDA]

http://www.nysora.com/exparel/pdfs/Ayad_ASRA_poster_3-26-14FINAL.pdf

 

[BLADEMDA]

I've performed a great number of TAP blocks across a wide variety of surgeries and patient populations. I will admit that an Epidural is superior to a TAP/Subcostal TAP block in terms of the reliability of the pain control postop. That said, for most patients the TAP blocks do help significantly in reducing postop pain. The subgroup with the highest dissatisfaction after TAP blocks are generally female, anxious, low pain tolerance and history of "unsatisfactory" response to previous pain control efforts following surgery. Even the addition of Buprenorphine (which is a MUST in this subgroup) may not be enough to satisfy their complaints.

I highly recommend TAP blocks for any open procedure of the abdomen or groin and would recommend one to friends/family.

 

[Mman]

Unless you are the patient that is.

No patient I've ever taken care of has felt a pain score difference of <1 was clinically relevant. Oh, you're a 4 now instead of a 5? Well hallelujah!!! Because you literally just posted a graph showing a pain score difference of <1 from a study that showed a TAP block was "noninferior" to IV narcotics.


(and yes, I've done a ton of TAP blocks)

 

[BLADEMDA]

No patient I've ever taken care of has felt a pain score difference of <1 was clinically relevant. Oh, you're a 4 now instead of a 5? Well hallelujah!!! Because you literally just posted a graph showing a pain score difference of <1 from a study that showed a TAP block was "noninferior" to IV narcotics.


(and yes, I've done a ton of TAP blocks)

Proving something in a study can be difficult as that same study did not show superiority of Epidural vs IV PCA either.

 

[Mman]

Proving something in a study can be difficult as that same study did not show superiority of Epidural vs IV PCA either.

If the effect is large, it isn't difficult to prove in a study.

Like I said, I have done and do plenty of TAP blocks. But citing a graph from a study that shows noninferiority isn't how you should try to prove it is better.

 

[BLADEMDA]

If the effect is large, it isn't difficult to prove in a study.

Like I said, I have done and do plenty of TAP blocks. But citing a graph from a study that shows noninferiority isn't how you should try to prove it is better.

Sometimes the study is under-powered like the one in this post. FYI, I add Dexamethasone to the local (Including Exparel) for the vast majority of my TAP blocks.

http://epostersonline.com/asraspring2015/node/361?view=true

 

[sleepallday]

Well one thing is for sure- the Exparel reps have figured out that instead of talking to us, all they need to do is talk to the surgeons to get there drug used. We have multiple surgeons asking for TAP blocks w/ Exparel.

 

[BLADEMDA]

Well one thing is for sure- the Exparel reps have figured out that instead of talking to us, all they need to do is talk to the surgeons to get there drug used. We have multiple surgeons asking for TAP blocks w/ Exparel.

Tap blocks with 0.375% Bup/Dexamethasone/Buprenorphine = 24 hours

Tap blocks with Exparel plus Dexamethasone = 40 hours

Number 1 costs $16 for medications
Number 2 costs $288 for the meds

 

[sleepallday]

Tap blocks with 0.375% Bup/Dexamethasone/Buprenorphine = 24 hours

Tap blocks with Exparel plus Dexamethasone = 40 hours

Number 1 costs $16 for medications
Number 2 costs $288 for the meds

That may be the cost to the hospital, but the cost to the patient is a lot more.

 

[BLADEMDA]

That may be the cost to the hospital, but the cost to the patient is a lot more.

Medicare doesn't cover Exparel for inpatients so the hospital has to eat the cost.

 

[yancantcook]

What is the group's opinion for doing TAP single shot vs catheters? I'm in an academic institution and there is a wide range of opinions on it. I don't think we should be putting TAP catheters in every open abdominal surgeries since we don't have the resources to round on 20 catheters daily. Also, I don't think putting 10cc/hr solution is going to do much of anything unless we go up and bolus them q8h ATC with 20cc of solution.

I tried to do a pubmed search for TAP catheter vs single shot but couldn't find good data. What about rectus sheath single shot vs catheter?

 

[dhb]

I've never done an abdominal wall catheter and never felt the need to. I'd rather do an epidural than a double catheter.

 

[yancantcook]

I've never done an abdominal wall catheter and never felt the need to. I'd rather do an epidural than a double catheter.

True, however not all surgeons want epidurals due to hypotension issues/coagulopathy, etc.

Is there evidence that abdominal wall catheter vs single shots provides better outcome?

 

[psychbender]

Sixty percent of the time, they work all the time.

Sent from my SM-G920V using SDN mobile

 

[jwizle]

Blade,

what dose of buprenorphine are you using ?

how much does a TAP block pay in practice ?

 

[BLADEMDA]

Blade,

what dose of buprenorphine are you using ?

how much does a TAP block pay in practice ?

I add Dexamethesaone and Buprenorphine to my TAP blocks for OPEN Surgical cases. If the case is laparoscopic then I only add dexamethasone. I vary the Buprenorphine dosage based on patient history, pain tolerance and length of incision. Most of the time I utilize 60-90 ug of Buprenorphine per side (total dosage 120-180 ug) for open cases. Sometimes I may give the entire dosage (150 ug per side) if the patient has low pain tolerance, on pain meds, etc. Buprenorphine is quite potent and helps with the visceral pain from these operations.

My full cocktail of Exparel, Dexamthesaone and Buprenorphine typically lasts 39-48 hours postop (single shot technique). The surgeons have provided positive feedback on the blocks and typically request them now when appropriate.