TAP blocks - yay or nay?

[pgg]

Advertisement - Members don't see this ad

The downsides of a couple extra oxy are bigger than the downsides of a 3 minute tap block

It's a rare, rare patient for whom a couple of oxy tablets are a problem

Sure, there are obese OSA'ers getting painful procedures, who might have real risks with high doses of opioid-only pain regimens. Maximizing multimodal efforts, including medications of small effect (acetaminophen, ketorolac, maybe even fringe silliness like Mg++ and dexmedetomidine), including blocks of dubious coverage/quality - all perhaps worthwhile.

But some procedures just aren't that painful. They don't need to get snowed with IV opioids to hold off the screaming. And if they get an oxycodone tablet in PACU and another one once they get home ... it's just not a problem.

I'm not going to stick a needle in a person, anywhere, without a more compelling benefit than avoiding a couple extra oxy (the alleged benefit claimed by some p-value chasing publish-or-perish academics).

 

[AKMD_1984]

personally i have not seen a difference in pain control for tap vs no tap for choles across multiple hospitals (some places where there is at least a culture vs places where they look at you puzzled that you even think of it).

literally no difference where i can say oh yes….tap would have made a difference in this pt. looking back i can’t even say that my post op mgt has been different across all pts and all hospitals - it really not a big deal

people are saying that tap is curative…its really not…pt can still c/o pain despite best taps on ultrasound

so clearly there’s a financial incentive here

that’s just my longitudinal experience and observation

the research behind is its data mining - at best…statistically significant at some nitpicked time interval/ window but no real difference in opioid consumption or length of stay… doesn’t make sense to me

and yes it ok to give opioids for acute post op pain short term…that along with malignant pain are the only two actual indications for opioid use - not everyone is an addict or is going to overdose.

we are anesthesiologists and physicians first. very important to remove personal bias from some downstream risk of addiction - not saying it’s not a real risk but i often see regional anesthesiologists push a billion blocks because they’re afraid that pt will get addicted…addiction is a complex psychosocial phenomenon and impossible to anticipate in preop unless the pt has a history already

because of this “no opioid/ jo general” mindset - this includes doing spinals/ femoral blocks while a 90 year old patient is coming for orif…they’d rather poke this poor pt and force the pt to position with a broken femur than do a quick general on bed and get the case done and do appropriate blocks/ fascia iliaca/femoral…before incision or pre extubation

either or…

not everything is academic or science…there needs to be an art and appropriateness to what we do as well

sometimes opioids are the best option and in fact they are quite effective against visceral pain and stretch receptors (as is the case for chole/appy).

 

[UscGhost]

I posted

personally i have not seen a difference in pain control for tap vs no tap for choles across multiple hospitals (some places where there is at least a culture vs places where they look at you puzzled that you even think of it).

literally no difference where i can say oh yes….tap would have made a difference in this pt. looking back i can’t even say that my post op mgt has been different across all pts and all hospitals - it really not a big deal

people are saying that tap is curative…its really not…pt can still c/o pain despite best taps on ultrasound

so clearly there’s a financial incentive here

that’s just my longitudinal experience and observation

the research behind is its data mining - at best…statistically significant at some nitpicked time interval/ window but no real difference in opioid consumption or length of stay… doesn’t make sense to me

and yes it ok to give opioids for acute post op pain short term…that along with malignant pain are the only two actual indications for opioid use - not everyone is an addict or is going to overdose.

we are anesthesiologists and physicians first. very important to remove personal bias from some downstream risk of addiction - not saying it’s not a real risk but i often see regional anesthesiologists push a billion blocks because they’re afraid that pt will get addicted…addiction is a complex psychosocial phenomenon and impossible to anticipate in preop unless the pt has a history already

because of this “no opioid/ jo general” mindset - this includes doing spinals/ femoral blocks while a 90 year old patient is coming for orif…they’d rather poke this poor pt and force the pt to position with a broken femur than do a quick general on bed and get the case done and do appropriate blocks/ fascia iliaca/femoral…before incision or pre extubation

either or…

not everything is academic or science…there needs to be an art and appropriateness to what we do as well

sometimes opioids are the best option and in fact they are quite effective against visceral pain and stretch receptors (as is the case for chole/appy).

I posted multiple studies showing a reduction in opiod use

Not sure why the non regional folks are so determined to flood their patients with dilaudid and then let them lay unconscious in pacu until they wake up nauseous.

Meanwhile the patients with regional are awake, happy and discharged.

Multimodal works

 

[AKMD_1984]

I posted

I posted multiple studies showing a reduction in opiod use

Not sure why the non regional folks are so determined to flood their patients with dilaudid and then let them lay unconscious in pacu until they wake up nauseous.

Meanwhile the patients with regional are awake, happy and discharged.

Multimodal works

you’re biased. just because you own a hammer all you see is nail.

 

[UscGhost]

you’re biased. just because you own a hammer all you see is nail.

And you're biased.

You own a screwdriver and you are too afraid to buy a hammer

 

[AKMD_1984]

And you're biased.

You own a screwdriver and you are too afraid to buy a hammer

i thought i owned a golf bag full of nice clubs - each for different situations...

 

[Howard888]

Length of stay is only metric that matters. Medicine is financial. It’s the US. You honestly don’t seem to get this. Good luck to you in your career

 

[pgg]

Not sure why the non regional folks are so determined to flood their patients with dilaudid and then let them lay unconscious in pacu until they wake up nauseous.

Meanwhile the patients with regional are awake, happy and discharged.

