TAP blocks - yay or nay?

[spike7585]

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Have a surgeon wanting TAP blocks for all robotic cases. Not really our culture at our gig but looking for literature either way to see.

I remember looking 5-6 years ago and most of what I found then didn't see significant change in pain scores following TAP blocks.

Fine doing it if it shows definitive benefit. But if it's partial benefit at best, not thrilled of just blocking because I'm being "told so". None of the other surgeons (even for robots) have requested (demanded) TAPs

 

[cchoukal]

I joined a practice recently where it is the culture to do TAP blocks (or QL or whatever) for robot cases, having come from an academic setting where parsimony and adherence to the "won't change management" mantra were virtues. Notwithstanding the bias inherent in a fee-for-service situation (we pay ourselves 5 units for bilateral TAP under u/s, although I don't know if insurance pays it or not), I do find I get fewer calls about post-op pain after robot prostates with the blocks. Considering, too, that these are very low risk in terms of injury to vessels and nerves, I feel decent about doing them.

 

[Remxed]

Same here. Most surgeons will request or don’t mind TAP/QL blocks. We just make sure we communicate with them about how much to share for local if they want to infiltrate some in the field.

 

[aneftp]

This surgeon wanted tap block at 3am robotic gallbladder.

Would u do that??

Community hospital. Beeper calls from home.

I said no. He complained to admin.

He wants tap for all his robotic cases 1pm or 3am

This dude crazy. Will do anything elective 24/7

 

[Howard888]

Evidence does not support tap blocks for robotic or laprascopic surgery vs surgeon injecting local at sites. Cleveland clinic had another recent study showing this. Many other studies show similar results.

 

[Howard888]

I expect insurance companies to stop paying for them soon whether outright or just bundling the payment in the cpt code…just like a few have done with chest wall blocks recently

 

[spike7585]

Evidence does not support tap blocks for robotic or laprascopic surgery vs surgeon injecting local at sites. Cleveland clinic had another recent study showing this. Many other studies show similar results.

Any chance you can send me what study you're referring to?

 

[abolt18]

This surgeon wanted tap block at 3am robotic gallbladder.

Would u do that??

Community hospital. Beeper calls from home.

I said no. He complained to admin.

He wants tap for all his robotic cases 1pm or 3am

This dude crazy. Will do anything elective 24/7

Hard pass. I would also say no.

 

[GassYous]

It's Yea or Nay!!!

Tap block takes a few minutes and pays

 

[spike7585]

It's Yea or Nay!!!

Tap block takes a few minutes and pays

Take the pay out of it

Straight salary. We block plenty of Ortho cases where there's an obvious benefit

If you're not getting reimbursed for it, then is it "Yea or Nay"

 

[deleted643396]

This surgeon wanted tap block at 3am robotic gallbladder.

Would u do that??

Community hospital. Beeper calls from home.

I said no. He complained to admin.

He wants tap for all his robotic cases 1pm or 3am

This dude crazy. Will do anything elective 24/7

No blocks after 5pm is probably a more strict guideline for me than NPO guidelines.

 

[UscGhost]

Tap block takes 90 seconds to do.

I notice, pretty consistently that i need to use more fentanyl if i dont block

So i block

 

[coffeebythelake]

Tap block takes 90 seconds to do.

I notice, pretty consistently that i need to use more fentanyl if i dont block

So i block

Takes 90 seconds to do but takes 15 minutes to get things drawn up and prepared to do it

 

[UscGhost]

Takes 90 seconds to do but takes 15 minutes to get things drawn up and prepared to do it

If you have a good tech and nurse..they set up for you

 

[Remxed]

Takes 90 seconds to do but takes 15 minutes to get things drawn up and prepared to do it

Even if I’m setting up everything myself, it shouldn’t take 15 minutes.. 30 seconds to draw up the local. 2 minutes at most to boot up the ultrasound. All my block needles, gel, gloves are all in the back of the ultrasound.

 

[Howard888]

Any chance you can send me what study you're referring to?

https://www.painmedicinenews.com/Interventional/Article/02-25/No-Benefit-From-TAP-Block-in-Abdominal-Surgery-Study-Shows/76342?ses=ogst

So many more studies. Pick what surgery robotic or laparoscopic and while you might find a couple small ones supporting taps you’ll find way more that show no lasting benefit to taps.

Taps get zero visceral component. You might get a couple hours longer with taps vs surgical local infiltration but nothing significant outcome wise at all

 

[GassYous]

Take the pay out of it

Straight salary. We block plenty of Ortho cases where there's an obvious benefit

If you're not getting reimbursed for it, then is it "Yea or Nay"

I would still do it as it decreases the amount of phone calls I get from pacu.

