"TAP" blocks by surgeons

[Hork Bajir]

Over the last few years, I've noticed a widespread and pervasive trend of surgeons refusing to let us place epidurals for gnarly abdominal cases (including stem-to-stern ex-laps), and instead either asking for TAP vs rectus sheath blocks/catheters - or more often, "placing their own TAP block". There are 1 or 2 surgeons who do this laparoscopically and actually are probably doing real plane blocks, but the vast majority seem to be basically doing field blocks where most of the local anesthetic ends up in the sub-Q or muscle.

The stated reasons for refusing to allow their patients to have an epidural vary... Most commonly they will cite concerns regarding postop hypotension (which is bogus with the dilute mix we use, but that's a whole different discussion). I'm convinced that a real driver of this trend is the fact that our surgeons don't want to have their case start delayed at all- we're an academic institution with slow turnovers to begin with, residents doing our epidurals, and so it does delay the case start a bit. Having followed a fair number of these patients on the floor, they usually do OK; but they almost always need some narcotic (often a considerable amount vs a PCA), and just because we're getting away with doing this doesn't mean that we're really doing the optimal thing for the patient. The real kicker, which makes me see red, is that the surgeons insist that their TAP blocks are just as good as an epidural, and continue to call these cases ERAS.

I'm curious, how often are others encountering this? Any strategies for dealing with this? I feel like all I can do at the end of the day is make my strong recommendation as a consultant known, and if the surgeon chooses not to follow that recommendation, then I provide the anesthetic- or lack thereof- that they request. Even so, it's frustrating: I don't tell them how to do the surgery, but they apparently feel qualified to dictate the anesthetic.

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[psychbender]

If they have two of the same case booked in a day, tell them to do their BS TAP on one, and you'll have an epidural placed on the other. Have the surgeons actually look at their patient while awake in PACU. Note the time to PACU discharge. Note how much opiate in the first 24 and 48 hours. Tell them to actually pay attention on the ward. This got us to sway a few stubborn surgeons at my old program. Where I am now, this is only an issue with one Gyn surgeon, who doesn't think anything she does is painful, and doesn't want us putting local in her patients.

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[Psai]

Put an 11 in the surgeon then offer them a tap

 

[Velefunt]

General surgeons doing their own TAP blocks laparoscopic and intraabdominally strikes me as BS. How can they tell they are injecting between the IO and TA? Short of an ultrasound allowing you to see the needle tip and spread, I find it hard to believe they're achieving accurate, if not consistent results. We have a few doing this, and I haven't called them on it... yet.

 

[Psai]

Us guided tap blocks are better than lapatoscopic because they only know if theyre in the peritoneum or not. It takes less than five minutes to do us guided bilaterally. I think epidurals provide much superior pain relief though.

Either you need to get preop buyin for doing epidurals with a dedicated block nurse or if the scrub and circulator are amenable, bring the patient in while they are still setting up to place the epidural.

 

[deleted50478]

No benefit of ultrasound‐guided transversus abdominis plane blocks over wound infiltration with local anaesthetic in elective laparoscopic colonic surgery: results of a double‐blind randomized controlled trial


Google Scholar

 

[deleted875186]

I’m at an academic hospital, generally all the surgeons prefer no block or epidural preop because it delays the case as well. But for big scheduled laparotomies, most all of them are ok with epidurals. The exception is te GYN people who do the C section type incisions.

 

[Hork Bajir]

No benefit of ultrasound‐guided transversus abdominis plane blocks over wound infiltration with local anaesthetic in elective laparoscopic colonic surgery: results of a double‐blind randomized controlled trial

This study is bogus though. Llaparoscopic colonic surgery shouldn't hurt enough to justify any sort of block beyond local by the surgeon, and any visceral pain wouldn't be addressed by TAP block anyway.

We have a few general surgeons and GYN surgeons who have started requesting b/l rectus sheath catheters for their big scheduled ex-laps... Again, I'm convinced that this is at least in part because the time it takes to place those catheters is at the end of the case, once the attending surgeon is long gone and the resident/fellow is left to babysit the patient and put on the dressings at the end. Do they work? Definitely better than nothing... But also definitely not as good as a well-placed epidural. Almost all patients end up getting some narcotic as well.