Are you seriously suggesting that a TAP block is the difference between "awake happy and discharged" and "flooded with dilaudid unconscious and then nauseous"??

C'mon man. At least try to argue in good faith. You do this a lot - pretend edge cases are the norm, make dramatic strawmen to tear down, act like crappy data is actually compelling support for what you want.


I think we'd agree that lots of regional blocks are extremely effective and even (dare I say it?) standard of care.

Interscalene for a total shoulder in an obese OSA'er? 100%. That guy would need high doses of opioids otherwise, elevating his risk of respiratory events.

Some kind of femoral/saphenous block for an ordinary TKA? Hell yeah.

TAP for a lap appy in a 25 yo healthy patient? Ridiculous. If a bit of IV opioid + acetaminophen + ketorolac + half-assed-surgeon-local isn't enough, give him an oxy for the road as you wheel him out the door.

I'm not anti regional when it makes sense. But TAPs just aren't worth the effort for a lot of these cases.

 

[UscGhost]

Are you seriously suggesting that a TAP block is the difference between "awake happy and discharged" and "flooded with dilaudid unconscious and then nauseous"??

C'mon man. At least try to argue in good faith. You do this a lot - pretend edge cases are the norm, make dramatic strawmen to tear down, act like crappy data is actually compelling support for what you want.


I think we'd agree that lots of regional blocks are extremely effective and even (dare I say it?) standard of care.

Interscalene for a total shoulder in an obese OSA'er? 100%. That guy would need high doses of opioids otherwise, elevating his risk of respiratory events.

Some kind of femoral/saphenous block for an ordinary TKA? Hell yeah.

TAP for a lap appy in a 25 yo healthy patient? Ridiculous. If a bit of IV opioid + acetaminophen + ketorolac + half-assed-surgeon-local isn't enough, give him an oxy for the road as you wheel him out the door.

I'm not anti regional when it makes sense. But TAPs just aren't worth the effort for a lot of these cases.

Not in the slightest. My posts have consistently argued for a balanced approach, as tap blocks are extremely fast, virtually zero risk and easy to do, and consistently have been shown to reduce opiod requirements.

The ridiculous counter arguments have been that they dont reduce the length of stay for an outpatient procedure or an ex lap. So a ridiculous counter argument deserves to the same type of response.

So far, i have presented multiple studies and RCTs showing effectiveness. The counter arguments are that well, so what if they need only 2 oxy instead of 4-5...

And quite often, a tap block is the difference...because those folks that dont do regional, tend to be opiod heavy (such as those who argued that 4 oxys is the same as 2), so their patients tend to be snowed in pacu. Is it all patients? No

But just like your obese total shoulder example..we also have plenty of 80 year old lap choles. And the non regional folks dont do blocks for them either

 

[UscGhost]

Are you seriously suggesting that a TAP block is the difference between "awake happy and discharged" and "flooded with dilaudid unconscious and then nauseous"??

C'mon man. At least try to argue in good faith. You do this a lot - pretend edge cases are the norm, make dramatic strawmen to tear down, act like crappy data is actually compelling support for what you want.


I think we'd agree that lots of regional blocks are extremely effective and even (dare I say it?) standard of care.

Interscalene for a total shoulder in an obese OSA'er? 100%. That guy would need high doses of opioids otherwise, elevating his risk of respiratory events.

Some kind of femoral/saphenous block for an ordinary TKA? Hell yeah.

TAP for a lap appy in a 25 yo healthy patient? Ridiculous. If a bit of IV opioid + acetaminophen + ketorolac + half-assed-surgeon-local isn't enough, give him an oxy for the road as you wheel him out the door.

I'm not anti regional when it makes sense. But TAPs just aren't worth the effort for a lot of these cases.

Efficacy of ultrasound-guided transversus abdominis plane block for po | LRA | Dove Medical Press

Efficacy of ultrasound-guided transversus abdominis plane block for postoperative analgesia in patients undergoing inguinal hernia repair Rajagopalan Venkatraman, Ranganathan Jothi Abhinaya, Ayyanar Sakthivel, Govindarajan Sivarajan Department of Anaesthesia, SRM Medical College Hospital and...

www.dovepress.com

Another article..can do this all day

Saline vs ropiv tap block.

Ropiv blocked required half as much tylenol, half as much tramadol and time to first dose twice as long

But hey, i guess all those metrics (standard metrics used in any study about pain control by the way) dont matter.

 

[Gern Blansten]

Efficacy of ultrasound-guided transversus abdominis plane block for po | LRA | Dove Medical Press

Efficacy of ultrasound-guided transversus abdominis plane block for postoperative analgesia in patients undergoing inguinal hernia repair Rajagopalan Venkatraman, Ranganathan Jothi Abhinaya, Ayyanar Sakthivel, Govindarajan Sivarajan Department of Anaesthesia, SRM Medical College Hospital and...

www.dovepress.com

Another article..can do this all day

Saline vs ropiv tap block.

Ropiv blocked required half as much tylenol, half as much tramadol and time to first dose twice as long

But hey, i guess all those metrics (standard metrics used in any study about pain control by the way) dont matter.

