TAP block consent

[ethilo]

I've had it come up a few times where I didn't consent pre-op for TAP block but surgery takes an unexpected course and now they have an unanticipated abdominal incision and the patient really could benefit from a TAP block prior to emergence at this point. Is it reasonable to perform the block? They are so safe, I do them under GA anyway, and the benefits if the person has significant chronic pain issues would be potentially great. I don't want to have to wait until they're awake and in agony before performing it just to get consent because it would ruin the success of the block with a patient who can't sit still.

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[AdmiralChz]

It’s an extra procedure you didn’t consent for. That would be a hard pass for me and my group as well. It’s not a life-saving maneuver and if anything happened just be ready to write the check.

Take the extra 60 seconds preop and get consent before surgery if you think there is a high likelihood. That’s what we used to do for cases we considered high risk for rescue blocks in training.

 

[DrZzZz]

It’s an extra procedure you didn’t consent for. That would be a hard pass for me and my group as well. It’s not a life-saving maneuver and if anything happened just be ready to write the check.

Take the extra 60 seconds preop and get consent before surgery if you think there is a high likelihood. That’s what we used to do for cases we considered high risk for rescue blocks in training.

Seconded. You do that to the wrong patient, you'll get sued even without a complication for performing a procedure that wasn't consented for. Consent them preop if there's a chance they'll need to open. If not, I'm waiting til I can consent them in pacu.

 

[nimbus]

Or just consent everybody getting abdominal surgery for a possible TAP block.

“If the surgeon has to open for any reason, I will give you an injection on both sides of your tummy to reduce the amount of pain you experience when you wake up.”

 

[deleted59964]

I wouldn't do it either, very low risk of any complaint or getting sued here - but the benefit case for TAPs for me isn't worth even that

 

[ryanjmy]

I would call the next of kin and get consent.

 

[deleted171991]

I would call the next of kin and get consent.

That will not absolve you of anything (and nor will the next of kin), unless s/he's a designated healthcare proxy. This is textbook assault and battery, a crime, without the patient's or his proxy's consent. It's an elective procedure. I don't know why it is so hard to understand (the poll results are downright scary).

There is exactly one correct answer here: No. The patient would probably not qualify as consentable in the PACU for about 2 hours (even more, some would argue). It's supposed to be an informed consent, meaning that the patient has to be able to understand the risks, benefits and alternatives. Very debatable on POD0.

 

[anbuitachi]

what about arterial line..? i dont consent everyone for arterial line but ive definitely done it before intraop
Also kind of odd cause surgeons dont consent for infiltration of local

 

[ryanjmy]

That will not absolve you of anything (and nor will the next of kin), unless s/he's a designated healthcare proxy. This is textbook assault and battery, a crime, without the patient's or his proxy's consent. It's an elective procedure. I don't know why it is so hard to understand (the poll results are downright scary).

There is exactly one correct answer here: No. The patient would probably not qualify as consentable in the PACU for about 2 hours (even more, some would argue). It's supposed to be an informed consent, meaning that the patient has to be able to understand the risks, benefits and alternatives. Very debatable on POD0.

By this logic you could never do a procedure in the unit unless it’s an absolute emergency.

 

[deleted875186]

By this logic you could never do a procedure in the unit unless it’s an absolute emergency.

Central lines and arterial lines are necessary to provide care. TAP blocks are in no way necessary, and honestly have limited therapeutic value in many cases.

 

[psychbender]

By this logic you could never do a procedure in the unit unless it’s an absolute emergency.

Not really. We call the POA all the time for procedures, even in urgent situations. In general, if I have to do an invasive procedure on an ICU patient, they are suck enough that they are not consentable.

 

[ryanjmy]

Central lines and arterial lines are necessary to provide care. TAP blocks are in no way necessary, and honestly have limited therapeutic value in many cases.

The OP stated he believes the pt would benefit from the procedure. If you don’t feel that way you shouldn’t do the procedure in the first place.

Take tap blocks out of the equation. If you think a non consentable pt would benefit from a procedure you get consent however necessary. You don’t let the pt suffer.

