Advertisement - Members don't see this ad
At this point they’re just trolling. Multi-modal analgesia is a good thing and almost never the wrong answer
TAP blocks - yay or nay?
Started by spike7585
That's a little dismissive.
One can favor multi modal anesthesia and regional techniques without buying into the notion of TAP blocks for lap appys, or Exparel for brachial plexus blocks, or Bier blocks for carpal tunnels, or any number of things that some regional "gurus" advocate.
No one here is dismissing the appropriateness and utility of nerve blocks for shoulder and knee arthroplasties.
Gold standard was in quotes because the author used that term.
Epidurals certainly provide excellent pain control for Major abdominal procedures..the gold standard as you say. But then...the same author of the Cleveland study also published a study where he concluded that Taps provided similar pain control (clinically insignificant different in opiod requirements, per his own conclusions), with less hypotension. I personally think epidurals can and should provide better pain control, but the hypotension was always a big issue)
So a tap block doesnt work... but it works enough to be comparable to an epidural and a viable alternative? Seems contradictory opinions from the same author
Epidurals arent life threatening..but certainly much more risky than a tap block. We have all seen patients requiring blood patches. (After days of pain, return ED visit, additional procedures), retained catheter fragments, site infections, and even medication errors with the infusions. I have never seen or heard of a tap block complication.
Epidurals also take much more time and effort to place, require postop rounding, nursing care, dealing with hypotension, etc
Thats why small PP groups avoid placing epidurals.
Tap blocks? Massively less risk, complications, cost, logistics, time. That's why ASA recommends them. Risk/cost vs benefit.
Epidurals (random study)
During the study period, 5083 patients were interviewed and their details were recorded (98% capture rate). Sixty-nine (1.36%) experienced major complications: epidural hematoma in 1 patient (0.02%), post-operative neurologic deficits in 57 patients (1.12%), post-dural puncture headache in 7 patients (0.14%), and systemic local anesthetic toxicity in 4 patients (0.08%).
Advertisement - Members don't see this ad
That's all mostly fair.
I don't believe for a second that 1.12% of epidurals cause major neurologic deficits. That's just ridiculous on the face of it.
You think payers care one bit about the ASA panel. Haha No. They realize it’s all revenue for anesthesiologists. Payers already bundled some fascial plane blocks this year and ASA could do nothing to stop it. Taps blocks most certainly don’t have enough evidence to justify payment. They’ll bundle them and take away a separate payment. Then do them all you want but you won’t be getting paid for them
Oh i don't doubt insurance companies will try anything to cut payments. They also tried to cut us out from cataracts, and tried to tie payment to the procedure instead of time.
Not sure why you appear to be fixated on the idea that payment should drive the decision you make regarding care for your patients though.
In fairness - and I feel a little dirty agreeing with an insurance company - what do we really contribute to 98% of cataracts?
It's a rare cataract that needs more than a whiff of midazolam or fentanyl, and most of them probably need nothing at all.
If a patient is fit for a haircut, they can get a cataract done. Even our role as preop assessors of fitness for surgery is essentially irrelevant and unneeded for these cases. There's basically no medical condition short of an immediate life-threatening condition needing transport to an ER that would make me cancel a cataract.
I had it once....colonoscopy done by a surgeon directing a sedation RN. wasn't bad. Do I think that it is as good as Propofol administered by anesthesia personnel?...Not even close. Plus this was a long time ago. My sense is that the GI fellows and surgeons we've graduated in the last 20 or so years aren't that skilled in the former technique. Also the patients have only gotten fatter and sicker and patient expectations for "comfort" during this procedure have only gone up.
Only because the ophthos pushed back against the insurance companies did this ridiculous reimbursement for cataracts persist. Because if insurance didn’t pay us to do them, they’d have to hire sedation nurses in the ASCs and that would take away from their bottom line.
My schedulers know I will do literally any case there is to do in anesthesia except one- cataracts with topical anesthesia.
Anywho yeah TAPs for laparoscopic anything are bunk.
But as a result of this “guidance”‘we’ve now started to do parasternal blocks for hearts after dabbling for a while sporadically. Any experience with those out there? Seems like they have some efficacy with our low n. Maybe. Probably. Maybe.
