TAP Blocks

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Shimmy8

Shimmy8

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Curious what drug/combos and volume other folks out there are using?
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Thanks. I know it probably doesn't truly matter, but I'm a new grad and pretty much have free reign to do whatever I want. And we had variable practices in my residency.
 
Volume is important for plane blocks. 30mL 0.5 bup + Dex. 30mL of 0.25 bup + Dex per side for bilaterals.
 
Do you guys get good results with TAPs? Most of my attendings in residency hated them and never used taps
 
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Like any block, whether it works depends largely on whether you're using it for the right indication. TAP blocks provide no visceral coverage, somatic only. So if you're hoping they're gonna be the bees knees for an ex-lap, you'll be sorely mistaken (or rather your patient will be...). On the other hand, they're great for inguinal hernias, supracervical hysterectomy, etc...

Personally though, I've stopped using TAP's entirely. Quadratus lumborum is a superior block in my opinion and not much harder to do usually. QL gives you more spread and also has visceral coverage.
 
acidbase1 said:
Do you guys get good results with TAPs? Most of my attendings in residency hated them and never used taps
Click to expand...

QL is gaining a lot of popularity here too but I think tap is much easier and quicker. I've had great results with tap blocks. They pretty much always work. Just had a 10 hour kidney pancreas transplant case. Didn't give any long acting narcs. Did tap blocks before extubation. Patient was so comfortable he snored thru transport and kept snoring in ICU.
 
QL take more time yes....you should have better spread/pain control though
 
Anaesthesia. 2017 Apr;72(4):452-460. doi: 10.1111/anae.13814. Epub 2017 Feb 11.
The analgesic efficacy of pre-operative bilateral erector spinae plane (ESP) blocks in patients having ventral hernia repair.
Chin KJ1, Adhikary S2, Sarwani N3, Forero M4.
Author information

Abstract
Laparoscopic ventral hernia repair is an operation associated with significant postoperative pain, and regional anaesthetic techniques are of potential benefit. The erector spinae plane (ESP) block performed at the level of the T5 transverse process has recently been described for thoracic surgery, and we hypothesised that performing the ESP block at a lower vertebral level would provide effective abdominal analgesia. We performed pre-operative bilateral ESP blocks with 20-30 ml ropivacaine 0.5% at the level of the T7 transverse process in four patients undergoing laparoscopic ventral hernia repair. Median (range) 24-h opioid consumption was 18.7 mg (0.0-43.0 mg) oral morphine. The highest and lowest median (range) pain scores in the first 24 h were 3.5 (3.0-5.0) and 2.5 (0.0-3.0) on an 11-point numerical rating scale. We also performed the block in a fresh cadaver and assessed the extent of injectate spread using computerised tomography. There was radiographic evidence of spread extending cranially to the upper thoracic levels and caudally as far as the L2-L3 transverse processes. We conclude that the ESP block is a promising regional anaesthetic technique for laparoscopic ventral hernia repair and other abdominal surgery when performed at the level of the T7 transverse process. Its advantages are the ability to block both supra-umbilical and infra-umbilical dermatomes with a single-level injection and its relative simplicity.
 
A A Case Rep. 2017 Jul 19. doi: 10.1213/XAA.0000000000000605. [Epub ahead of print]
Bilateral Continuous Erector Spinae Plane Block Contributes to Effective Postoperative Analgesia After Major Open Abdominal Surgery: A Case Report.
Restrepo-Garces CE1, Chin KJ, Suarez P, Diaz A.
Author information

Abstract
The erector spinae plane (ESP) block is a regional anesthetic technique involving local anesthetic injection in a paraspinal plane deep to the erector spinae muscle. Originally described for thoracic analgesia when performed at the T5 transverse process, the ESP block can provide abdominal analgesia if performed at lower thoracic levels because the erector spinae muscles extend to the lumbar spine. A catheter inserted into this plane can extend analgesic duration and can be an alternative to epidural analgesia. In this report, we describe using bilateral ESP catheters inserted at the T8 level to provide effective perioperative analgesia for major open lower abdominal surgery.
 