 

[deleted875186]

The OP stated he believes the pt would benefit from the procedure. If you don’t feel that way you shouldn’t do the procedure in the first place.

Take tap blocks out of the equation. I you think a non consentable pt would benefit from a procedure you get consent however necessary. You don’t let the pt suffer.

I disagree, a procedure for pain is never necessary and is always elective.

 

[coffeebythelake]

Consent POA and tell patient about it, perform postop

Had this exact same thing happen last week

 

[Urzuz]

I disagree, a procedure for pain is never necessary and is always elective.

Disagree with this wholeheartedly. The vast majority of the time, yes, procedures for analgesia are elective. But I strongly believe you need to use nuance and judgment at times to provide the best patient care (i.e.: not think about mitigating your risk of getting sued and actually provide care to a patient in need who is suffering). I have had patients howling and thrashing around wildly in PACU even after receiving x mg of dilaudid and they are causing safety concerns to them or the PACU staff, and I have "emergently" provided peripheral nerve blocks without a full-fledged consent (something to the effect of, "I'm going to give you an injection to numb your foot up"). Same with women coming in while in active labor when they are in no mental state to be fully consented. In a perfect world I would have consented the foot patient preoperatively for a nerve block (99.9999% of the time I do) and the woman in labor will be able to listen to my spiel for two minutes before needling her back. But the world isn't perfect and sometimes you have to use your judgment.

You can play the hypothetical "what if" game for me rendering those services (what if I skewer the sciatic nerve, what if I bag the nerve root during epidural placement), but those are medicolegal risks I am willing to accept in the name of actually rendering care to patients who need my help.

 

[GravelRider]

I would say no, but it may be worth talking to your malpractice insurance about it. I bet they would say no too.

The debatable question is would you consider this part of the anesthetic? We don’t consent patients for every detail of our anesthetic plan. Is a TAP block a low enough risk with minimal contraindications that it can be assumed to be part of anesthetic management? Your anesthesia consent likely did assume some plan for immediate postoperative pain control. Could a TAP block be part of that plan? A nerve block is a definite no, but a TAP is a dark shade of gray for me. I would probably say no, but I could hear an argument for it.

 

[nimbus]

I would use the mom test. What would you want for your mom/spouse/child? Then do that.

 

[Planktonmd]

People who get surgery usually consent to anesthesia, so if you do a procedure that is part of your anesthesia management you already have a consent.
Most importantly, try to do what's right for your patients and resist the influence of clipboard nursing administrators.

 

[deleted171991]

People who get surgery usually consent to anesthesia, so if you do a procedure that is part of your anesthesia management you already have a consent.
Most importantly, try to do what's right for your patients and resist the influence of clipboard nursing administrators.

That's very nice, but that's not how the law works. I will always do what's best for my patients, unless my hands are tied. This is a semi-invasive procedure which has complications, even if rare, so I will not risk it unless I have a very good reason and explanation for the patient. Pain control won't cut it, when there are alternatives.

Also, the patients don't consent to anesthesia in general, they consent to an anesthesia plan, its risks, benefits and alternatives, at least that's how it should be.

 

[deleted171991]

what about arterial line..? i dont consent everyone for arterial line but ive definitely done it before intraop
Also kind of odd cause surgeons dont consent for infiltration of local

You don't have an alternative to an arterial line, and it's usually not elective if decided intraop. You do have medications for pain control.

Also, if doing a non-emergent arterial line without an informed consent, do pray it's not the rare one that will turn into pseudoaneurysm or thrombosis.

 

[deleted171991]

Consent POA and tell patient about it, perform postop

Had this exact same thing happen last week

Yes! That's the right way to do it in the PACU. Consent the proxy, and ask the patient's OK when completely awake, before performing the procedure.

 

[deleted171991]

The lesson of this thread should be to always mention to the patient anything one may do to him, even if less likely. When in doubt, I always tell them "I may do this or that, depending on what the surgeon does". Never had an issue. They actually like to see that one is prepared for anything.

 

[ethilo]

Thanks everyone for the nice discussion! I think I'm also hesitant and wouldn't do it unless I consented for "possible" in pre op. I think it represents good communication that way.