Ropivacaine TAP block vs saline? It reduced the use of Tylenol and tramadol? You mean those two drugs that are killing Americans every day and we can use a little less of them?
If the argument is that a TAP block with ropivacaine is better than saline and it can reduce the dose of tramadol and acetaminophen used, my interpretation of that is that we are dealing with a surgery for which barely any post op analgesia is needed and we should respond with giving appropriate amounts of those oral medications. But when you read the abstract, that is not what the study found. They showed no difference in VAS between the groups. **see quote below in bold.
Better than saline is a pretty dang low bar. Reducing tramadol and acetaminophen and the time to first dose does not seem to be a useful endpoint because, well, who cares if you use double the Tylenol or tramadol. Tramadol is our weakest opioid in the war chest of pain meds and abuse of tramadol is something that is uncommon.
I just reread the conclusion and they say the following:
There was no distinction in VAS scores at 0, 2, and 24 hours between the two groups

Their conclusion is, a TAP block with saline performed the same as a TAP block with ropivacaine? Did I read that correctly? They set a VERY low bar and TAP block could not clear that hurdle.

I guess I’m not sure why you think this argument is compelling. I suspect there are way better studies to use than this one. This would be an article that should be posted in support of abandonment of TAP blocks.

I am not a strict “anti TAP block” person, but this study you posted trying to argue its value actually pushed me further away from believing it has value.

Well done! Your “I could do this all day” comment was the chef’s kiss of your argument after being completely oblivious to the fact that you solidified the argument against your own proposal.

 

[UscGhost]

Ropivacaine TAP block vs saline? It reduced the use of Tylenol and tramadol? You mean those two drugs that are killing Americans every day and we can use a little less of them?
If the argument is that a TAP block with ropivacaine is better than saline and it can reduce the dose of tramadol and acetaminophen used, my interpretation of that is that we are dealing with a surgery for which barely any post op analgesia is needed and we should respond with giving appropriate amounts of those oral medications. But when you read the abstract, that is not what the study found. They showed no difference in VAS between the groups. **see quote below in bold.
Better than saline is a pretty dang low bar. Reducing tramadol and acetaminophen and the time to first dose does not seem to be a useful endpoint because, well, who cares if you use double the Tylenol or tramadol. Tramadol is our weakest opioid in the war chest of pain meds and abuse of tramadol is something that is uncommon.
I just reread the conclusion and they say the following:
There was no distinction in VAS scores at 0, 2, and 24 hours between the two groups

Their conclusion is, a TAP block with saline performed the same as a TAP block with ropivacaine? Did I read that correctly? They set a VERY low bar and TAP block could not clear that hurdle.

I guess I’m not sure why you think this argument is compelling. I suspect there are way better studies to use than this one. This would be an article that should be posted in support of abandonment of TAP blocks.

I am not a strict “anti TAP block” person, but this study you posted trying to argue its value actually pushed me further away from believing it has value.

Well done! Your “I could do this all day” comment was the chef’s kiss of your argument after being completely oblivious to the fact that you solidified the argument against your own proposal.

Same VAS scores are 0,2,24 with half the pain meds

Lower vas scores with block at 4,6,12 with half the pain meds

Lets dive into that a bit. Hour zero (arrival in pacu?), most patients are still emerging and were likely given a small dose of fent at the end of the procedure, so i wouldn't expect much pain or difference at this point

Hour 24? I wouldnt expect a weak ropiv 0.2 block to still linger at hour 24. Many interscalene blocks have worn off by then.

So the clinically relevant time periods would be 2,4,6,12. And a low dose tap block reduced pain scores at 4,6,12 and same score at 2. All with half the pain meds

Also posted studies with significant less oxy. I posted multiple articles in prior posts. Pretty easy to find studies on their effects. Besides, in the US, few patients get offered tramadol postop. If you have pain, its Vicodin/oxy. Americans dont handle pain well

Better than saline is a low bar? You do realize that saline is a control? People here argued that it wasnt better than saline. Ropiv 0.2 is also a very low strength local to use.. yet still effective.

Solidified the argument that TAPS work for pain control
Solidified argument that they work better than local infiltration

I will add your ridiculous counterargument, that since it doesn't reduce the amount drugs killing americans, then it isnt effective..to the list of other ridiculous counterarguments

 

[Dantrolene FC]

I posted

I posted multiple studies showing a reduction in opiod use

Not sure why the non regional folks are so determined to flood their patients with dilaudid and then let them lay unconscious in pacu until they wake up nauseous.

Meanwhile the patients with regional are awake, happy and discharged.

Multimodal works

You talk about TAP blocks like they’re brachial plexus blocks or something.

Yeah, when my patient has a brachial plexus blocks, they get no narcs because they’re insensate. But when my patient has a TAP block, I give them the same amount of narcs as if they didn’t have a TAP block because they don’t work the same as a brachial plexus block.

When you have a lap chole, I hope you get Tylenol, Toradol, and a TAP block. Then come back and post about your experience.

 

[Maz777]

Of course

Couple more for ya

Comparison of ultrasound-guided bilateral subcostal transversus abdominis plane block and port-site infiltration with bupivacaine in laparoscopic cholecystectomy - PMC

Many patients experience moderate-to-severe pain after laparoscopic cholecystectomy. We aimed to compare the efficacy of ultrasound-guided bilateral subcostal transversus abdominis plane (TAP) block with port-site infiltration for post-operative ...

pmc.ncbi.nlm.nih.gov

https://www.mdpi.com/2673-4095/5/3/44

All garbage I'm sure. I usually encounter such resistance amongst the older docs who dont know how to use an ultrasound...

Keep em coming.

Just shows you have no clue what you are citing and have zero research literacy.

You haven't even cited some ****ty publication stating that ultrasound-guided TAPs are better than port site infiltration for lap appy's. At least cite something that is relevant to the point you are trying to make.

If you are going to provide one, here are some basic requirements for citing an RCT: 1) reputable journal, 2) reasonable comparison groups, 3) blinding, 4) randomization, 5) reasonable primary outcomes, 6) registered with NCT/relevant national trial site pre-enrollment with no changes afterwards), 7) reasonable and simple data analysis, 8) reasonable interpretation of outcomes, 9) reasonable differences between groups, 10) confounding variables accounted for.