 

[Psai]

This study is bogus though. Llaparoscopic colonic surgery shouldn't hurt enough to justify any sort of block beyond local by the surgeon, and any visceral pain wouldn't be addressed by TAP block anyway.

We have a few general surgeons and GYN surgeons who have started requesting b/l rectus sheath catheters for their big scheduled ex-laps... Again, I'm convinced that this is at least in part because the time it takes to place those catheters is at the end of the case, once the attending surgeon is long gone and the resident/fellow is left to babysit the patient and put on the dressings at the end. Do they work? Definitely better than nothing... But also definitely not as good as a well-placed epidural. Almost all patients end up getting some narcotic as well.

Why not have the attending surgeon be called in when the patient is ready? Do you need them to hang out in the OR running their mouth when you're trying to get your work done?

 

[Hork Bajir]

Because when they are done with cases for the day, they go home. When they are waiting for a case to start, they are in the hospital. Does it really make a ton of sense? Not really... But don't ask me to explain the psychopathology of some of our surgeons.

 

[acidbase1]

A surgeon I work with does TAP via laparoscopic technique, problem is, he’s injecting between the peritoneum and transversus abdominis, ie not TAP plane

 

[polar403]

TAP blocks are not as predictable for sensory blockade as you’d expect. There are studies out there on this. They may be better than nothing but they are not the answer to everything and are pretty much useless for pain with port placement in laparoscopic surgery.

If the incision is midline just do a rectus sheath or QL3


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[Planktonmd]

If a surgeon thinks he has a solution for post-op pain that does not require my involvement I usually shake his hand and encourage him.
Why are you so upset that they want to do some sort of TAP block or whatever else they want to do?

 

[narcusprince]

Tap blocks in my humble opinion do not cut the mustard as it pertains to postop pain control. They are patchy and the cases they do work are almost always in conjunction with IT morphine. The pain control is not as thorough as a well placed epidural. I have been reluctant in the past to jump on these field plane blocks. Call me dumb but the argument that this may reduce your pain by less then 20% seems like little gain for lots of risk. Your placing a large volume of local anesthetic in a plane. What if you need to give more local anesthesia in the patient for a takeback?

 

[Psai]

Tap blocks in my humble opinion do not cut the mustard as it pertains to postop pain control. They are patchy and the cases they do work are almost always in conjunction with IT morphine. The pain control is not as thorough as a well placed epidural. I have been reluctant in the past to jump on these field plane blocks. Call me dumb but the argument that this may reduce your pain by less then 20% seems like little gain for lots of risk. Your placing a large volume of local anesthetic in a plane. What if you need to give more local anesthesia in the patient for a takeback?

Are you doing a lot of takebacks? Risks are minimal, time is minimal and there is a lot of potential benefit. I've had a few patients that have had a tap block that required zero opiates in pacu after an open procedure.
I put maybe 20 cc of 0.25% bupi on both sides. Should last long enough but if your pain relief is inadequate you'd probably do something else instead.

 

[sigrhoillusion]

Tap blocks in my humble opinion do not cut the mustard as it pertains to postop pain control. They are patchy and the cases they do work are almost always in conjunction with IT morphine. The pain control is not as thorough as a well placed epidural. I have been reluctant in the past to jump on these field plane blocks. Call me dumb but the argument that this may reduce your pain by less then 20% seems like little gain for lots of risk. Your placing a large volume of local anesthetic in a plane. What if you need to give more local anesthesia in the patient for a takeback?

Uh oh... you're gonna have Blade in here any minute posting 20 review articles on TAP blocks.

 

[narcusprince]

Are you doing a lot of takebacks? Risks are minimal, time is minimal and there is a lot of potential benefit. I've had a few patients that have had a tap block that required zero opiates in pacu after an open procedure.
I put maybe 20 cc of 0.25% bupi on both sides. Should last long enough but if your pain relief is inadequate you'd probably do something else instead.

