TAP Blocks

Started by Metalblade
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Metalblade

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Just learning to do TAP blocks. Wondering about a few things ...

I've read about the Lateral/classic approach and the subcostal approach. My understanding is that the lateral block will cover T10 and below. Does the subcostal approach cover T7-L1? Or would that mean two blocks on each side (lateral and subcostal) in order to get coverage from T7-L1?

Secondly, what are you guys using for local? I don't have access of Exparel. And what volume on each side? Are you adding any adjuvants - decadron, clonidine, etc? How many hours or pain relief are you getting roughly?

Thank you all.
 
We just use 0.5% bupivicaine for unilateral and 0.25% for bilateral. 20-30ml per side. We used Exparel for a while but absolutely saw no difference to even a worse block even with the most beautiful tap blocks. Usually do subcostal as it wastes time to do lateral especially for bilateral. Just keep supine and do both sides and stay at one side of the patient. Have been getting anywhere from 10-16 hours if its a good block.
I don't think this block does anything for anything above the umbilicus whether it be lateral or subcostal. Definitely a waste of time for laparoscopic cases as those port sites have more benefit with bupivicaine injected directly at incision sites.
 
Couple of points -

Above the umbilicus - use rectus sheath blocks ....works better as subcostal TAPS are spotty. Use about 15 cc each side (rectus sheath and TAP) so 60cc total. For a really high incision, add a serratus block.

If you can't get the facia to split, go below fascia instead of above - seems to work better.

When you DO get Exparel, I would try it a bunch. Some (as mentioned) have not had good outcomes, but that hasn't been our experience. We just presented our data at AAPM - we showed a huge decrease in length of stay (when compared to epidurals), decreased cost, increased return of bowel function, decreased ICU time. Our biggest findings was since we started using TAPS with it, our use of epidurals have dropped significantly. The issue is you need to mix it with something (Exparel) because unmixed, it doesn't seem to spread well in the fascial plane (like a thing of peanut butter). And better if you mix with local so you get an immediate effect (which you won't see with straight Exparel and it will seem like it doesn't work). If you mix WITH local, there is no way it is going to be worse than with just local straight.
 
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I knew a surgeon in residency that would insist on it for all his inguinal hernias, one or two sided. 0.25% bupiv, 30mL/side. His feedback when he saw them in clinic is that they didn't touch a pain pill, narcotic or otherwise, for up to 3 days post-op.

I sold an older surgeon on them when I forced the issue to let me do it on a prisoner who had a heroin history, complete with tattoos of drug paraphernalia on his forearms. I didn't want him to break his two year remission hunting down drugs in the prison. I did it, and he had no pain for days, and didn't have to hunt for narcotics.

Those subcostals can be a bit of a problem. We called them four-point blocks and did 15mL at each corner at 0.25%. First four-point I did for a full midline laparotomy I didn't get a good view on a subcostal, and may have missed the plane. Patient was comfortable for save for that missed corner. Attending hit him for another 10mL and turned of the pain like a switch.
 
Ronin2258 said:
TAPs bilaterally on the lower abdomen quadrants, and TAP/subcostal bilaterally on the upper quadrants. Bought a few who refused/couldn't have a epidural at least a day or so of pain control.
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I do them as close to the incision as possible, wherever I get the best view, and stand on one side of the patient for both blocks. I go way lateral if anatomy is distorted by surgery or body habitus. I find these to be a hit or miss, with a hit being ~50% of the time, but I have not found even successful blocks to be a miracle, and I think doing them for silly laparoscopic procedures or minimally open procedures (ing hernia repair with a good surgeon) to be overkill and mostly done for billing purposes. Id use 30ml of 0.5% bupi/ropi diluted to 40-45cc and give 20 on each side.
 
epidural man said:
And better if you mix with local so you get an immediate effect (which you won't see with straight Exparel and it will seem like it doesn't work). If you mix WITH local, there is no way it is going to be worse than with just local straight.
Click to expand...

Well considering a vial of Exparel is 266 mg of Bupivicaine, if you dilute it with 30 mls of 0.25% bupivicaine (75 mg) you are giving the patient a massive total dose of bupivicaine so your risk of local anesthetic toxicity has to go way up (relatively speaking).
 
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Great replies so far. Thank you. It seems TAPs cover well below the umbilicus. Any preference for lateral or subcostal approach? Also, do clonidine or decadron prolong these blocks like they do peripheral nerve blocks?
 
