TAP blocks inferior blocks?

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chocomorsel

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Just recently started doing these blocks and I am getting convinced that they are not worth it. It was a learning curve for me but I think I am getting good and the last few I have done looked good. However the patients are still in PACU complaining of pain. I ask the nurses and they say that yeah, the patients sometimes still complain of pain from the gas from laparoscopy but I am getting disappointed each and every time. I know they only help with somatic and not visceral pain, but it's quite disappointing to see patients in pain after telling them that the blocks really help with post operative pain.

Our surgeons apparently are loving these TAPS and once when one of our patients cancelled the surgeon seemed very surprise and asked "how can he refuse"? Well it's called informed consent for a reason, not informed coercion.

Did an ISB today and although I didn't get around all the nerve roots, since I hadn't done one in like two years, and the patient was pain free after surgery compared to any on my TAPs. Is it just me? I was convinced that maybe it was, but now I am starting to believe that I am not the only problem. If the patients are still experiencing visceral pain, is this worth it? Are y'all getting complete pain free patients afterwards?

I plan on checking back in a few weeks and see if things improve.
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chocomorsel said:
Are y'all getting complete pain free patients afterwards?
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Sometimes yes sometimes no, the ones that complain in PACU do well with 4-5mg of morphine on average.
For me the biggest factor in post op pain is the use of potent opiods per-operatively.
I have a hard time remembering when was the last time i used sufentanil and patients do fine afterwards.
I strongly believe that it's harder to elect a response from your receptors with morphine in PACU when you've been hitting those receptors with fentanyl/sufentanil or remi during the operation.
 
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Certainly wouldn’t do it for all laparoscopic cases. It’s worth it for open abdominal cases.
 
chocomorsel said:
I realized today that I miss the Unit. It's only been a little more than two weeks.
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That's a good sign that you are doing what you love. Haven't worked in the unit since a couple years ago as a resident. I think I celebrated more about finishing that rotation (realizing that I would probably never work in an ICU ever again) than I did for residency graduation. I am glad that we all enjoy different things and I hope you get the chance to get back into the Unit at your next gig.
 
I agree that TAP blocks are disappointing, but it also seems to be the trend among many of our surgeons that they prefer them to epidurals. They definitely don't control pain as well, although you do avoid the hassles of managing a patient with an epidural.
 
I see them work decently often enough that the ease of doing them makes them worth it in my view. Do you guys notice much of a difference using liposomal bupivacaine vs regular bupi?
 
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chocomorsel said:
Haha. Just locums right now as I decide where to go. I realized today that I miss the Unit. It's only been a little more than two weeks.
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You’re wasting your time doing them for lap cases (I know you’re just along for the ride at this gig, but your results are expected). TAPs are really only good for incisions below the umbilicus, and they are much more effective for non-midline incisions - think IHRs and Pfannenstiels (sp?). Even then, 50% of the time, they work every time.

Subcostal TAPs will help more with higher incisions, but you just can’t expect a plexus block results from a field block.
 
The problem with TAPs is that it was taught one way: lateral.

Nobody bothered to learn the other sites which are much more effective: subcostal, and posterior.
 
My residency did tons of them. They work well for what they are. They’re meant for adjuncts not the sole pain control modality. We can usually get the pain score down at least 2-3 points. It’s the management of nurse and patient expectation that’s more work than the TAP blocks. Usually when you tell the more educated patients that it can cut down on their narcotic use, they’re more than happy to get it.
Added benefit when the insurance pay for them, they’re definitely worth it.
 
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chocomorsel said:
Damn near all the laparoscopic cases. Apparently that's the culture here. I am locums.
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It has been proved in an RCT that infiltration with LA before placing the laparoscopic portals has the SAME effect as doing TAP blocks. You are right, in that scenario, they are not worth it.

After doing them for a LOT of different procedures with very variable results, nowadays I only do them for iliac crest bone graft extraction (they work wonders for this). For laparoscopic procedures simply don't do subcostal/lateral TAPs, since only the posterior approach provides any sympathetic/visceral analgesia. For big midline incisions my go to is rectus sheath block, much more reliable.

Hope it helps! 😉
 
JWebar said:
It has been proved in an RCT that infiltration with LA before placing the laparoscopic portals has the SAME effect as doing TAP blocks. You are right, in that scenario, they are not worth it.