What open procedure? Umbilical hernia repair? Inguinal hernia repair? Are Tap blocks superior to local infiltration with exparel. I don’t do many TAPs. But the patients that I have followed the superiority to local infiltration has not been established. Taps for c/s in my opinion are not superior to Duramorph. Taps for c/s are a large volume of local in patients that you may need to activate an epidural to take back to the OR. I see very few takebacks but I dont want to say well this patient needs to have a GA because she got a Tap. In colorectal ERAS protocols yes its warranted.

 

[Psai]

Why would you do a tap in someone with an epidural

 

[facted]

What open procedure? Umbilical hernia repair? Inguinal hernia repair? Are Tap blocks superior to local infiltration with exparel. I don’t do many TAPs. But the patients that I have followed the superiority to local infiltration has not been established. Taps for c/s in my opinion are not superior to Duramorph. Taps for c/s are a large volume of local in patients that you may need to activate an epidural to take back to the OR. I see very few takebacks but I dont want to say well this patient needs to have a GA because she got a Tap. In colorectal ERAS protocols yes its warranted.

TAP blocks can definitely be effective in open abdominal cases if you keep in mind the following
They

Unless you add a subcostal TAP, they don't cover above the umbilicus generally.
They don't have visceral coverage.

If you plan on doing a TAP for a huge ex-lap for a colectomy, it's going to a lot less effective than it would be for a abdominal hysterectomy for example.

I would argue QL1 or QL2 should be done in place is any TAP block anyway, or if you want to go fancy, do an erector spinae block. Epidural is still gold standard but ES AND QL are pretty effective and don't have to worry about anticoagulation post-op, hypotension, etc...

 

[deleted697535]

Hold up. Are we talking laparotomy or laparoscopy here?

Do you guys do epidurals or tapstaps laparoscopic surgery?
Why?

There's barely evidence that epidurals improve outcomes in open abdo surgery?

Also time to discharge from pacu isn't really an outcome, nor is opioid consumption...

Real things that matter to patients is what I usually go by

About 1 in 7 epidurals don't work either by the way, especially when residents are doing them

 

[narcusprince]

Too much variability with erector spinae and Tap blocks for my liking. And their is a learning curve. Even if the best guy does all the Taps or ES blocks their is still variability in coverage. Thats my gripe. Supraclav/pop/sciatic/femoral/adductor canal/ those blocks are pretty simple blocks with a high degree of success. Arguably TAPs/ES/QL should be done by the best regionalist because even when done perfectly don’t provide the level of analgesia the previous blocks do.

 

[facted]

Too much variability with erector spinae and Tap blocks for my liking. And their is a learning curve. Even if the best guy does all the Taps or ES blocks their is still variability in coverage. Thats my gripe. Supraclav/pop/sciatic/femoral/adductor canal/ those blocks are pretty simple blocks with a high degree of success. Arguably TAPs/ES/QL should be done by the best regionalist because even when done perfectly don’t provide the level of analgesia the previous blocks do.

I will agree with this to an extent, though less so with ES. ES Is remarkably easy, I would argue almost easier than a TAP.

But honestly, if I had a big whack of my belly, I'd get an epidural any day of the week.

 

[psychbender]

TAPs: sixty percent of the time, they work all the time.

 

[pgg]

Why would you do a tap in someone with an epidural

The fad these days is TAPs for c-section patients. The idea is that they get some pain relief that lasts longer than the spinal (or the augmented labor epidural which gets pulled in the OR). It probably helps some patients. Our dept can do it because the labor/time has no cost, billing isn't an issue, and the reps are good for residents.

Not a hill I care to die on, so I just go along with it.

For a very brief time our dept was doing them instead of intrathecal/epidural morphine, until even the TAP advocates had to admit they weren't as good.

 

[narcusprince]

I totally agree for resident education and opiate sparing I go with the flow. Either way you are creating data that can be compared and then decide collectively this is how we will proceed forward. Many years ago in training we compared TAPs placed by the surgeons versus those placed by us and found both techniques had a high variability in coverage. I think though with field plane blocks you have to get nursing education to buy in and they have to be on board with the knowing your goal is to reduce narcotic usage and that the block may not be as good as IT morphine or well placed epidural.