Regarding adding dexamethasone. We are experimenting with enhanced recovery for colon resections using TAP blocks. We placed catheters bilaterally and dosed after surgery 20 mL 0.5% ropivacaine mixed with 5 mg dexamethasone per side on a chronic pain patient (Crohn's). Tested the block level and after 24 hours we still had a T9 and T10 level. I believe we only had to redose every other day.
 
Impromptu said:
Regarding adding dexamethasone. We are experimenting with enhanced recovery for colon resections using TAP blocks. We placed catheters bilaterally and dosed after surgery 20 mL 0.5% ropivacaine mixed with 5 mg dexamethasone per side on a chronic pain patient (Crohn's). Tested the block level and after 24 hours we still had a T9 and T10 level. I believe we only had to redose every other day.
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You don't need to add decadron to the mixture. Give it IV in the same dose, you will have the exact same results.
 
Question as far as spread.

I always hear "make sure the muscles separate." I don't recognize a huge difference either way though be it in the muscle or in the plane. How do you really know you're in the plane based on spread?
 
Impromptu said:
Regarding adding dexamethasone. We are experimenting with enhanced recovery for colon resections using TAP blocks. We placed catheters bilaterally and dosed after surgery 20 mL 0.5% ropivacaine mixed with 5 mg dexamethasone per side on a chronic pain patient (Crohn's). Tested the block level and after 24 hours we still had a T9 and T10 level. I believe we only had to redose every other day.
Click to expand...
At what level do you insert the catheter for colon surgery? Subcostal or traditional?
 
image1.png
 
My success for Open Abdominal wall surgeries requires using the 4 point Tap block as described by Hebbard. Here are the keys to a successful Abdominal wall block T8-T12:

1. Subcostal Block for dermatomes above the Umbilicus. I do a Rectus Sheath block with 3-5 mls combined with 10 mls for the TA fascial plane betwen the RA and TA muscles (see picture)

2. Traditional Tap for dermatomes at the Umbilicus and below. I place 15 mls in the TAP plane (see picture).

My mixture is Exparel 266mg (20 mls) with 40 mls of PF NS +/- decadron. This cocktail works like a charm and provides 36-40 hours of good, postop analgesia.

IMHO, the only way to get 48 hours of postop analgesia with Exparel is to inject all 266 mg (20 mls) undiluted into the TAP plane. I have never gotten more than 48 hours of analgesia from a single shot TAP block utilizing Exparel.
 
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Subcostal TAP Block
Initially we were using a mid-axillary approach for our TAP blocks for our patients undergoing upper abdominal surgery and we had a higher than expected failure rate. After reading Peter Hebbard’s article describing the subcostal approach for TAP blocks (Hebbard P. Subcostal transversus abdominis plane block under ultrasound guidance. Anesth Analg. 2008;106:674.), we tried this technique and our results were markedly improved. We have also found this approach is easier and faster so we now use this approach for all of our surgeries above the umbilicus.


Posted by Theresa Bowling on 10/24 at 01:15 PM in
 
Wow thanks Blade. Very useful papers. Now, from what I understand you are injecting 3-5cc into the posterior rectus sheath, and then moving lateral and injecting 10cc into the oblique subcostal plane, as described by Hebbard? These are two separate injections on one side, am I correct? And then you do a third injection on each side laterally (the traditional TAP) to get the dermatomes below the umbilicus.
 
Metalblade said:
Wow thanks Blade. Very useful papers. Now, from what I understand you are injecting 3-5cc into the posterior rectus sheath, and then moving lateral and injecting 10cc into the oblique subcostal plane, as described by Hebbard? These are two separate injections on one side, am I correct? And then you do a third injection on each side laterally (the traditional TAP) to get the dermatomes below the umbilicus.
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I do the Rectus Sheath and Subcostal Tap block with one needle stick. I'm able to vary the angle of the needle to get the rectus sheath then the TAP via the subcostal approach. I perform the Lateral/Traditional TAP with a second needle stick. This way the patient gets two sticks per side for T7-T12 coverage.

Some Gurus recommend a separate Rectus Sheath stick if coverage of the T7 dermatome is crucial for postop analgesia. For most patients a few mls of local in the posterior rectus sheath followed by moving the needle a bit more lateral to get the TAP plane between the Rectus Sheath and TA muscles allows excellent postop analgesia.
 
Ignatius J said:
Question as far as spread.

I always hear "make sure the muscles separate." I don't recognize a huge difference either way though be it in the muscle or in the plane. How do you really know you're in the plane based on spread?
Click to expand...