I've had patients with zero pain post surgery. I've had patients crying from pain in pacu that the surgeon initially didn't want a block get a rescue tap bedside and they do great. I'm a big believer in blocks in general.

 

[cchoukal]

I would still do it as it decreases the amount of phone calls I get from pacu.

I've had patients with zero pain post surgery. I've had patients crying from pain in pacu that the surgeon initially didn't want a block get a rescue tap bedside and they do great. I'm a big believer in blocks in general.

This has been my observation as well, and I came at it with a lot of skepticism initially.

 

[2Fast2Des]

Absolutely TAP blocks help for robotic. Especially helps even more when we billed 5 units for a bilateral TAP block and had a busy robot day 😂

 

[Howard888]

again the evidence does not support. You need surgeons will inject local well of course.

I give it 3 years at most before insurance companies stop paying for them

 

[Hoya11]

I would still do it as it decreases the amount of phone calls I get from pacu.

I've had patients with zero pain post surgery. I've had patients crying from pain in pacu that the surgeon initially didn't want a block get a rescue tap bedside and they do great. I'm a big believer in blocks in general.

The key is believing in the right ones , and recognizing the BS ones .. they’re is lots of BS out there with articles barely showing benefit but the author looking for recognition ..

 

[GassYous]

I don't believe in ESP blocks. They are very different from pvb, you need a large volume and a pump and they still don't do much. Peng probably doesn't do much either.

 

[UscGhost]

again the evidence does not support. You need surgeons will inject local well of course.

I give it 3 years at most before insurance companies stop paying for them

I totally get it.

Why the studies dont support it...i dont know. Maybe its dosing, technique, skill, surgeons dose/ technique..etc

I try not to practice on acecdotal.. especially when the data doesn't necessarily support it.

However, its readily apparent for most cases that if a surgeon refused a tap block, i will need more fentanyl.

Similarly, the pacu nurses are happy if i do a block and upset if i dont .so they apparently notice a difference. They also tend to know who's blocks work and who's dont

So, based on that plus the extremely low risk and ease of the procedure...ill do them

 

[abolt18]

I don't believe in ESP blocks. They are very different from pvb, you need a large volume and a pump and they still don't do much. Peng probably doesn't do much either.

I've seen ESP work dramatically. Guy in terrible pain post VATS in PACU. Barely able to breathe, can't lie back or relax..did ESP and when I came back 20 minutes later, he was totally comfortable laying back in bed. Also done ESP catheters on a lady with rib fractures but on anticoagulation. Provided her substantial relief.

I feel like the benefit is most pronounced when the patient feels the pain first. Otherwise, doing these blocks while the patient is asleep, and then they still have pain, it's easy to feel like it didn't work.

 

[DesiredMemberName?]

I feel like the benefit is most pronounced when the patient feels the pain first. Otherwise, doing these blocks while the patient is asleep, and then they still have pain, it's easy to feel like it didn't work.

This is probably true for all blocks.

I’ve had patients who can’t move their hand or arm calmly tell me, “I dunno… yeah… I guess it does hurt a little bit. I’m not sure if the block is working.”

I also had someone tell me with a straight face that the pain during the block for their shoulder surgery was even worse than the postop pain! 🤔 Never getting one of those again!

 

[ScarfTheVerb]

I've seen ESP work dramatically. Guy in terrible pain post VATS in PACU. Barely able to breathe, can't lie back or relax..did ESP and when I came back 20 minutes later, he was totally comfortable laying back in bed. Also done ESP catheters on a lady with rib fractures but on anticoagulation. Provided her substantial relief.

I feel like the benefit is most pronounced when the patient feels the pain first. Otherwise, doing these blocks while the patient is asleep, and then they still have pain, it's easy to feel like it didn't work.

I’ve had the same experience. I want an esp if I ever break my ribs.

 

[narcotics999]

If you have a good tech and nurse..they set up for you

Good luck to have a good tech and nurse to set up for you at 3AM!

 

[Ronin786]

I don't believe in ESP blocks. They are very different from pvb, you need a large volume and a pump and they still don't do much. Peng probably doesn't do much either.

Not a regional guru here, but I find it hard not to believe in ESP blocks when you can do awake spine surgery with them. Not sure of the difference in anatomy between upper and lower though.

 

[pgg]

This surgeon wanted tap block at 3am robotic gallbladder.

Would u do that??

Community hospital. Beeper calls from home.

I said no. He complained to admin.

He wants tap for all his robotic cases 1pm or 3am

This dude crazy. Will do anything elective 24/7

Aren't you getting paid $2837/hour for that beeper call?