Im glad someone brought up labor epidurals though. I'll admit I've done plenty of LEs where the "consenting" process was laughable.

I think technically one needs to have finished all documentation including the consent before proceeding with the labor epidural, yet at our place the flow is to walk in, have the discussion, put the LE in, then leave and chart everything at that point. Much more efficient but not technically "right."

 

[Ronin786]

Thanks everyone for the nice discussion! I think I'm also hesitant and wouldn't do it unless I consented for "possible" in pre op. I think it represents good communication that way.

Im glad someone brought up labor epidurals though. I'll admit I've done plenty of LEs where the "consenting" process was laughable.

I think technically one needs to have finished all documentation including the consent before proceeding with the labor epidural, yet at our place the flow is to walk in, have the discussion, put the LE in, then leave and chart everything at that point. Much more efficient but not technically "right."

As far as labor epidurals go, one could argue that they are so ubiquitous with regards to anesthesia and pregnancy that the bar for consent is much lower than a TAP block. A pregnant patient knows what an epidural is and probably thinks that it has more side effects than it really does. At least from an assault and battery perspective.

 

[coffeebythelake]

Thanks everyone for the nice discussion! I think I'm also hesitant and wouldn't do it unless I consented for "possible" in pre op. I think it represents good communication that way.

Im glad someone brought up labor epidurals though. I'll admit I've done plenty of LEs where the "consenting" process was laughable.

I think technically one needs to have finished all documentation including the consent before proceeding with the labor epidural, yet at our place the flow is to walk in, have the discussion, put the LE in, then leave and chart everything at that point. Much more efficient but not technically "right."

realistically, you can do a well explained consent for labor epidural in about 1 minute

 

[AdmiralChz]

As far as labor epidurals go, one could argue that they are so ubiquitous with regards to anesthesia and pregnancy that the bar for consent is much lower than a TAP block. A pregnant patient knows what an epidural is and probably thinks that it has more side effects than it really does. At least from an assault and battery perspective.

Yeah, I agree with this.

Side note - not every ex lap needs a block. Do they help? Sure, but NOT a necessity. We usually opt for epidurals or nothing... and the latter aren’t in PACU dying of pain (subjectively, it’s the back surgeries and orthopedic join replacements who refused the block have much more pain). We do few TAPs and still manage to have get through our schedule just fine.

 

[narcotics999]

I would use the mom test. What would you want for your mom/spouse/child? Then do that.

Your mom will not sue you.

 

[projectpat]

worst case, you perf bowel. unexplainable.
give fentanyl

 

[Section31]

if the TAP is for surgical anesthesia and not post-op pain, no consent is necessary.

Truth be told, the whole idea of consents in anesthesia is preposterous. Explain things to the patient and allow them to refuse if they don’t like an option. But a formal consent for doing one facet of a complicated job is a bridge too far.

 

[Urzuz]

worst case, you perf bowel. unexplainable.
give fentanyl

If you get anywhere close to perforating bowel while doing a TAP you have no business doing them, even with a consent.

 

[nimbus]

Your mom will not sue you.

True but she could do a lot worse.

 

[fakin' the funk]

I disagree, a procedure for pain is never necessary and is always elective.

Do you get consent for Dilaudid PCAs?

 

[Mman]

anybody ever personally seen a complication from a TAP block?

 

[daneeka]

I think "we'll give you some medicine to make sure you wake up comfortable" covers opioids, LA infiltration by the surgeons or TAP block just fine.

 

[Section31]

anybody ever personally seen a complication from a TAP block?

Pain relief

 

[deleted875186]

Do you get consent for Dilaudid PCAs?

How is a PCA a procedure? I agree it’s semantics at some point, but I think you draw the line somewhere and any time I’m sticking needles near nerves I consider it a procedure that needs consent.

 

[nimbus]

anybody ever personally seen a complication from a TAP block?

How is a PCA a procedure? I agree it’s semantics at some point, but I think you draw the line somewhere and any time I’m sticking needles near nerves I consider it a procedure that needs consent.

I’ve heard of more complications from PCAs than from TAP blocks.