This is a great questions...lots of questions remain.

I will say that when you do get that perfect picture (a split fascia) it is very obvious and clear picture of that characteristic lenticular looking split.
 
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Blade-

Regarding Exparel and time...

I have had patients in the plane clinic deceive clear numbness for over 3 days. I did a saphenous and it lasted more than 5 days.

On one thoracic medial scapular and trapezius trigger points I did, the patient said their face was numb for 4 days. That is some impressive fascial plane spread (I do trigger points under ultrasounds so get a good amount in fascial planes).

It may have to do with nerve location.
 
epidural man said:
Blade-

Regarding Exparel and time...

I have had patients in the plane clinic deceive clear numbness for over 3 days. I did a saphenous and it lasted more than 5 days.

On one thoracic medial scapular and trapezius trigger points I did, the patient said their face was numb for 4 days. That is some impressive fascial plane spread (I do trigger points under ultrasounds so get a good amount in fascial planes).

It may have to do with nerve location.
Click to expand...


I'm not disagreeing with you here. IMHO, I've used over 500 bottles of Exparel for TAP and Adductor Canal blocks. Even when I don't dilute the Exparel the analgesia doesn't seem to extend past 48 hours for those blocks. Since my "N" is still relatively low for making any concrete statements I'll leave it at that.
FYI, I did a saphenous nerve block with 0.5% Bup plus decadron and the patient reported "numbness"in that nerve distribution for 5 days after the block.
 
epidural man said:
Blade-

Regarding Exparel and time...

I have had patients in the plane clinic deceive clear numbness for over 3 days. I did a saphenous and it lasted more than 5 days.

On one thoracic medial scapular and trapezius trigger points I did, the patient said their face was numb for 4 days. That is some impressive fascial plane spread (I do trigger points under ultrasounds so get a good amount in fascial planes).

It may have to do with nerve location.
Click to expand...
Are you billing for using an ultrasound for a trigger point?
 
BLADEMDA said:
I'm not disagreeing with you here. IMHO, I've used over 500 bottles of Exparel for TAP and Adductor Canal blocks. Even when I don't dilute the Exparel the analgesia doesn't seem to extend past 48 hours for those blocks. Since my "N" is still relatively low for making any concrete statements I'll leave it at that.
FYI, I did a saphenous nerve block with 0.5% Bup plus decadron and the patient reported "numbness"in that nerve distribution for 5 days after the block.
Click to expand...

No I agree that maybe 3 days is stretching it for a TAP.

I think it is strictly a mass effect. I absolutely believe that technology works as proposed...meaning that it does release the drug over 72 hrs. The reason a TAP doesn't work is not because there isn't buoivicaine being released still, more likely it isn't enough for the last day to make a difference. In a small adductor canal space, it probably is a different story for two or thre small nerves. How many nerves need to be covered for a TAP? 14?

Alternatively, maybe the liposome works different in different parts of the body.
 
Blade, I assume you are using 64488 to bill for bilateral TAP blocks? And does this include the bilateral Rectus Sheath blocks as well or is there a separate code for that as well? And what is the unit value for this?

Also, just did a TAP/Rectus sheath block using your technique for a Lap Sigmoidectomy. Worked well. I used total 60 cc of .25 Bupiv with 8mg Decadron, as we do not have exparel on formulary. I got about 20 hours out of it. Thank you.
 
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The hebbard oblique subcostal technique uses a 6" tuohy in thin patients, two insetions, with 60-80ml total local deposited in subcostal and classic TAP. Margin of error seems less because it forces you to hydrodissect a long distance which helps confirm the proper plane. Downside is that you run out of needle in big patients and everyone is scared ****less of the 6" tuohy. Search for BD TAP or bilateral dual TAP, and that is the description of a regular tuohy, 4 insertions, 15ml per side. Decadron prolongs the block. The new papers saying IV decadron is just as good are crap
 
BLADEMDA said:
I'm not disagreeing with you here. IMHO, I've used over 500 bottles of Exparel for TAP and Adductor Canal blocks. Even when I don't dilute the Exparel the analgesia doesn't seem to extend past 48 hours for those blocks. Since my "N" is still relatively low for making any concrete statements I'll leave it at that.
FYI, I did a saphenous nerve block with 0.5% Bup plus decadron and the patient reported "numbness"in that nerve distribution for 5 days after the block.
Click to expand...
Wow Blade, you personally have given that company over $150,000 for a drug that is still looking for a place in practice.
 
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