After doing them for a LOT of different procedures with very variable results, nowadays I only do them for iliac crest bone graft extraction (they work wonders for this). For laparoscopic procedures simply dont do them, since TAP doesn't provide any sympathetic/visceral analgesia. For big midline incisions my go to is rectus sheath block, much more reliable.

Hope it helps! 😉
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Thanks. I am glad others are telling me this. I feel like this is just a waste of time and a money maker for this group. I know we all want to make money, but I feel a little crappy about this one.
@IMGASMD, I totally don't agree with your last line.
 
chocomorsel said:
Thanks. I am glad others are telling me this. I feel like this is just a waste of time and a money maker for this group. I know we all want to make money, but I feel a little crappy about this one.
@IMGASMD, I totally don't agree with your last line.
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don't worry, they aren't getting paid that much for a TAP block, not nearly as much as for an ISB. TAP blocks help a bit for lower abdominal incisions but that's about it. They aren't perfect analgesia like an ISB is for a shoulder, but they can help cut back on narcotic requirements for the right cases.
 
In my experience, they work well for the types of incisions they're indicated for. I don't see why one would have to do them for all laparoscopic cases lol. Doesn't make sense. Also, I think some may have a higher failure rate with this block if they're not depositing the local precisely in the plane it needs to be in. It's a bit trickier than it seems. If you don't deposit that local in that exact plane and see the spreading you're supposed to be seeing, it's literally not gonna work at all.
 
Ezekiel2517 said:
In my experience, they work well for the types of incisions they're indicated for. I don't see why one would have to do them for all laparoscopic cases lol. Doesn't make sense. Also, I think some may have a higher failure rate with this block if they're not depositing the local precisely in the plane it needs to be in. It's a bit trickier than it seems. If you don't deposit that local in that exact plane and see the spreading you're supposed to be seeing, it's literally not gonna work at all.
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Very true! Usually for this blocks I'll start with a syringe of NS, cause some times it takes a long time to get the spread in the right plane (and you can end up wasting a lot of LA in the process). I remember when they were being sold for being an "easy block". I remember seeing a study afterward where they found 50% failure rate in obese patients.
 
I think the efficacy is around 50% if you read some of the older threads. Agree with others that it's not worth it for lap cases, it's probably done to increase billing for the group. However, if you go more proximal (quadratus lumborum or erector spinae) you can often cover open cases better than the traditional tap if you think about the nerve anatomy.
 
Mikkel said:
The problem with TAPs is that it was taught one way: lateral.

Nobody bothered to learn the other sites which are much more effective: subcostal, and posterior.
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Tap blocks do help with REDUCING the pain but not eliminating it. Remember, it doesn't touch any visceral pain at all.
Second, most people don't do the blocks properly. For analgesia above the umbilicus a subcostal TAP is required or a QL block. The "standard" TAP is only good for analgesia at the mid-umbilicus level and below to T12.

Please note the term "analgesia" which is far different than the ISB which provides surgical level anesthesia (if the skin area is localized well) for shoulder surgery.
 
BLADEMDA said:
Tap blocks do help with REDUCING the pain but not eliminating it. Remember, it doesn't touch any visceral pain at all.
Second, most people don't do the blocks properly. For analgesia above the umbilicus a subcostal TAP is required or a QL block. The "standard" TAP is only good for analgesia at the mid-umbilicus level and below to T12.

Please note the term "analgesia" which is far different than the ISB which provides surgical level anesthesia (if the skin area is localized well) for shoulder surgery.
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When doing a 4 quadrant tap, how much/what % local are you using?
 
I almost never do a 4 quadrant, regular TAP works fine even for incisions over the umbilicus (maybe not up to the xyphoid but those are rare).
 
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2Fast2Des said:
Why not just do erector spinae or QL? It will provide visceral coverage as well.
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Never done one. I know I can look at you tube and attempt it, but it seems like overkill for these laparoscopic cases honestly. Have done tons of lap choles and don't remember these to be that painful, but then again, I didn't spend as much time in the PACU as I do these days pencil pushing.
Anyway, apparently there's a semi retired block jock who comes in about one week a month to cover the surgi center and his patients are almost always, pain free. I don't know what he's doing, but I think some of this is just me. Whatever the case, I wish I could just decline, but have to keep doing it and hopefully get to be a block chic with these.