I'll provide one example for you: Ultrasound-guided transversus abdominis plane blocks for laparoscopic appendicectomy in children: a prospective randomized trial - PubMed

I'm guessing you have never done any sort of regional anesthesia RCT in your career. If so, I would love to read it. Feel free to post a link. Part of my job is reviewing regional anesthesia studies on a weekly basis.

I would also love for you to answer to this question. When you compare TAP blocks to port site infiltration for lap appy's, what magical nerves are you covering with a TAP block that aren't being covered by port site infiltration? Are you saying that TAP blocks are spreading back to the PV space and epidural space and getting more than simply T10-L1 intercostals and thereby getting visceral coverage like a PVB? That is what you are contending?

I'll wait.

You're a clown for doing TAP blocks for lap appy's. I think we have a consensus here.

 

[AKMD_1984]

seems like a private practice vs academic type of debate…pp high volume anesthesia is built on getting things done efficiently with most bang for the buck

less is more approach

hence we do more single shots than catheters because there is no dedicated staff having to deal with post op issues- even though catheters may be better strictly analgesia wise

but logistics and resources make it a difficult thing…but hey if you can manage it go for it

similarly i’m not saying tap blocks are contraindicated, but i just don’t think doing them is very high yield and that has been my experience across multiple hospitals with various culture - it’s one of the most commonly done surgeries, some places to do them some dont…and i just personally haven’t seen a big need for it

that’s why no one really gets excited about them

in an academic center perhaps with residents operating - the operative time is much longer therefore needing more visceral analgesia

there may be a difference between a 25 minute gall bladder vs a 90 minute one

it would interesting to see if there’s a correlation between operative time, type of facility and trainees vs non trainees

 

[UscGhost]

Keep em coming.

Just shows you have no clue what you are citing and have zero research literacy.

You haven't even cited some ****ty publication stating that ultrasound-guided TAPs are better than port site infiltration for lap appy's. At least cite something that is relevant to the point you are trying to make.

If you are going to provide one, here are some basic requirements for citing an RCT: 1) reputable journal, 2) reasonable comparison groups, 3) blinding, 4) randomization, 5) reasonable primary outcomes, 6) registered with NCT/relevant national trial site pre-enrollment with no changes afterwards), 7) reasonable and simple data analysis, 8) reasonable interpretation of outcomes, 9) reasonable differences between groups, 10) confounding variables accounted for.

I'll provide one example for you: Ultrasound-guided transversus abdominis plane blocks for laparoscopic appendicectomy in children: a prospective randomized trial - PubMed

I'm guessing you have never done any sort of regional anesthesia RCT in your career. If so, I would love to read it. Feel free to post a link. Part of my job is reviewing regional anesthesia studies on a weekly basis.

I would also love for you to answer to this question. When you compare TAP blocks to port site infiltration for lap appy's, what magical nerves are you covering with a TAP block that aren't being covered by port site infiltration? Are you saying that TAP blocks are spreading back to the PV space and epidural space and getting more than simply T10-L1 intercostals and thereby getting visceral coverage like a PVB? That is what you are contending?

I'll wait.

You're a clown for doing TAP blocks for lap appy's. I think we have a consensus here.

Big problem with that study, is that it doesnt reflect real world practice.

They injected 0.5 ml per kg of local at the port site. So, if we have a 90kg adult patient, our surgeons should be injecting 45ml at the port sites then??

Goodluck with that. Most surgeons inject 3-5ml per site

If a surgeon injects 15ml per port site i would be thrilled. Never seen it. Thats basically a tap block at each site.

Our tap blocks are typically 20-30ml per side.

And who on earth takes 14 mins to do a tap block?? Our surgeons would flip out if it took that long

 

[pgg]

Efficacy of ultrasound-guided transversus abdominis plane block for po | LRA | Dove Medical Press

Efficacy of ultrasound-guided transversus abdominis plane block for postoperative analgesia in patients undergoing inguinal hernia repair Rajagopalan Venkatraman, Ranganathan Jothi Abhinaya, Ayyanar Sakthivel, Govindarajan Sivarajan Department of Anaesthesia, SRM Medical College Hospital and...

www.dovepress.com

Another article..can do this all day

Saline vs ropiv tap block.

Ropiv blocked required half as much tylenol, half as much tramadol and time to first dose twice as long

But hey, i guess all those metrics (standard metrics used in any study about pain control by the way) dont matter.

No, that metric doesn't matter. Touting a delay to first dose to Tylenol or Tramadol (1/10th the potency of morphine) is just silly. Who cares? And why aren't those patients getting acetaminophen, a cornerstone of multimodal pain therapy, before they wake up anyway?


This morning I did a lap salpingectomy for an ectopic pregnancy. I didn't do a TAP block. (Obviously. 🙂) You know what makes that operation hurt? It ain't the cutaneous innervation of the port sites that a TAP block (usually) covers, it's the visceral innervation to the adnexa that gets cut fried and tied.

I gave her some hydromorphone, acetaminophen, and ketorolac and she was awake and comfortable before we even got to the PACU.

I guess I could've flooded her with dilaudid and then let her lay unconscious in pacu until she woke up nauseous, but that would've been even sillier than doing a TAP block. 🙂

 

[Maz777]

Big problem with that study, is that it doesnt reflect real world practice.

They injected 0.5 ml per kg of local at the port site. So, if we have a 90kg adult patient, our surgeons should be injecting 45ml at the port sites then??