Did them in residency. They did seem to do a decent job of managing the incisional pain from the sternotomy. But obviously they don’t to anything for the discomfort from the various chest tubes which also affected the patients.
I’m not really cheerleading for TAPs for laparoscopic cases but I’m not against an additional non-opioid method of analgesia that’s low risk. I don’t offer it up but if a surgeons requests one because they feel it helps I don’t say no. Again, most of our surgeons inject up to a max dose of local into the port sites so for the most part in our practice a TAP isn’t necessary
ive found some of the worst pain control protocols come from surgeons - very poor understanding, very high level of confidence.. but yes hard to say no to. i try to respectfully chip away at it over time and continue to give my opinion in hopes they may see the light. after a few conversations i think they start to see that they are discussing with someone with a higher level of understanding than they have and some of their minds become more open to your side
Advertisement - Members don't see this ad
After getting inspired by this thread, our practice has decided to start doing thoracic epidurals and attaching on q pumps to them so patients can go home with them. So far, so good. Zero pain. Although sometimes I'm struggling to put on the epidural in which case I am giving 50-100 iv fentanyl to help facilitate placement. But overall we are saving a ton of fentanyl, which is good because our Venezuelan suppliers are telling us to brace for potential shortages.
Question why you guys. Most superstar athletes who need surgery do not get regional anesthesia. Yet you guys will argue how effective interscalene and popliteal etc blocks work.
So why are you not insisting on doing nerve blocks on super star athletes or potential super star players? Even if the Asa task force says it’s good for them? So don’t believe everything the Asa task force says. I wont do any popliteal block on any known athlete who has aspirations for professional sports. So im ignoring the asa task force recommendations on pain control
So why are you not insisting on doing nerve blocks on super star athletes or potential super star players? Even if the Asa task force says it’s good for them? So don’t believe everything the Asa task force says. I wont do any popliteal block on any known athlete who has aspirations for professional sports. So im ignoring the asa task force recommendations on pain control
1. Obvious medicolegal risk/benefit ratios and individual risk/benefit ratios.
2. To an extent, the incidence of nerve injury depends on how hard one looks and how often a patient notices something. It wouldn't surprise me if a highly trained person such as an athlete might have a lower threshold for noticing loss of function that your typical patient wouldn't. I can't provide a reference, but there is some old literature showing changes in nerve conduction after upper extremity blocks in which patients had no clinical complaints.
As an analogy, whenever I get a patient who is a vocalist, radio announcer, etc. I always counsel them that because of their profession, they might have a higher incidence of temporary and permanent voice change for having their airway instrumented with an ETT or SGA.
This is the answer. Its pretty obvious...
$180M Orthopedic Malpractice Lawsuit Filed by NFL Player
Our physician-attorney is ready to provide an honest and thorough evaluation of your case when you call us or contact us online to receive a free consultation.
Probably the same time that you realize its recommended by the ASA...which means (drumroll)..its best practice
Asa is a joke. We all know that.
Tap blocks only treat somatic pain and only for a short period of time. They do nothing to treat visceral pain, Again read the Cleveland trial. There are no true lasting benefits if any at all.
Here’s another related study. https://www.sciencedirect.com/science/article/pii/S0952818025003198
Notice Sweden isn’t doing tap blocks. Just surgeon local. Half the patients with zero opioids came out with pain scores less than 4. And yes some still need opioids but again there is visceral pain with these surgeries Tap blocks do nothing for laparoscopic procedures and even in open procedures where I do favor something taps or otherwise there probably isn’t data to support
It’s all about multimodal, carb loading, early ambulating. Tap blocks for laparoscopic stuff just makes us look bad
Tap blocks only treat somatic pain and only for a short period of time. They do nothing to treat visceral pain, Again read the Cleveland trial. There are no true lasting benefits if any at all.
Here’s another related study. https://www.sciencedirect.com/science/article/pii/S0952818025003198
Notice Sweden isn’t doing tap blocks. Just surgeon local. Half the patients with zero opioids came out with pain scores less than 4. And yes some still need opioids but again there is visceral pain with these surgeries Tap blocks do nothing for laparoscopic procedures and even in open procedures where I do favor something taps or otherwise there probably isn’t data to support
It’s all about multimodal, carb loading, early ambulating. Tap blocks for laparoscopic stuff just makes us look bad
Just hit the ignore button. Kid is clearly just trolling now. No skilled, non-fraudulent anesthesiologist would do TAPs for a lap appy.