Has anyone had any experience/success with ESP single shots or catheters for major abdominal surgeries?
 
txhorn said:
Has anyone had any experience/success with ESP single shots or catheters for major abdominal surgeries?
Click to expand...

I'm doing some QL2 and QL3 blocks for major abdominal surgery. They work well and only require a single shot on each side. The coverage with QL2 or QL3 is excellent, T6-L1, so I'm questioning why one would choose an ESP over QL2.

I like TAP blocks (as described by Hebbard) or QL2 blocks for Abdominal surgery with a slight edge to the QL2 (anecdotal data of course).

Subcostal Transversus Abdominis Plane Block Under... : Anesthesia & Analgesia

http://www.anesthesiauniverse.net/sites/default/files/resources/Ultrasound_Guided_Continuous_Oblique_Subcostal.7_[1].pdf

The Analgesic Efficacy of Transversus Abdominis Plane Block ... : Anesthesia & Analgesia

Quadratus Lumborum Block Versus Transversus Abdominis Plane Block for Postoperative Pain After Cesarean Delivery: A Randomized Controlled Trial. - PubMed - NCBI


http://medcraveonline.com/JACCOA/JACCOA-06-00214.pdf (worth reading especially for the Exparel haters out there)
 
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Noyac said:
What do you do for the visceral discomfort these pts experience?
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QL Blocks seem to be "more dense" and may have a bit of visceral analgesia vs TAP blocks where there is none. Hence, with a TAP block sometimes narcotics are still needed in the PACU/postop.


it was later elucidated that the main advantage of the QL block was an extension of the local anaesthetic beyond the TAP-plane spreading into the thoracic paravertebral space with the provision of both visceral and somatosensory blockade of the abdominal wall [2]. There have been reports of excellent post-operative pain management with the QL block for both abdominal and retroperitoneal surgery [3,4] and a recent double-blinded RCT on the quadratus lumborum block for post-operative pain in caesarean section patients has shown promising results [5]

Ultrasound-guided Transmuscular Quadratus Lumborum (TQL) Block for Pain Management after Caesarean Section | ClinMed International Library | International Journal of Anesthetics and Anesthesiology
 
BLADEMDA said:
QL Blocks seem to be "more dense" and may have a bit of visceral analgesia vs TAP blocks where there is none. Hence, with a TAP block sometimes narcotics are still needed in the PACU/postop.


it was later elucidated that the main advantage of the QL block was an extension of the local anaesthetic beyond the TAP-plane spreading into the thoracic paravertebral space with the provision of both visceral and somatosensory blockade of the abdominal wall [2]. There have been reports of excellent post-operative pain management with the QL block for both abdominal and retroperitoneal surgery [3,4] and a recent double-blinded RCT on the quadratus lumborum block for post-operative pain in caesarean section patients has shown promising results [5]

Ultrasound-guided Transmuscular Quadratus Lumborum (TQL) Block for Pain Management after Caesarean Section | ClinMed International Library | International Journal of Anesthetics and Anesthesiology
Click to expand...
Sorry, but I don’t practice in the “seems to have more visceral coverage” world. I place epidurals. They work. Nothing worse than tomhave a nurse or surgeon calling you expecting the pain control of an epidural and you are trying to limp along with a bogus peripheral block. I like your regional prowess Blade but I call BS on this one.
 
Noyac said:
Sorry, but I don’t practice in the “seems to have more visceral coverage” world. I place epidurals. They work. Nothing worse than tomhave a nurse or surgeon calling you expecting the pain control of an epidural and you are trying to limp along with a bogus peripheral block. I like your regional prowess Blade but I call BS on this one.
Click to expand...

Have you tried a TAP block? I believed as you, before I tried/got proficient with TAP blocks.

You may never run into issues such as epidural not working, hypotension post op and calls from floor, LE motor weakness, maintaining the foley before epidural out, anticoag issues, etc., but most anesthesiologists do.

In my experience TAP blocks aren’t as great as epidurals, but they’re not far off. And the upside is worth getting good with them.
 