 

[deleted162650]

What’s wrong with TAP plus IT morphine?

 

[narcusprince]

The other argument where I truly believe a TAP could provide some relief are the anticoagulated patient whom could not recieve an epidural. Or patients that have spinal hardware or contraindicated to neuraxial techniques. Nothing wrong with IT morphine and a TAP.

 

[facted]

The fad these days is TAPs for c-section patients. The idea is that they get some pain relief that lasts longer than the spinal (or the augmented labor epidural which gets pulled in the OR). It probably helps some patients. Our dept can do it because the labor/time has no cost, billing isn't an issue, and the reps are good for residents.

Not a hill I care to die on, so I just go along with it.

For a very brief time our dept was doing them instead of intrathecal/epidural morphine, until even the TAP advocates had to admit they weren't as good.

There is a lot of data that TAP block + duramorph is no better than duramorph alone. TAP block also won't last as long as duramorph. TAP blocks in C-section are really only indicated for GA section. We have a pretty demanding pt population at my institution, and post-op c-section pain is not an issue, and we just do multi-modal and duramorph.

 

[facted]

What’s wrong with TAP plus IT morphine?

For what surgery? For C-section? Lots of data shows it doesn't improve pain scores...Not sure for other surgery.

 

[deleted162650]

For what surgery? For C-section? Lots of data shows it doesn't improve pain scores...Not sure for other surgery.

Thanks. The idea has been floated at my shop to start doing TAPs on top of duramorph. I’ll pull up the data. It’s s amazing how well duramorph works having witnessed it first hand with my wife. Agree it’s a great option for GA sections.

 

[MirrorTodd]

Why doesn't duramorph still count as opiate use though? I mean, if one of the goals is to decrease opiate usage...

 

[deleted162650]

Why doesn't duramorph still count as opiate use though? I mean, if one of the goals is to decrease opiate usage...

LOL. Waiting for the study where the authors brag about sparing 0.2mg of morphine.

 

[MirrorTodd]

LOL. Waiting for the study where the authors brag about sparing 0.2mg of morphine.

 

[Gaslamp]

If surgeons/hospitals aren't used to epidurals or have an epidural program setup (ie RN's & pharmacy knowing what to do, etc) I'll just do TAP until I get enough buy-in from everyone. In the meantime, depending on the hospital setting, formally or informally talk about epidurals.

I've had surgeons tell me they can see the plane when they open. I tell them, "go for it, it's your patient. Let me know if you need my help."

 

[deleted697535]

Can someone please answer me why ppl are doing tap blocks or any kind of blocks for laparoscopic surgery?

 

[polar403]

Can someone please answer me why ppl are doing tap blocks or any kind of blocks for laparoscopic surgery?

When all you have is a hammer and everything looks like a nail...

 

[Psai]

Can someone please answer me why ppl are doing tap blocks or any kind of blocks for laparoscopic surgery?

Because I would like to be comfortable after being stabbed in the belly multiple times

 

[vector2]

Because I would like to be comfortable after being stabbed in the belly multiple times

How is a tap any better than the surgeon just infiltrating bupi into the port sites? Neither covers visceral pain...

 

[Psai]

How is a tap any better than the surgeon just infiltrating bupi into the port sites? Neither covers visceral pain...

Because i like doing things more than watching the surgeon do things.

 

[deleted50478]

Can someone please answer me why ppl are doing tap blocks or any kind of blocks for laparoscopic surgery?

Surgeon request.

 

[facted]

Can someone please answer me why ppl are doing tap blocks or any kind of blocks for laparoscopic surgery?

There are some studies, particularly for lap chole, that TAP blocks are very effective. With that being said, I don't routinely do them for lap surgery.

Honestly, if anything, we should all be doing rectus sheath for the belly button port.

 

[Gaslamp]

Can someone please answer me why ppl are doing tap blocks or any kind of blocks for laparoscopic surgery?

I dont, I'm just talking about open cases.