Goodluck with that. Most surgeons inject 3-5ml per site

If a surgeon injects 15ml per port site i would be thrilled. Never seen it. Thats basically a tap block at each site.

Our tap blocks are typically 20-30ml per side.

And who on earth takes 14 mins to do a tap block?? Our surgeons would flip out if it took that long

You have yet to cite a well-done RCT showing that TAP blocks are superior to port site infiltration for lap appy's. I'm still waiting.

I'm also waiting for you to answer my question about what mythical nerves you are anesthetizing with a TAP block that you aren't covering with port site infiltration. I am really curious to learn your expertise in nerve anatomy and abdominal wall innervation outside of what is written in anatomical textbooks. I am assuming you have authored a publication that is contrary to all of the anatomy books out there describing said mythical nerves and where they transverse from the neuraxis.

I will continue to wait.

 

[gunnershow]

You have yet to cite a well-done RCT showing that TAP blocks are superior to port site infiltration for lap appy's. I'm still waiting.

I'm also waiting for you to answer my question about what mythical nerves you are anesthetizing with a TAP block that you aren't covering with port site infiltration. I am really curious to learn your expertise in nerve anatomy and abdominal wall innervation outside of what is written in anatomical textbooks. I am assuming you have authored a publication that is contrary to all of the anatomy books out there describing said mythical nerves and where they transverse from the neuraxis.

I will continue to wait.

In theory, PNBs along the nerve trunk should last longer than infiltration along free nerve endings. The clinical effect of this for an infiltration block like TAP is probably marginal though.

 

[UscGhost]

You have yet to cite a well-done RCT showing that TAP blocks are superior to port site infiltration for lap appy's. I'm still waiting.

I'm also waiting for you to answer my question about what mythical nerves you are anesthetizing with a TAP block that you aren't covering with port site infiltration. I am really curious to learn your expertise in nerve anatomy and abdominal wall innervation outside of what is written in anatomical textbooks. I am assuming you have authored a publication that is contrary to all of the anatomy books out there describing said mythical nerves and where they transverse from the neuraxis.

I will continue to wait.

I am waiting as well. So far you posted a study that doesnt reflect the real world.

But let me know how it goes when you tell your surgeons to start injecting 40-50ml at their port sites. I am sure they will start right away.

Additionally, your logic doesnt line up.

Apparently, you think that local infiltration works. Ok. And we do know that a higher concentration and volume of injection will work better than lower.

So then, why would you think that a tap block (40-50 ML of 0.5 bupiv) wouldn't work....yet the 5ml per port site that most surgeons inject will somehow work just as well?

 

[Maz777]

I am waiting as well. So far you posted a study that doesnt reflect the real world.

But let me know how it goes when you tell your surgeons to start injecting 40-50ml at their port sites. I am sure they will start right away.

Thanks for telling me the answer I need.

You don't know what you are talking about and are not a subject matter expert.

Appreciate you. Your devotion to ignorance is commendable.

 

[Maz777]

In theory, PNBs along the nerve trunk should last longer than infiltration along free nerve endings. The clinical effect of this for an infiltration block like TAP is probably marginal though.

That does not make pharmacologic sense for a fascial plane block that requires LA to be spread out over a great distance. Only makes sense for a legitimate peripheral nerve block like a sciatic with subparaneural deposition. So, no, the theory does not make sense for TAP blocks.

 

[UscGhost]

Thanks for telling me the answer I need.

You don't know what you are talking about and are not a subject matter expert.

Appreciate you. Your devotion to ignorance is commendable.

Lol ooook

 

[PpfSuxTube]

I posted

I posted multiple studies showing a reduction in opiod use

Not sure why the non regional folks are so determined to flood their patients with dilaudid and then let them lay unconscious in pacu until they wake up nauseous.

Meanwhile the patients with regional are awake, happy and discharged.

Multimodal works

Who is flooding anyone with anything after an appy? This is surely hyperbole.

 

[Dantrolene FC]

Who is flooding anyone with anything after an appy? This is surely hyperbole.

I flood mine with Tylenol, Toradol, 0.5 mg of Dilaudid, and surgeon’s local. /s

 

[PpfSuxTube]

Exactly right, there isnt even time to give them opioid sometimes.
20 mins op so 0.5 Dilaudid. 2 hour pacu stay so max 2mg there... thats it...
Chole same.

Is there any data that shows someone becoming an addict after day surgery chole or appy?

I think we conflating two separate issues into one and adding drama to create a dilemma that doesn't exist...

Again as I said before, if this is cancer surgery or big incision stuff im all about regional for that but there has to be something else other than regular appy etc...

Where are all these hoardes of zombie junkies were creating? I guess we've all done hundreds if not thousands of chole/appys between us all and almost no one does blocks? So where is the issue?

I think a lot of this is either billing misadventures or someone trying to buy clicks and likes just like social media...

 

[UscGhost]

Exactly right, there isnt even time to give them opioid sometimes.
20 mins op so 0.5 Dilaudid. 2 hour pacu stay so max 2mg there... thats it...
Chole same.

Is there any data that shows someone becoming an addict after day surgery chole or appy?

I think we conflating two separate issues into one and adding drama to create a dilemma that doesn't exist...

Again as I said before, if this is cancer surgery or big incision stuff im all about regional for that but there has to be something else other than regular appy etc...

Where are all these hoardes of zombie junkies were creating? I guess we've all done hundreds if not thousands of chole/appys between us all and almost no one does blocks? So where is the issue?