I was going to post this in the opiod sparring thread but i'll do it here:

I belive that if you can avoid using opiods per-operatively by whatever mean; i prefer some form of regional over esoteric infusions then the morphine you might need to give post-op will hit all those free receptors that have not been saturated or upregulated by a potent synthetic opiod and will result in a much stronger effect.
Typically when i do a TAP block pre-op i can count on no pain in PACU in a significant number of cases and the ones that receive morphine will get between 2 and 6mg 95%+ of the time. Which is acceptable to me.

Of course we don't have an opiod epidemic in Europe as you have in the US, so if my patient were all on chronic narcotic use and abuse an epidural might make more sense...
 
Noyac said:
Sorry, but I don’t practice in the “seems to have more visceral coverage” world. I place epidurals. They work. Nothing worse than tomhave a nurse or surgeon calling you expecting the pain control of an epidural and you are trying to limp along with a bogus peripheral block. I like your regional prowess Blade but I call BS on this one.
Click to expand...

Sorry, these are good blocks for post op pain control. The field of Regional anesthesia has advanced well beyond just Epidurals. While I still place an epidural from time to time my preference is to place a block like a TAP, QL, ESP or Serratus Plane for postop pain control. There are simply less issues postoperatively and no contraindications to anti-coagulation. Ambulation can begin almost immediately as well.
 
Continuous catheter infusion of transversus abdominis plane (TAP) block provides as satisfactory analgesia as epidural in the postoperative period for abdominal surgery.[1,2] Single shot ipsilateral quadratus lumborum (QL) block has been reported to provide effective analgesia for 24 h.[3] A case of continuous unilateral QL block was reported in pediatric surgery.[4] This is the first report of continuous bilateral use in an adult laparotomy.

An 89-year-old man presented for open right hemi colectomy with a midline incision. His co-morbidities were sick sinus syndrome and one recovered episode of mini stroke. His physical examination and investigations were unremarkable. A written informed consent was obtained for QL block infusion as part of multimodal analgesia. He was administered a standard uneventful general anesthesia. The peri-operative fentanyl used was 300 mcg in the operating room and 200 mcg in the recovery room. After the surgical procedure he was positioned supine with lateral tilt to administer QL block under the ultrasound (Sonosite Inc., Bothel, WA, USA) guidance. An 18 gauge Touhy's epidural needle was used to reach the junction of TAP and QL muscle. Normal saline 5 mL was used to identify that plane. A volume of 20 ml of 0.5% of Ropivacaine (Naropin-Astra Zeneca Sydney, NSW, Australia) bolus was injected in that plane just over QL [Figure 1]. This was followed by epidural catheter insertion to facilitate continuous infusion [Figure 2]. A similar technique was performed on the other side. A continuous infusion of 0.2% Ropivacaine at 5 ml/h was delivered by ‘On Q pain relief system’ pain buster pump (Kimberly Clark CA USA). On the pain scale of 0-10, the 1st h dynamic pain scores were 6 on arrival and reduced to 2 after 1 hr stay in recovery. The day 1 and day 2 dynamic pain scores were between 1 and 2. He was administered paracetamol- 1 g qid and tramadol- 100 mg tid. The only rescue medication used for 48 h was 10 mg of oxycodone. This QL block infusion has the advantage of covering pain arising from long incisions such as supra and infra umbilical regions without requiring multiple catheters. This could be due to spread of LA from QL and Psoas muscles to the paravertebral space covering more segments possibly from T4 to L2. Many case series or trials need to be conducted before confirming its efficacy.


Figure 1
Ultra sound image of the QL block with LA. EO = external oblique, IO = internal oblique, QL = Quadratus lumborum

Figure 2
Lateral tilt position QL block with secured catheter
In conclusion, ultrasound guided QL catheter infusion had low pain scores with minimal use of opioid analgesia without any complication.


