TAP block with prior tummy tuck?

[Oggg]

Female pt s/p gastric bypass and tummy tuck now 80kg goes for laparoscopic ovarian cystectomy. Too many adhesions, so 1.5h after induction, they decide to convert to open cystectomy.

Will the previous tummy tuck restrict the flow of local anesthetic from a TAP block, making the block fail?

Moot right now as I didn't get block consent prior to going asleep

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[sevoflurane]

The space between the internal oblique and transversus abdominus isn't violated in abdominoplasties. You should be good to go next time. If doing it under USD, you'll see hydrodissection in this space which contains divisions of the anterior rami/cutaneous nerves of T11-L1.

 

[epidural man]

Female pt s/p gastric bypass and tummy tuck now 80kg goes for laparoscopic ovarian cystectomy. Too many adhesions, so 1.5h after induction, they decide to convert to open cystectomy.

Will the previous tummy tuck restrict the flow of local anesthetic from a TAP block, making the block fail?

Moot right now as I didn't get block consent prior to going asleep

Depends really, often with a tummy tuck, they bring the rectus abdominus together. I'm not sure how this would have distorted the anatomy. My guess is that if you go in the flank region, it wouldn't have changed it much.

Paravertebrals at the appropriate dermatomal level would work even better and side swipe the conundrum.

 

[sevoflurane]

Paravertebrals at the appropriate dermatomal level would work even better and side swipe the conundrum.

True but, you can do TAP blocks under GA with little to no risk to the patient and in 1/10th the time.

 

[dhb]

They only tuck fat so no reason to affect diffusion through the intermuscular fascia

 

[Oggg]

I might have a scheduled open cystectomy next week -- I plan to use 30cc of 0.25% bupiv plain on each side.

Lower thoracic paravertebrals would technically work, but I have yet to sell the surgeons on it yet. I could do 15ml of 0.25%bupiv plain at T12 on both sides, I suppose, and pray for spread to other levels?

I have the impression that these blocks aren't as long lasting as limb blocks, more like 12hrs max on the pain relief?

 

[Mman]

Is there a benefit to bilateral paravertebral blocks compared to just a single dose in the epidural space? I think any benefit is mostly theoretical if you are going to do paravertebral blocks on both sides.

 

[sevoflurane]

Is there a benefit to bilateral paravertebral blocks compared to just a single dose in the epidural space? I think any benefit is mostly theoretical if you are going to do paravertebral blocks on both sides.

No.

 

[sevoflurane]

I like them for thoracotomies and mammoplasties.

 

[Oggg]

Is there a benefit to bilateral paravertebral blocks compared to just a single dose in the epidural space? I think any benefit is mostly theoretical if you are going to do paravertebral blocks on both sides.

No.

I am under the impression that a TAP with 0.25%bupiv will last 12h. I am also thought that TPVBs last at least that long. That is surely longer than a one time epidural bolus of anything. You can do TAP or TPVB when a pt is under GA, unlike an epidural. So like in my scenario above, an epidural is not warranted preop, but after we convert to open, the pt could benefit from TAPs. No hypotension with TAP/TPVBs either. No chance for PDPH. Having said all that, I still haven't done these blocks yet, but it does sound like there is some utility in them. I don't trust any of our CT surgeons so I am not offering them TPVB yet. Maybe I can convince a surgeon to let me do TPVB + local so some scaredy cat pt doesn't have to go to sleep.

 

[Oggg]

I like them for thoracotomies and mammoplasties.

Sevo, how many levels do you do for these and how much local per level? I read you can skip one or two levels and give up to 15cc per level and get spread of 1-5 levels.

 

[epidural man]

Sevo, how many levels do you do for these and how much local per level? I read you can skip one or two levels and give up to 15cc per level and get spread of 1-5 levels.

I have done a lot of single shot paravertebrals and got excellent coverage and spread, easily T2-T8 (T1 is the money shot for axillary lymph node dissection, and for some reason, that often needs it's own shot). The key to get a good spread - I think - haven't proved this - is using ultrasound and getting the pleura to depress or displace with your injection.

 

[sevoflurane]

Sevo, how many levels do you do for these and how much local per level? I read you can skip one or two levels and give up to 15cc per level and get spread of 1-5 levels.

I usually do one (carefully picked) level. I rarely do single shots. About 90% of the time I thread and tunnel a catheter into the PV space. With an infusion you have more control as to how many levels you are going to shoot up into the paravertebral gutter. + I can use them postoperatively like an epidural or top them off and pull it at the end of the case/pacu.

I find no advantage of a BPVB over a well placed epidural. For unilateral procedures, I find them very useful. They are a great tool to have in your anesthesia bag.

 

[sevoflurane]

http://ats.ctsnetjournals.org/cgi/content/full/79/6/2109

 

[Oggg]

If you top off a TPVB catheter in pacu and pull the catheter, roughly how many hours of analgesia can you get?

 

[epidural man]

If you top off a TPVB catheter in pacu and pull the catheter, roughly how many hours of analgesia can you get?

Why would you do that? If you have paid the piper placing the catheter, give her a portable pump and send her home with it. Give her 2 days of relief.

 

[sevoflurane]

If you top off a TPVB catheter in pacu and pull the catheter, roughly how many hours of analgesia can you get?

3-4 hours of anesthesia (Marcaine .5%)

6-10 hrs of analgesia (Marcaine .5%)

I personally haven't sent anyone home with a paravertebral catheter. Too close to the neuraxis for my comfort (epidural spread). I've seen a couple of PVC end up intrapleural... which is actually good for thoracotomies, but wouldn't do squat for mammo's.

Peripheral indwelling catheters are another story.

http://www.ncbi.nlm.nih.gov/pubmed/16701196

Just my opinion. Seems like epidrual man has more experience with outpatient PVC than I do.

 

[epidural man]

3-4 hours of anesthesia (Marcaine .5%)

6-10 hrs of analgesia (Marcaine .5%)

I personally haven't sent anyone home with a paravertebral catheter. Too close to the neuraxis for my comfort (epidural spread). I've seen a couple of PVC end up intrapleural... which is actually good for thoracotomies, but wouldn't do squat for mammo's.

Peripheral indwelling catheters are another story.

http://www.ncbi.nlm.nih.gov/pubmed/16701196

Just my opinion. Seems like epidrual man has more experience with outpatient PVC than I do.

I've never sent someone home on the same day. They have the catheter in-house for a while.

I agree - I probably would be uncomfortable sending home six hours after surgery with a catheter.

Although I have sent cancer patients home with epidurals before - maybe I am being too conservative.