 

[pgg]

I don't believe in ESP blocks. They are very different from pvb, you need a large volume and a pump and they still don't do much. Peng probably doesn't do much either.

We used to do ESP catheters for minimally invasive mitral valves. Good results.

The only thing I didn't like about them was the not-infrequent issue of placing a very nice ESP catheter preop, only have to the surgeon change his mind about the mini approach and just do a sternotomy instead. 😡

That surgeon left, haven't done one in a year or two now.

 

[aneftp]

Aren't you getting paid $2837/hour for that beeper call?

Worked out to $4800/hr on Wednesday with no cases. So win some. Lose some

 

[pgg]

Worked out to $4800/hr on Wednesday with no cases. So win some. Lose some

Nice

Sounds win win, TAP block or not!

 

[triggermaster]

Tap block takes 90 seconds to do.

I notice, pretty consistently that i need to use more fentanyl if i dont block

So i block

Publish your study.

 

[UscGhost]

Publish your study.

Eh

Academia doesn't pay enough

 

[Hoya11]

Not a regional guru here, but I find it hard not to believe in ESP blocks when you can do awake spine surgery with them. Not sure of the difference in anatomy between upper and lower though.

i think local just gets to the intercostal space, and they are the same as intercostals.. my 0.02

you probably can do the same "awake spine surgery" with surgeon local in the area the port goes through and light sedation

 

[Dantrolene FC]

i think local just gets to the intercostal space, and they are the same as intercostals.. my 0.02

you probably can do the same "awake spine surgery" with surgeon local in the area the port goes through and light sedation

It’s the United States of America. We can’t even do awake MRIs.

 

[painquestions8989]

Worked out to $4800/hr on Wednesday with no cases. So win some. Lose some

For real?

 

[aneftp]

For real?

Yup. It’s all a gamble. Sometimes u win. Sometimes u get hammered. Only fools do beeper for $1000/1200 per 12 hrs or $2000/2400 per 24 hr plus hourly wages if called in

U gotta think like mlb or nba players. They have gurantee pay even if they sit on the bench or injured.

Time on beeper is very valuable. I value it as 100% of my hourly pay regardless of going in or not.

I actually think if u are on beeper and get called in. If u go that route. Ur beeper rate should be $1200 plus $650/hr (min 4 hr) if called in. I think that’s a fair beeper rate. That’s the Hawkeye state rate currently. Or else I won’t work unless it’s a guaranteed flat rate.

I’m literally toying with them for next Saturday’s call. Only cause I don’t like the surgeon. He’s not mean or anything. He just makes me work and do cases at night. And I’d rather be at home and getting paid to do no cases. So that may require a flat $7k for 12 hrs. Up from the contracted $4800 rate per 12 hr/$9600/24 hrs.

Maybe some sucker MD with an ex wife who raped him in the divorce and now a 32 year old new wife who’s 28 years younger than him who desperately wants to lock him down with a kid will take the call next Saturday night for less.

There is usually a doc who doesn’t know any better.

 

[Dr. Anonymouss]

I think that lateral TAP blocks are useless. I believe we should only be doing QL blocks. I found an interesting paper looking at the spread of local anesthetic when using different QL approaches

"Cadaveric and imaging studies confirm that lateral QLB often results in limited dermatomal coverage, primarily T12–L1, and less reliable spread to the paravertebral space. The posterior quadratus lumborum block approach revealed consistently deep staining T11, 12, and L1 nerve roots. The anterior subcostal quadratus lumborum block approach in all specimens demonstrated staining T9, T10, T11, T12 and L1 nerve roots as well as variable staining of higher thoracic nerve roots."

source: Injectate spread following anterior sub-costal and posterior approaches to the quadratus lumborum block: A comparative cadaveric study - PubMed

 

[Simba1711]

I stopped doing tap blocks too. Don’t find the evidence convincing like another person posted when the surgeon injects local at the port site. Ql Covers more area than the tap block , somatic and visceral, and some paravertebral spread. The problem is it is a challenging block.

 

[pgg]

TAP block:

 

[Greenbayslacker]

Yup. It’s all a gamble. Sometimes u win. Sometimes u get hammered. Only fools do beeper for $1000/1200 per 12 hrs or $2000/2400 per 24 hr plus hourly wages if called in

U gotta think like mlb or nba players. They have gurantee pay even if they sit on the bench or injured.

Time on beeper is very valuable. I value it as 100% of my hourly pay regardless of going in or not.

I actually think if u are on beeper and get called in. If u go that route. Ur beeper rate should be $1200 plus $650/hr (min 4 hr) if called in. I think that’s a fair beeper rate. That’s the Hawkeye state rate currently. Or else I won’t work unless it’s a guaranteed flat rate.