Ultrasound guided quadratus lumborum block or posterior transversus abdominis plane block catheter infusion as a postoperative analgesic technique for abdominal surgery
 
The transverse abdominis plane (TAP) and quadratus lumborum 1 (QL1) blocks: anterior view. Injection of 20 mL of contrast in the TAP block resulted in the posterolateral spread from the 12th rib to the iliac crest. The QL1 block after injection of 20 mL of contrast resulted in the spread of the contrast toward the transverse process cephalad alongside the thoracolumbar fascia to the 11th and 10th intercostal spaces.

m_hadzic2_ch34_f001.png
 
"All previous works underlines the importance of US-guided TAP block for postoperative analgesia and its versatility in every type of abdominal surgery, through laparotomic and laparoscopic via: it reduces complication rate of opioid use, improves state-of-life of patients in first two days, allowing a faster recovery of bowel function without reduction of respiratory function, reduces length of in-hospital stay after surgery and corresponding costs."

Transversus Abdominis Plane Block: A New Gold Standard for Abdominal Surgery?


https://pdfs.semanticscholar.org/c044/0112916abcec1a65efb1c5a1b12bbd5a33cc.pdf
 
TAP: A New Standard for Abdominal Surgery?

Loran Mounir Soliman, MD, Cleveland, Ohio



bbraun_55_01.jpg
IN THE NEAR FUTURE, NERVE BLOCKS MAY BE AS PREVALENT IN ABDOMINAL SURGERY as they are today in orthopedic surgery. At least that's what our experience here at the Cleveland Clinic indicates. For two years, we have been performing transversus abdominus plane (TAP) blocks for pain control after abdominal surgery. These blocks have been so successful that we now are exploring their use for new different indications in a large percentage of our abdominal surgery cases.

TAP blocks produce a sensory block of the anterior abdominal wall — namely, the lower six thoracic and upper lumbar abdominal afferents. Just like peripheral nerve blocks, TAP blocks effectively control pain, reducing the need for opioids and related side effects like drowsiness and PONV. These patients also typically do not require epidurals, so we also avoid side effects like urinary retention, hypotension, and delayed ambulation due to compromised lower extremity motor function.

Our first foray into TAP blocks consisted of single-shot blocks for minor procedures like inguinal hernia repair. They were so successful that we soon started using continuous TAP blocks (with indwelling catheters for two to three days) for more extensive procedures like kidney transplants, hysterectomies and colostomy closures.

More recently, we began using TAP blocks to treat chronic post-surgical anterior abdominal wall pain, which can develop in 10%-30% of patients after inguinal hernia repair, cholecystectomy and other laparoscopic procedures due to activation of peripheral sensory neurons or direct nerve injury during surgery. Traditionally, patients with this kind of pain have had to undergo the epidural differential test. However the interpretation of the differential epidural test sometimes is very confusing. It is time consuming (takes few hours) and it carries the limitations and disadvantages of neuroaxial. On the other hand, the TAP block provides near immediate diagnostic feedback, so we can pinpoint the source of the chronic pain much faster.

Ultrasound has been a big factor in our success. Traditionally, TAP block technique was blind; we used a blunt needle and confirmed needle placement by feeling double "pops" as the needle passed through the external and internal oblique muscles and fascia. Now, with ultrasound, we can visualize the different layers of muscle and can see both the needle position and the injection. This has made the technique much more reliable. We still use a blunt needle for the reassuring tactile feedback.

TAP blocks are so effective, and they are easier than ever to administer. If our experience here is any indication, TAP blocks are destined to experience a rapid rise in popularity equivalent to that of peripheral nerve blocks. And that will be a good thing for patients and practitioners.

Reference
Ref: Ultrasound-guided transversus abdominus plan block for the management of abdominal pain: An alternative to differential epidural block. Techniques in Regional Anesthesia and Pain Management, 2009: Volume 13, Issue 3, Pages 117-120 L. Soliman, S. Narouze

Dr. Mounir Soliman is Staff Anesthesiology Section Head for Orthopedic Anesthesia and Director of the Regional Anesthesia Fellowship at the Cleveland Clinic, Cleveland, Ohio.
 
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