I think a lot of this is either billing misadventures or someone trying to buy clicks and likes just like social media...

Who was talking about about addiction?

The initial discussion was whether they worked for pain control. Which multiple studies show that they do.

Then it was, well they work the same as local infiltration. Well, studies show that they work better.

Then it was, well our surgeons take 15 mins to do an appy and they inject 40ml at the port sites. Oook...but i would wager 99% dont inject anywhere close to that.

Then it was, well if the patient doesnt go home sooner, then it doesnt work. Even those discharge time is based on a dozen other factors.

Now its, well tap blocks dont reduce addiction??

Holy smokes people. Its a 3 min harmless procedure that reduces opiod use and improves pain control. Our appys take about an hr of op time. I give 50mcg fent on intubation, 25 at incision and 25 before extubating. Tylenol and toradol. Wide awake and pain free in pacu.

If i dont do a tap, then i will generally need to add another 100mcg fent or dilaudid. Pacu nurses are much happier with the patients that get blocks (less work for them)

Will a tap block help your pelvic exenteration go home on POD 0? Probably not. So lets temper our expectations a bit

 

[LivetoTell]

Sorry to side track. But are you guys being summoned to the ER (at all hours) to perform Peng blocks / fascia iliaca blocks for broken hips?
Thoughts?
Thanks

 

[PpfSuxTube]

Sorry to side track. But are you guys being summoned to the ER (at all hours) to perform Peng blocks / fascia iliaca blocks for broken hips?
Thoughts?
Thanks

Not summoned but yes we are immediately consulted on any hip fracture from emerg. This i definitely agree with. These lovely old folk are often writhing in agony but not safe for much opioid. Its a palliative block and procedure often to give them dignity in their last few weeks or months alive. Some cant clear secretions or even go to the washroom with the pain.

 

[gunnershow]

Not summoned but yes we are immediately consulted on any hip fracture from emerg. This i definitely agree with. These lovely old folk are often writhing in agony but not safe for much opioid. Its a palliative block and procedure often to give them dignity in their last few weeks or months alive. Some cant clear secretions or even go to the washroom with the pain.

What about when they come in overnight? Also is anyone familiar for billing for regional anesthesia *not* for postoperative pain control? Let's say rib fractures. What are the required elements? And for documentation, do you need a pre and postop evaluation and an "intraop" record?

 

[UscGhost]

Not summoned but yes we are immediately consulted on any hip fracture from emerg. This i definitely agree with. These lovely old folk are often writhing in agony but not safe for much opioid. Its a palliative block and procedure often to give them dignity in their last few weeks or months alive. Some cant clear secretions or even go to the washroom with the pain.

Is there any data that shows they will become an addict if we dont do a block and give opiods?

Does it reduce their length of stay?

 

[PpfSuxTube]

Is there any data that shows they will become an addict if we dont do a block and give opiods?

Does it reduce their length of stay?

No they die actually. Lots of data.
I know youre just trying to joke around but this probably isnt the one for u

 

[PpfSuxTube]

What about when they come in overnight? Also is anyone familiar for billing for regional anesthesia *not* for postoperative pain control? Let's say rib fractures. What are the required elements? And for documentation, do you need a pre and postop evaluation and an "intraop" record?

Partner dependant. If were still awake and free most of us go do them quick. We rolled out a program. The nurses on the ward bring all the stuff incl uss.

Rib # not as common but we used do sap block. Works well. Rarely epidurals but that was very rare

 

[UscGhost]

No they die actually. Lots of data.
I know youre just trying to joke around but this probably isnt the one for u

Lower mortality rates with peng/FI blocks? Addiction rates? Length of stay?

Links to those studies?

 

[PpfSuxTube]

Lower mortality rates with peng/FI blocks? Addiction rates? Length of stay?

Links to those studies?

Nope never said that. I said this was a palliative block/procedure. Literally wrote those words.

You're funny. You block the 20 yr old appy that makes no difference but deny the 90 yo nof# grandma with copd that cant use the washroom.

You can do or think as you wish. Ive said my say good luck. Ill never block an appy and I will always consider blocking a nof #. I dont care thats there's no mortality benefit. This is an end of life condition. I may not always block em if theyre robust but ill try help

 

[AdmiralChz]

Sorry to side track. But are you guys being summoned to the ER (at all hours) to perform Peng blocks / fascia iliaca blocks for broken hips?
Thoughts?
Thanks

Every few years someone asks us to consider this. But a few issues particularly those in care team models:

1) It's not part of the anesthetic so you need to have a free doc (not supervising) to do the block.
2) It pays pretty terribly, and commercial insurers are quickly doing away with paying for next day post-op pain visits.
3) Hip fractures happen at all time of the day including middle of the night, imagine driving in from home to do it at night.
4) Hospital wasn't much interested in supplemental pay for it.

So, we declined to do it. But a few of us worked with the ED folks, they have an ultrasound fellowship and they do the fascia iliaca blocks themselves - apparently it's a nice addition for their own billing and they have staff already present to do it.

Extra work like this is often requested by hospitals, since anesthesia billing blows be sure that the hospital is making it worth it to you. For some groups with very large stipends, you have several million reasons to do it already and suck it up. In general, hospital admins won't remember for very long the favors you do for them but they have elephant memories when it comes to things that make their jobs more obnoxious.

 

[Hoya11]

Nope never said that. I said this was a palliative block/procedure. Literally wrote those words.

You're funny. You block the 20 yr old appy that makes no difference but deny the 90 yo nof# grandma with copd that cant use the washroom.