Those "regionalists" that do mostly fascial plane blocks are the same that struggle with actual nerve blocks, in my experience.
Lots of data to support. Posted multiple studies. Asa task force supports
Aww. Its ok. Change is hard. Any other asa task force recommendations that you ignore?
Yes. I read the Cleveland trial. I also read the trial from the same author when he concluded that TAPs are a suitable alternative to epidurals for a major abdominal procedures.
Most everyone ignores the recommendation to use quantitative twitch monitoring. And quite a few ignore the recommendation to use sugammadex over neostigmine.
There’s a preprint PDF available on the website once you log in and click “download PDF”
Yup. And i have come across many patients in pacu who had residual paralysis (when sugammadex wasnt used)...and data on residual paralysis has documented that. So docs certainly SHOULD be checking twitches when using gluco/neo
Would be a potential medicolegal liability as well if patient has a postop resp complication
Sugammadex is superior to neo and glyco in many (if not all) ways.. outside of cost.
This was an interesting thread to read. My own practice is to do TAP or other regional for larger sized incisions and not for port site sized incisions. Surgeons do local at port sites. The patients usually complain about shoulder pain more so than anything else, and this would not be addressed by a TAP block.
The exception would be for OB C-sections in patients getting duramorph and scheduled acetaminophen & ketorolac.
IIRC, in the C-Section population there is data to show that TAP did not improve pain scores or opioid consumption when multimodal analgesia was used IE duramorph, tylenol, ketorolac. In patients not able to use multimodal analgesia (eg. alpha gal syndrome & tylenol, ketorolac and NSAID allergy, duramorph and GA C-section), I’ll usually do a TAP block. Additionally, one might consider a TAP block for those patients on buprenorphine, other chronic opioids, or heavy weed users. AFAIK these particular cohorts of patients were not addressed in studies.
The exception would be for OB C-sections in patients getting duramorph and scheduled acetaminophen & ketorolac.
IIRC, in the C-Section population there is data to show that TAP did not improve pain scores or opioid consumption when multimodal analgesia was used IE duramorph, tylenol, ketorolac. In patients not able to use multimodal analgesia (eg. alpha gal syndrome & tylenol, ketorolac and NSAID allergy, duramorph and GA C-section), I’ll usually do a TAP block. Additionally, one might consider a TAP block for those patients on buprenorphine, other chronic opioids, or heavy weed users. AFAIK these particular cohorts of patients were not addressed in studies.
Advertisement - Members don't see this ad
Sedation and itching was always a big complaint after duramorph..hospital never has nubain, only Benadryl. We still used it though. OB docs ask for TAPS from time to time...but no ultrasound available in OB and hospital doesn't want to buy it
It’s a shame most OB nurses are scared to do this because a little dilute narcan works wonders for opioid itching
The real question is why can’t the surgeon do the tap block themselves. Many surgeons can do it.
this or similar people are the same Asa task force who met around 2010/2011 and couldn’t decide what bmi should be a general guideline to exclude from Stand a lone surfer centers.
It’s so money driven these days. The private ob c/s get tap blocks and the Medicaid ones don’t at one hospital I go to.
The private ones get running epidurals for post op pain management overnight and the Medicaid ones don’t.
There are some tap blocks I don’t mind doing like colectomy. But lap gb and appy is where I really draw the line.
Oh interesting. Never tried that. How often do you need to re-dose? .04mg ?
Oddly enough every time I’ve had to resort to this it really has only taken 1 40 mcg dose. Now that probably doesn’t make much pharmocologic sense but that’s been my anecdotal experience. In residency some post c section patients who were on post op dilute epidural pcas ( don’t ask that’s just what we did) would need an additional narcan pca
The protocol at a hospital I used to work at was 0.4 mg in a liter of LR, 100 mL bolus followed by 100 mL/hr. Seemed to work well, low N of personal observation for me though.