BTW, supervising at the surgi-center blows. Mind numbing work. I can't believe people do this and enjoy it. The full time guys apparently don't go there. The pace is fast, and really, all I do, is pre op patients and sign a bunch of charts all day long. Most cases are 15 min cases and it feels like a factory. Churn them, move them, move them, churn them. Really? My mouth was dry as hell repeating the same thing over, and over, and over.... Jesus, Lord.
 
chocomorsel said:
Never done one. I know I can look at you tube and attempt it, but it seems like overkill for these laparoscopic cases honestly. Have done tons of lap choles and don't remember these to be that painful, but then again, I didn't spend as much time in the PACU as I do these days pencil pushing.
Anyway, apparently there's a semi retired block jock who comes in about one week a month to cover the surgi center and his patients are almost always, pain free. I don't know what he's doing, but I think some of this is just me. Whatever the case, I wish I could just decline, but have to keep doing it and hopefully get to be a block chic with these.

BTW, supervising at the surgi-center blows. Mind numbing work. I can't believe people do this and enjoy it. The full time guys apparently don't go there. The pace is fast, and really, all I do, is pre op patients and sign a bunch of charts all day long. Most cases are 15 min cases and it feels like a factory. Churn them, move them, move them, churn them. Really? My mouth was dry as hell repeating the same thing over, and over, and over.... Jesus, Lord.
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Im from Chile and there lap chole is one of the most common surgical procedures (high risk of gallbladder ca). Port infiltration and some narcotics is the go–to because it works very good. Only "special cases" (<1%) get anything else, like chronic opioid use or w/e. Conversion to OPEN is different topic, and that usually will require paravertebral or epidural.
 
I’m interested in the erector spinae block as an alternative to taps but alas I have graduated and don’t have anyone experienced with this to teach it to me.
 
With follow-up for our enhanced recovery patients, the pain they experienced was mostly above the umbilicus.

I try to set up proper expectations for the patients to let them know that this will reduce, but not eliminate their pain, but that they will likely use less narcotic than they otherwise would have. That satisfies most of them.
 
rakotomazoto said:
I agree that TAP blocks are disappointing, but it also seems to be the trend among many of our surgeons that they prefer them to epidurals. They definitely don't control pain as well, although you do avoid the hassles of managing a patient with an epidural.
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Probably because the epidurals were not placed well. There is a lot that goes into proper placement. Choosing the appropriate site is first. The mixture and dose that is right for the pt is last. IMO, a well placed epidural is the cats meow.
 
T-burglar said:
I’m interested in the erector spinae block as an alternative to taps but alas I have graduated and don’t have anyone experienced with this to teach it to me.
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No one taught me ESP either but I learned between videos and talking to my regional buddies over the phone. It is very, very easy, works well, and much safer than paravert since you land on transverse process.

QL otoh, I'm not super keen on attempting without being shown in person (although likely you could just dump a bunch of local where EO, IO, and TA originate proximally and be ok), but luckily we just hired a regional guy who finished fellowship in June.
 
dhb said:
He'll teach you the big bad blocks!
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Not sure if you're being sarcastic, but in my experience in the US it's usually CRNAs have zero respect for techniques they're unfamiliar with. If I'm uncomfortable with something I have no problem admitting so and getting help
 
Like all blocks, the greatest reason for failure is inappropriate localization, as others have pointed out. I have had very good success doing TAPs in kids and adults by waiting until the end of the case and blocking the sites cephalolateral to the incisions.

Infraumbilical: lateral TAP
Periumbilical: rectus sheath
Supraumbilical: subcostal TAP

They are highly effective when tailored for the procedure being done. The exception that comes to mind is with uterine surgery due to the high degree of visceral pain.
 
Noyac said:
Probably because the epidurals were not placed well. There is a lot that goes into proper placement. Choosing the appropriate site is first. The mixture and dose that is right for the pt is last. IMO, a well placed epidural is the cats meow.
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agree about epidurals being so nice

you would be surprised how many places are shocked at the idea for anything other than a thoracotomy

then when you have one on the floor the clueless nurses call and page about it constantly, the surgeons just say forget it - youve got to have a system in place for it.
 