 

[narcotics999]

How is a PCA a procedure? I agree it’s semantics at some point, but I think you draw the line somewhere and any time I’m sticking needles near nerves I consider it a procedure that needs consent.

How about an IV at AC? Stick a needle near a nerve with bleeding?

 

[sigrhoillusion]

As far as labor epidurals go, one could argue that they are so ubiquitous with regards to anesthesia and pregnancy that the bar for consent is much lower than a TAP block. A pregnant patient knows what an epidural is and probably thinks that it has more side effects than it really does. At least from an assault and battery perspective.

What are your guys usually consents on pregnant patients like?

Whenever I get called to place an epidural, I go over the epidural, but then also add the fact that if at any point during labor the physicians are concerned about you or the baby they may call for a c-section. I then go over the possibility of using the epidural for the c-section, as well as using GA if for some reason the epidural isn't working well enough, which is rare. I like to mention that possibility while things are relatively calm (outside of the screaming labor patients) than when the OBs are running around like idiots, rushing the patient back for a section.

I work with residents and they always just consent to the epidural/regional, which I don't feel talks about the full anesthetic plan.
Also, where I trained, OB used to call us for every admitted patient in labor or for induction. And as a resident we'd consent them right away.
Where I work now, we only get consents when the patients want their epidural. Very rarely will OB send a patient to our pre-op testing office for medically challenging patients. This is an urban academic center, with not the healthiest patients.

What does everyone else do?

 

[deleted171991]

If you get anywhere close to perforating bowel while doing a TAP you have no business doing them, even with a consent.

Your patient moves/jumps suddenly, because s/he's an idiot. Never seen that when placing a small IV?

 

[deleted162650]

Your patient moves/jumps suddenly, because s/he's an idiot. Never seen that when placing a small IV?

Who does TAPs awake?

 

[coffeebythelake]

Who does TAPs awake?

We do

 

[Mman]

Who does TAPs awake?

under GA or spinal. Never had a patient flinch. It's not a nerve block where you worry about an intraneural injection.

 

[deleted162650]

We do

Why??

 

[deleted171991]

Who does TAPs awake?

Anybody who does them in the PACU. Why? Because you need (some form of) an informed consent. Why? Because it's an invasive procedure with a non-zero risk of complications. Why? Try explaining to a jury that a 5-8" needle in the belly is not invasive and doesn't need consent.

 

[sigrhoillusion]

Why??

When I first started at my place ~3 yrs ago, they used to do TAPs in the holding area. I think it was to save time. But I haven't seen anyone do any out there for at least 2 years. I think the thought was to save time, but since we are an academic teaching hospital there's always two providers (and usually a free resident) so that we can almost induce and prep the belly at the same time. I can see if you're a solo provider where it may take a little extra time to induce/intubate and then do the TAP while the surgeon is waiting to cut. Then again, I'm assuming if you're solo, you don't have that much time between cases to see the patient and do the block.

I just think it's easier to just do it on an asleep patient who can't move.

 

[Mman]

Anybody who does them in the PACU. Why? Because you need (some form of) an informed consent. Why? Because it's an invasive procedure with a non-zero risk of complications. Why? Try explaining to a jury that a 5-8" needle in the belly is not invasive and doesn't need consent.

for the sake of discussion, do you have a separate consent to start an extra peripheral IV on the patient after they are asleep? It probably has a higher complication rate than a TAP block.

(in my preop consent I mention to the patient that if the surgeon deems appropriate they may ask me to put a numbing shot in their belly before they wake up to help decrease pain. The primary reason I mention it is because they will get a bill for it.)

 

[deleted171991]

An IV is not an invasive procedure. Also, an IV is a patient safety issue. Still, I do inform my patients preop when I plan to insert extra IVs during the surgery. Not because I bill them, but because I respect their autonomy.

That's why my conclusion for this thread is to always mention the TAP (and other blocks) preop, for the appropriate surgeries, even if there is a small likelihood I will actually do it. The same way I always mention GA backup for my MAC cases.

 

[Mman]

An IV is not an invasive procedure.

 

[coffeebythelake]

I do consent pt for additional IVs as well as art line