You can do or think as you wish. Ive said my say good luck. Ill never block an appy and I will always consider blocking a nof #. I dont care thats there's no mortality benefit. This is an end of life condition. I may not always block em if theyre robust but ill try help

are you ever concerned that your block will somehow be blamed for contributing to their inevitable demise in the coming days?

What about when they come in overnight? Also is anyone familiar for billing for regional anesthesia *not* for postoperative pain control? Let's say rib fractures. What are the required elements? And for documentation, do you need a pre and postop evaluation and an "intraop" record?

i would think you do an acute pain consult note and a block and bill for both

 

[UscGhost]

No they die actually. Lots of data.
I know youre just trying to joke around but this probably isnt the one for u

Nope never said that. I said this was a palliative block/procedure. Literally wrote those words.

You're funny. You block the 20 yr old appy that makes no difference but deny the 90 yo nof# grandma with copd that cant use the washroom.

You can do or think as you wish. Ive said my say good luck. Ill never block an appy and I will always consider blocking a nof #. I dont care thats there's no mortality benefit. This is an end of life condition. I may not always block em if theyre robust but ill try help

Do only 20 year olds get appendicitis? What if they are 60..80? Copd? What if younger but hx of n/v with opiods? Chronic pain?

Since we no longer use the metrics of LOS and mortality...i am trying to figure out which patients deserve better pain control.

Certainly traveling to the ER to do a block is infinitely more time consuming. Need to travel, bring equipment, consent and interview a new patient, ED nurses unfamiliar with assisting...i know because i do those too.

 

[Arch Guillotti]

What about when they come in overnight? Also is anyone familiar for billing for regional anesthesia *not* for postoperative pain control? Let's say rib fractures. What are the required elements? And for documentation, do you need a pre and postop evaluation and an "intraop" record?

The required elements are somebody asking for it. Dictate a procedure note, have whoever document and record the vitals. I don’t create an anesthesia record. Don’t worry about what it pays because it probably is very little. Send to the billing people.

If all else fails just do what everyone else in the group does.

 

[PpfSuxTube]

are you ever concerned that your block will somehow be blamed for contributing to their inevitable demise in the coming days?

Not really.
We did a tonne of education with the orthopedic side and their nurses(not me, my partners). Everyone's on board with it now. Unless its like LAST or something there really isnt any scientific way any of these blocks could do that from the old school fem nerve block to the newer peng or sifi blocks...

I think the key to it is education and getting surgeons to buy into it. If you do things sporadically you may run into issues.

We had very poor hip# mortality rates worse than other centre's and now were improving.

Our biggest issue was bloody internal medicine thought they couldn't have the op until 5days off doac. Some of my old school colleagues also. Now were routinely getting everyone done inside 48 hrs

 

[Dantrolene FC]

Sorry to side track. But are you guys being summoned to the ER (at all hours) to perform Peng blocks / fascia iliaca blocks for broken hips?
Thoughts?
Thanks

My favorite is when I was consulted for a block on a patient who just arrived to the ER with a hip fracture from 5 days ago (it took him that long to make it to the hospital).

I talk to the guy and he said it hurts because they just moved him over and he wants something stronger than Tylenol.

It was a blind consult. Patient arrived to the ER and they blindly consulted us. But, in the ED’s defense, I’d rather be consulted immediately on admission at 8 pm while I’m awake than at 2 am when I’m asleep.

 

[Maz777]

Do only 20 year olds get appendicitis? What if they are 60..80? Copd? What if younger but hx of n/v with opiods? Chronic pain?

Since we no longer use the metrics of LOS and mortality...i am trying to figure out which patients deserve better pain control.

Certainly traveling to the ER to do a block is infinitely more time consuming. Need to travel, bring equipment, consent and interview a new patient, ED nurses unfamiliar with assisting...i know because i do those too.

You're really going to die on this hill, eh? As everyone else has said, doing any sort of block for a lap appy is universally agreed upon to be unnecessary and is not supported by any sort of literature. You are performing unnecessary procedures on patients, simple as that. I'm assuming this is a billing thing, so be sure your ducks are in a row. It's only a matter of time before this comes back to bite you in the ass. Someone eventually is going to narc on you and accuse you of billing fraud. Don't say we didn't warn you.

 

[Maz777]

Sorry to side track. But are you guys being summoned to the ER (at all hours) to perform Peng blocks / fascia iliaca blocks for broken hips?
Thoughts?
Thanks

Thankfully no longer. The ED guys eventually learned to do their own FI/PENG blocks after many years. The ED guys that did ultrasound fellowships got this going. None of us ever want to step a foot in the ED if you don't have to. When they finally come to the OR (and their overnight block has assuredly worn off), can be blocked again (but rarely necessary).

 

[UscGhost]

You're really going to die on this hill, eh? As everyone else has said, doing any sort of block for a lap appy is universally agreed upon to be unnecessary and is not supported by any sort of literature. You are performing unnecessary procedures on patients, simple as that. I'm assuming this is a billing thing, so be sure your ducks are in a row. It's only a matter of time before this comes back to bite you in the ass. Someone eventually is going to narc on you and accuse you of billing fraud. Don't say we didn't warn you.

Lol... billing fraud?

I just like poking the holes in the inconsistency.

The data is clear that they work. So then you said well you dont do them unless they reduce LOS. But evidently you are happy to do FI/peng blocks even they dont reduce LOS.

Then it was, well who cares if we need to give patients more opiods. Unless its a peng block, then we care.

Then it was..well hip fracture patients are old, so that why we block them. Ok, because all other lap abdominal cases are done on the young apparently.