15cc 0.25% Bup, 10cc Exparel (1.33%), 20cc NS per side (depending on toxic dose) - high volume, long duration. It ismeant to reduce pain from a 8-10 down to a 3-5. Subcostals for pubis to xyphoid incisions with the above dosing split in half. We do dozens of these a day and have good results; caveat - everyone knows these won't replicate epidurals, but they still reduce opioid consumption.

ESB are awesome for flank incisions, kidney/liver surgeries, rib fx's and are simple to do. I've been doing them with both catheters and with exparel - plain local last only for half a day max due to high vascular uptake.

Still need to advocate for patient's though, a chronic pain patient on lots of narcotics coming in for an ex-lap should still warrant an epidural, not a tap.
 
I do a lot of tap and ql and I don't think either works amazing. Helps reduce pain probably but not get rid, which is expected . Ql is often disappointing maybe bc I think it's a hard block in big people.

I haven't done too many subcostal blocks. And idk why but I can't find good videos like other blocks. Anyone know of any? Want to get into doing these
 
If a TAP block only covers somatic pain, this means that on initial assessment in the PACU, their pain levels should be largely equivalent to good surgeon local infiltration. So it stands to reason that you wouldn't and shouldn't see a difference in pain levels in the first few hours (ie PACU). The only difference would likely be the duration (6h for local infiltration and 12ish for TAPs w/o exparel, maybe 24-48ish hours with exparel). Am I missing something?

We do them as part of ERAS protocol and only on hand assisted patients, although I'm tempted to start doing rectus sheath blocks and having the surgeon infiltrate the port sites. epidurals for open bowels and thoracotomies. I agree with everyone else about having a system in place to support it, and because of this system, we have surgeon buy in. They in fact hate it when we can't do an epidural for an open case. VATS don't usually get any regional, but I've started thinking ESBs might be perfect for this, though we don't do a ton of thoracic.
 
Also, this is a really interesting study of classic approach TAP blocks in regional anesthesia and pain medicine. While there are limitations in skin testing, it's crazy how poorly a classic TAP block covers the midline, and if you want reliable pfannenstiel coverage, forget about it.

Regional Anesthesia and Pain Medicine • Volume 40, Number 4, July-August 2015
 

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Here's a follow up study with oblique TAP block and sensory distribution.

Regional Anesthesia and Pain Medicine • Volume 43, Number 2, February 2018
 

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I have stopped using TAP blocks altogether, finding ESP blocks give a much more dense and wider distribution block. The PACU nurses have been surprised, not having to give any opioids at all and intraop anesthesia requirements are much lower. ESP seems to give a more predictable coverage block, although the learning curve is steep.
 
algosdoc said:
I have stopped using TAP blocks altogether, finding ESP blocks give a much more dense and wider distribution block. The PACU nurses have been surprised, not having to give any opioids at all and intraop anesthesia requirements are much lower. ESP seems to give a more predictable coverage block, although the learning curve is steep.
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I did ESP blocks for thoracic cases with good results in residency, but I’ve hardly done them in private practice. What’s your technique for abdominal surgeries (dosing/position/level/timing)? I’m assuming you do it preop since you mentioned intraop anes requirements are lower. Would love to try these for abdominal surgeries instead of TAP blocks.
 
txhorn said:
I did ESP blocks for thoracic cases with good results in residency, but I’ve hardly done them in private practice. What’s your technique for abdominal surgeries (dosing/position/level/timing)? I’m assuming you do it preop since you mentioned intraop anes requirements are lower. Would love to try these for abdominal surgeries instead of TAP blocks.
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I typically go around T8-9ish (for abd) and inject 15cc 0.25% Bup and 10cc (133mg) of Exparel with 5-10cc saline for volume per side. Works very well.
Use a linear probe approx. 2cm from midline, find TP (differentiate from rib and laminae). In plane needle advancement, touch TP, pull back a mm and inject. You should see good planar spread just above the bone and under the erector spinae muscle. There are some good articles and videos out there on the standard sites. There was no research on using exparel in these blocks but it seems to work well and doesn't go over the max plain bupi dose while using exparel. One could also use bilateral catheters, but this feel excessive.

I have the patient sitting up in preop. Takes the same amount of time as doing bilat paravertebrals.
 
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