I’m literally toying with them for next Saturday’s call. Only cause I don’t like the surgeon. He’s not mean or anything. He just makes me work and do cases at night. And I’d rather be at home and getting paid to do no cases. So that may require a flat $7k for 12 hrs. Up from the contracted $4800 rate per 12 hr/$9600/24 hrs.

Maybe some sucker MD with an ex wife who raped him in the divorce and now a 32 year old new wife who’s 28 years younger than him who desperately wants to lock him down with a kid will take the call next Saturday night for less.

There is usually a doc who doesn’t know any better.

Thought you were saying 4800/hr. I would’ve moved my whole family to wherever that is lol

 

[aneftp]

Thought you were saying 4800/hr. I would’ve moved my whole family to wherever that is lol

It works out to $4800/hr for 12 hr of coverage and no or 1 hr of work.

Anyways it’s hard for me to do any type of beeper cause without some type of guranteee for 12 or 24 hrs.

 

[Maz777]

This surgeon wanted tap block at 3am robotic gallbladder.

Would u do that??

Community hospital. Beeper calls from home.

I said no. He complained to admin.

He wants tap for all his robotic cases 1pm or 3am

This dude crazy. Will do anything elective 24/7

That's brutal. I hate my job but at least our surgeons wouldn't thinking of doing a chole after hours. Who the hell leads your department to allow this nonsense? I wouldn't get out of bed for a chole let alone a useless TAP block.

 

[Maz777]

There is no way that a lateral TAP block could possibly be any better than good surgical infiltration at each port site. It's simply not possible. There is no special hidden ventral rami that you are covering with a TAP that you can't get distally with port site infiltration.

TAPs might make sense for decent sized Pfannenstiels (if you aren't doing neuraxial opioids). That's about it.

 

[DG51]

Yup. It’s all a gamble. Sometimes u win. Sometimes u get hammered. Only fools do beeper for $1000/1200 per 12 hrs or $2000/2400 per 24 hr plus hourly wages if called in

U gotta think like mlb or nba players. They have gurantee pay even if they sit on the bench or injured.

Time on beeper is very valuable. I value it as 100% of my hourly pay regardless of going in or not.

I actually think if u are on beeper and get called in. If u go that route. Ur beeper rate should be $1200 plus $650/hr (min 4 hr) if called in. I think that’s a fair beeper rate. That’s the Hawkeye state rate currently. Or else I won’t work unless it’s a guaranteed flat rate.

I’m literally toying with them for next Saturday’s call. Only cause I don’t like the surgeon. He’s not mean or anything. He just makes me work and do cases at night. And I’d rather be at home and getting paid to do no cases. So that may require a flat $7k for 12 hrs. Up from the contracted $4800 rate per 12 hr/$9600/24 hrs.

Maybe some sucker MD with an ex wife who raped him in the divorce and now a 32 year old new wife who’s 28 years younger than him who desperately wants to lock him down with a kid will take the call next Saturday night for less.

There is usually a doc who doesn’t know any better.

Is that rate for the group that just imploded in Des Moines?

 

[Burned_Out]

I do TAP blocks because they are easy to do. Even if the data says they don't work, I will still provide them because I believe in multi-modal pain control. The problem with TAP blocks is they don't cover the upper abdominal quadrants very well. To address this problem, I have begun to do external oblique intercostal blocks under ultrasound. They cover the T4-T9 dermatomes if you use 30 ml of local. Very simple block to do.

 

[<(^_^)>]

I don’t think TAP blocks are dramatically better than surgeon doing local, but if the surgeon wants it I don’t mind doing them. They’re incredibly fast and at least for now I get paid well to do them.

 

[OB1🤙]

I think TAP blocks are mostly bunk, especially for tiny incisions, but as a tangent- what I have found works real real nice for open upper abdominal incisions is the external oblique/intercostal fascial plane block. I was a deep skeptic and I am a convert. That block kicks ass for open liver type cases.

TAPs for anything not involving an open incision IMO is pretty worthless but if a surgeon actively asked for one I'd do it. Takes 2 minutes and is pretty risk-free. Whatever. My model doesn't (directly) pay me more to do them.

 

[zaitoun]

I do TAP blocks because they are easy to do. Even if the data says they don't work, I will still provide them because I believe in multi-modal pain control. The problem with TAP blocks is they don't cover the upper abdominal quadrants very well. To address this problem, I have begun to do external oblique intercostal blocks under ultrasound. They cover the T4-T9 dermatomes if you use 30 ml of local. Very simple block to do.

can't you just do rectus sheath block for more coverage?