Odd question. Clear risk/benefit issue.
Elite athletes need and use every last muscle fiber and motor nerve and proprioceptive nerve because the margins for success/failure in what they do are so small. Delayed recovery might mean the difference between playing this season or next season.
Risk: The risk of even a tiny residual issue is going to be noticed by them. The differences in ability for an athlete to get cut or stay in any pro league are tiny. Suzie homemaker and Joe deskpilot ... nothing they do is likely to be seriously impacted by a residual deficit, and they might not even notice it at all.
Benefit: Arguably dramatically reduced. Pro athletes have made a career out of enduring physical pain in training and competition. Suzie homemaker and Joe deskpilot ... much more likely to expect and demand comfort at all times, however unreasonable and unrealistic that might be.
Lol so I assume you block all nfl players? And dont take consent preop either? If its best practice it would be malpractice to not do, so no consent needed
Is best practice the same as standard of care?
Since when would an elective procedure not require consent?
Do you routinely not follow ASA recommendations. Which other ones can we routinely ignore?
Lol nope. You think youre weak attempt to put me on trial is gonna wash?
Doesn't matter to me.
But you do appear confused. Your question suggested you think its malpractice if you dont use "best practices"..which of course..we all know is a different level of care than "standard care"
Then you suggested that you don't need consent for an elective procedure.
So of course, i wouldn't expect you to have an answer for which other ASA recommendations that you routinely ignore.
I TAP robotic laps (not appys) when appropriate and block most of my consented patients that are candidates for regional anesthesia. I’ll do ESP for thoracotomies as they are easy, quick and requires no positioning in lateral positioning.
We have a multimodal pre-op order set that is easy to implement and customize.
I used to f/u with my patients for TAPs when they first expanded to the adult population. Anecdotally some of my patients would tell me when the TAP wore off which was eye opening.
TAP and ACB I don’t feel are snake oil blocks but certainly not a dense fem/sciatic, BPB, lumbar plexus, etc. Has it’s place in the right circumstances. Not a silver bullet for sure. These blocks have no place for rescue blocks IMO.
Funny how things repeat themselves. Our hospital has initiated an opioid “free” program probably in response to our very respected Ortho private practice billboards stating the “first opiod free blah blah blah” in our part of the state. None of us are restricting ourselves to “opiod free”.
I think “opiod free” is too much, but I am definitely a believer in multimodal analgesia.
Some recent articles in Anesthesiology looking at cardiac (again).
journals.lww.com
We have a multimodal pre-op order set that is easy to implement and customize.
I used to f/u with my patients for TAPs when they first expanded to the adult population. Anecdotally some of my patients would tell me when the TAP wore off which was eye opening.
TAP and ACB I don’t feel are snake oil blocks but certainly not a dense fem/sciatic, BPB, lumbar plexus, etc. Has it’s place in the right circumstances. Not a silver bullet for sure. These blocks have no place for rescue blocks IMO.
Funny how things repeat themselves. Our hospital has initiated an opioid “free” program probably in response to our very respected Ortho private practice billboards stating the “first opiod free blah blah blah” in our part of the state. None of us are restricting ourselves to “opiod free”.
I think “opiod free” is too much, but I am definitely a believer in multimodal analgesia.
Some recent articles in Anesthesiology looking at cardiac (again).
2026 American Society of Anesthesiologists... : Anesthesiology
This practice guideline addresses perioperative pain management using local and regional anesthesia for cardiothoracic, mastectomy, and abdominal...
Re. Cardiac analgesia, the best thing that has changed in the last 20 years is ditching midaz inductions (or anything over 2mg while you’re placing an aline) and 1-2 mg of fentanyl for a case while bringing in methadone as well as some dex near the end of the case. I tried a series of ESPs for open cases and personally found them to not add very much.
My N was maybe 10- So insignificant beyond personal experience.
My N was maybe 10- So insignificant beyond personal experience.
Listen there's no problem with you not blocking nfl players etc with your sham block. We understand, no need to be so defensive
Depends...what team do they play for?
Advertisement - Members don't see this ad
That was good!
I didn’t care much for Charlie kirk.
My name is Shane Bowen and I am the Defensive Coordinator for The New York Football Giants.