Seems strange to me, to avoid doing a TAP block when the surgeons request them (as the OP was asking about), presumably because he sees them work. The data shows they work. They are easy and quick to do and extremely low risk.

But hey, i am sure your patients appreciate your eagerness to increase their opiod needs

 

[Maz777]

Lol... billing fraud?

I just like poking the holes in the inconsistency.

The data is clear that they work. So then you said well you dont do them unless they reduce LOS. But evidently you are happy to do FI/peng blocks even they dont reduce LOS.

Then it was, well who cares if we need to give patients more opiods. Unless its a peng block, then we care.

Then it was..well hip fracture patients are old, so that why we block them. Ok, because all other lap abdominal cases are done on the young apparently.

Seems strange to me, to avoid doing a TAP block when the surgeons request them (as the OP was asking about), presumably because he sees them work. The data shows they work. They are easy and quick to do and extremely low risk.

But hey, i am sure your patients appreciate your eagerness to increase their opiod needs

There are no data for lap appy's. You are extrapolating from surgeries that are more painful. You have yet to cite a single publication showing that TAPs are superior than infiltration for lap appy's. A single study. A. Single. Study.

There are, however, many, many studies investigating blocks for hip fracture patients.

I have no idea why you keep repeating your nonsense. There isn't a single other poster on here that agrees with you. But, hey, we're all idiots. You are the genius.

 

[UscGhost]

There are no data for lap appy's. You are extrapolating from surgeries that are more painful. You have yet to cite a single publication showing that TAPs are superior than infiltration for lap appy's. A single study. A. Single. Study.

There are, however, many, many studies investigating blocks for hip fracture patients.

I have no idea why you keep repeating your nonsense. There isn't a single other poster on here that agrees with you. But, hey, we're all idiots. You are the genius.

https://www.sciencedirect.com/science/article/pii/S1110184914000671

The ultrasound guided TAP block increased the mean time to the first analgesic requirement (10.4 ± 1.5 h) in comparison with the local infiltration group (5.4 ± 1.5). The cumulative number of doses of analgesic was significantly lower in TAP group than in local infiltration group (3.7 ± 1.1 versus 5.3 ± 2.1) and the Pain Scale score was significantly lower in the TAP group over the study period. Besides, there were no complications attributable to the ultrasound guided TAP block

There's one for ya. Also posted articles on lap chole, meta analyses on other laparoscopic procedure.

Are you arguing that the port sites are less painful in lap appy than lap chole, lap gyn and lap urology procedures? First your argument was that tap blocks dont work..now its that they work, just not for lap appys if they are young, healthy, and no history of opiod intolerance, and the surgeon must inject 40-50ml at the port sites

 

[AKMD_1984]

i don’t do tap block on lap appy and chole for the same reason i don’t order ekg’s and preop labs on athletes coming for low risk surgery. doesn't mean its wrong to get labs and EKG (and many facilities do without any thought), but its not necessary and will not change outcome from surgery or anesthesia.

 

[UscGhost]

i don’t do tap block on lap appy and chole for the same reason i don’t order ekg’s and preop labs on athletes coming for low risk surgery. doesn't mean its wrong to get labs and EKG (and many facilities do without any thought), but its not necessary and will not change outcome from surgery or anesthesia.

Young healthy patients don't deserve better pain control?

I Must have missed the ASA guidelines suggesting that we dont offer regional to young patients.

If i had to guess, i would say that many who dont do them just arent interested in the fact that they work.

Its that they arent compensated for them...and if the patients are young, they dont feel guilty not doing them since extra Dilaudid wont be that detrimental in a young pt, right?

 

[DoctwoB]

Exactly right, there isnt even time to give them opioid sometimes.
20 mins op so 0.5 Dilaudid. 2 hour pacu stay so max 2mg there... thats it...
Chole same.

Is there any data that shows someone becoming an addict after day surgery chole or appy?

I think we conflating two separate issues into one and adding drama to create a dilemma that doesn't exist...

Again as I said before, if this is cancer surgery or big incision stuff im all about regional for that but there has to be something else other than regular appy etc...

Where are all these hoardes of zombie junkies were creating? I guess we've all done hundreds if not thousands of chole/appys between us all and almost no one does blocks? So where is the issue?

I think a lot of this is either billing misadventures or someone trying to buy clicks and likes just like social media...

To be fair, plenty of data now that ~10-15% of patients sent home from surgery on narcotics will still be on them a year later. A lot of not "addicts" but medical chronic pain patients. Doesn't even seem to matter too much whether the initial surgery was a CABG or a ureteroscopy, clearly there is something in the pathophysiology of chronic pain that makes some more susceptible then others. So i am all in favor of anything to reduce post op narc use.

That said, i haven't seen any effect from TAPs, where they were done where i trained and not where i practice. I'm not against them in principle, but refuse them when asked in particular cases, because since it is not "protocol", im signing up for 20 extra minutes unless there is a specific reason. Plus i use plenty of local both before and after incisions.

Speaking of post-op pain, you guys having any luck getting suzetrigine available/approved?

 

[AKMD_1984]

Young healthy patients don't deserve better pain control?

I Must have missed the ASA guidelines suggesting that we dont offer regional to young patients.

If i had to guess, i would say that many who dont do them just arent interested in the fact that they work.

Its that they arent compensated for them...and if the patients are young, they dont feel guilty not doing them since extra Dilaudid wont be that detrimental in a young pt, right?

illogical statements and incorrect, irrelevant answer to the question asked - is it necessary?

last i checked, it’s not standard of care or even considered best practice that it needs/should be done unequivocally on all patients…