TAP blocks inferior blocks?

[psychbender]

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Anyone doing ESBs for minimally invasive cardiac surgery? I put in ESB catheters for a pair of minimally invasive mitral valves today (Apollo TMVR and Neochord), and they seemed to work pretty well (no opiates intraop).

 

[dhb]

(no opiates intraop)

That's inhumane

 

[Gimlet]

Some of my attendings give it preop to "help with postop gas pain". While I can follow their thinking, I don't see how any discomfort related to intra-abdominal pressure would be addressed with the med, especially after desufflation.

It helps treat acidification of the peritoneum by CO2, which causes the referred shoulder pain. Nothing to do with pressure. I don’t give it unless they patient tells me they had an issue with it during a previous surgery.

 

[abolt18]

It helps treat acidification of the peritoneum by CO2, which causes the referred shoulder pain. Nothing to do with pressure. I don’t give it unless they patient tells me they had an issue with it during a previous surgery.

First I've ever heard of this...

 

[Mman]

It helps treat acidification of the peritoneum by CO2, which causes the referred shoulder pain. Nothing to do with pressure. I don’t give it unless they patient tells me they had an issue with it during a previous surgery.

Gotta be honest, the human body pH is so well buffered that I have a hard time imagining that insufflation with CO2 yesterday could cause a patient's peritoneum to be acidotic today causing referred shoulder pain. Patients have been insufflated with everything from room air to nitrous oxide to helium to argon to nitrogen in addition to CO2 and I am unaware of any evidence that using something other than CO2 prevents referred shoulder pain.

 

[Noyac]

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.

For example, we had a morbidly obese pt (BMI >50) for hernia repair sp colectomy. This was a low incision but large. My partner placed a very well working high lumbar epidural but this also added some LU weakness which made her a greater fall risk that she already was. I had options; replace the catheter at a higher level, decrease the infusion rate, change the infusion concoction.

What would others do? Trying to stoke the discussion rather than start a new one.

 

[Arch Guillotti]

For example, we had a morbidly obese pt (BMI >50) for hernia repair sp colectomy. This was a low incision but large. My partner placed a very well working high lumbar epidural but this also added some LU weakness which made her a greater fall risk that she already was. I had options; replace the catheter at a higher level, decrease the infusion rate, change the infusion concoction.

What would others do? Trying to stoke the discussion rather than start a new one.

I wouldn’t do an epidural to begin with.😵

 

[Hoya11]

For example, we had a morbidly obese pt (BMI >50) for hernia repair sp colectomy. This was a low incision but large. My partner placed a very well working high lumbar epidural but this also added some LU weakness which made her a greater fall risk that she already was. I had options; replace the catheter at a higher level, decrease the infusion rate, change the infusion concoction.

What would others do? Trying to stoke the discussion rather than start a new one.

if someone is having such a significant/painful surgery to require an epidural for post op pain, then im not concerned about them walking on post op day 1.

There is no problem with the above. Its a good epidural. You cant walk with it so stay in bed for POD 1. On POD2 well remove it and you walk later.

Its always a balance between patient comfort and speedy discharge.

If you think the surgery is going to be painful enough that an epidural would help, then who cares what happens on POD1 other than good pain control.

Many others would have you in agony all day on POD1 to be able to walk for 5 minutes with PT, why?

But judging whether or not to do the epidural at all is an art and depends on patient, surgery, surgeon, and facility

Personally, If I decide not to do an epidural on a seriously painful surgery, then the surgeon infiltrates the local at the incision site, and I give dilaudid, precedex, steroids, nsaids, tylenol - and skip the medicore tissue plane block

 

[dhb]

I give dilaudid, precedex, steroids, nsaids, tylenol

I skip all that and do the block but to each their own...

 

[fakin' the funk]

Our surgeons, particularly hepatobiliary, started asking for TAPs instead of epidurals on various open cases a few months back. They are semi- understandably annoyed with the hassle and problems and time associated with epidurals. Block time, sedation, post-op hypotension, need for extra fluid, weakness, etc etc.

My group was skeptical at first- TAPs for a Whipple? But they're only for somatic pain below the umbilicus, right? Why would we do a weak-ass block that won't even cover the incision?

We started doing them, on select patients. Crispy, old, scoliotic, vasculopaths, anticoagulated, insanely anxious, etc etc - the kind you'd expect even a great epidural to be a big PITA. I must say, I'm surprised at how effective TAPs can be, especially subcostals +/- rectus sheath blocks. Doing them all with Exparel and a lot of volume, preincision.

I'm not at all surprised at how variable they are.

I'm also surprised at how variable post-op pain from the same surgery is. Maybe I shouldn't be.

The initial experience has been good enough that the plan for now is to keep selecting patients who seem like good or bad epidural candidates.

 

[anbuitachi]

Our surgeons, particularly hepatobiliary, started asking for TAPs instead of epidurals on various open cases a few months back. They are semi- understandably annoyed with the hassle and problems and time associated with epidurals. Block time, sedation, post-op hypotension, need for extra fluid, weakness, etc etc.

My group was skeptical at first- TAPs for a Whipple? But they're only for somatic pain below the umbilicus, right? Why would we do a weak-ass block that won't even cover the incision?

We started doing them, on select patients. Crispy, old, scoliotic, vasculopaths, anticoagulated, insanely anxious, etc etc - the kind you'd expect even a great epidural to be a big PITA. I must say, I'm surprised at how effective TAPs can be, especially subcostals +/- rectus sheath blocks. Doing them all with Exparel and a lot of volume, preincision.

I'm not at all surprised at how variable they are.

I'm also surprised at how variable post-op pain from the same surgery is. Maybe I shouldn't be.

The initial experience has been good enough that the plan for now is to keep selecting patients who seem like good or bad epidural candidates.

I don't really done subcostal blocks. if you do bilateral subcostal with b/l rectus sheath in a 50kg patient. how much local are you giving per block??

 

[Hoya11]

Our surgeons, particularly hepatobiliary, started asking for TAPs instead of epidurals on various open cases a few months back. They are semi- understandably annoyed with the hassle and problems and time associated with epidurals. Block time, sedation, post-op hypotension, need for extra fluid, weakness, etc etc.

My group was skeptical at first- TAPs for a Whipple? But they're only for somatic pain below the umbilicus, right? Why would we do a weak-ass block that won't even cover the incision?

We started doing them, on select patients. Crispy, old, scoliotic, vasculopaths, anticoagulated, insanely anxious, etc etc - the kind you'd expect even a great epidural to be a big PITA. I must say, I'm surprised at how effective TAPs can be, especially subcostals +/- rectus sheath blocks. Doing them all with Exparel and a lot of volume, preincision.

I'm not at all surprised at how variable they are.

I'm also surprised at how variable post-op pain from the same surgery is. Maybe I shouldn't be.

The initial experience has been good enough that the plan for now is to keep selecting patients who seem like good or bad epidural candidates.

those sound like the kind of patients that need very little narcotic to begin with

try doing a TAP on a whipple for a big young person and avoiding all narcotics and see what happens

 

[Noyac]

A little more history, this is a chronic pain pt who had a good course post colectomy with epidural.

 

[fakin' the funk]

those sound like the kind of patients that need very little narcotic to begin with

try doing a TAP on a whipple for a big young person and avoiding all narcotics and see what happens

One of my points was that this isn't a homogeneous group of decepit patients, thanks tho

 

[Sonny Crocket]

the guy who invented the tap block doesn’t do them anymore. Good luck

 

[dhb]

the guy who invented the tap block doesn’t do them anymore. Good luck

Let’s take your word on it.