visceral pain

[GaseousClay]

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so had a young female patient getting a laparoscopic hysterectomy, BSO, all coming out the vagina. pt very concerned about post op pain so I offered IT morphine + GA and she would be getting local at port sites. Surgeon scoffs when I tell her about spinal and states the whole reason we do it laparoscopically is because there is not much pain for this surgery. I ask her about visceral pain and she says thats not an issue. Patient ends up being in a good amount of pain after surgery and the next day and it really pissed me off. Not that the IT morphine would be so amazing for her but just that some surgeons are so ignorant...

 

[Velefunt]

Surgeon should "walk a mile" in her patient's shoes (i.e.: get a lap total hyst without ITN) and then comment.

 

[Spinach Dip]

It's surgeons like that who give all doctors a bad name.

 

[urge]

so had a young female patient getting a laparoscopic hysterectomy, BSO, all coming out the vagina. pt very concerned about post op pain so I offered IT morphine + GA and she would be getting local at port sites. Surgeon scoffs when I tell her about spinal and states the whole reason we do it laparoscopically is because there is not much pain for this surgery. I ask her about visceral pain and she says thats not an issue. Patient ends up being in a good amount of pain after surgery and the next day and it really pissed me off. Not that the IT morphine would be so amazing for her but just that some surgeons are so ignorant...

Intrathecal morphine for lap hysterectomy? Isn't that overkill? Can she go to the floor post op, or is she stuck in pacu?

 

[Wiscoblue]

Tap block plus intrathecal morphine (.15 mg) plus 30 mg of toradol.


Sent from my iPad using Tapatalk

 

[Arch Guillotti]

It's surgeons like that who give all doctors a bad name.

What do you mean?

 

[Oggg]

1. Some pts are gonna have pain. 2. Remind the surgeon the next time you see them that you followed up, and pt had pain, and maybe spinal and or Taps could be useful in certain pts on a case by case basis which you can discuss prior to each case. 3. You could've done postop rescue spinal or TAPs in PACU. Surgeons are more cooperative at that point.

 

[Planktonmd]

At the end of the day you are just a consultant offering an opinion to the surgeon on how you think his patient's post-op pain would be best managed, and unless you are the one managing the post-op pain you should avoid having this type of conflict.
If you insist on doing a procedure that the surgeon does not understand or does not want, don't be surprised if both the patient and the surgeon blame you for whatever complications might occur even if they are not related to your procedure.

 

[Hoya11]

so had a young female patient getting a laparoscopic hysterectomy, BSO, all coming out the vagina. pt very concerned about post op pain so I offered IT morphine + GA and she would be getting local at port sites. Surgeon scoffs when I tell her about spinal and states the whole reason we do it laparoscopically is because there is not much pain for this surgery. I ask her about visceral pain and she says thats not an issue. Patient ends up being in a good amount of pain after surgery and the next day and it really pissed me off. Not that the IT morphine would be so amazing for her but just that some surgeons are so ignorant...

why not just give her opiate through her IV? Seems like an unneccessary spinal. ALso would not do a TAP block for a laparoscopic procedure. Also TAP blocks only help with somatic pain. Unless your going to do a celiac plexus block for this lady, the only thing that will truly help her "visceral" pain is opiate, tylenol, nsaids. Maybe a little ketamine but I wouldnt in this population. Like i said i see no reason to put the MSO4 in her Csf rather than her bloodstream.

 

[BLADEMDA]

why not just give her opiate through her IV? Seems like an unneccessary spinal. ALso would not do a TAP block for a laparoscopic procedure. Also TAP blocks only help with somatic pain. Unless your going to do a celiac plexus block for this lady, the only thing that will truly help her "visceral" pain is opiate, tylenol, nsaids. Maybe a little ketamine but I wouldnt in this population. Like i said i see no reason to put the MSO4 in her Csf rather than her bloodstream.

I do TAP blocks all the time for Laparoscopic procedures. Most don't need any opioids as they receive Tylenol, Toradol and the TAP. Postop N/V is reduced and patient satisfaction is high with this technique.
If you utilize Exparel expect 40 hours plus of postop analgesia (up to 72 hours).

http://www.joacp.org/article.asp?is...=31;issue=1;spage=67;epage=71;aulast=Kawahara

http://www.ncbi.nlm.nih.gov/pubmed/24575769

 

[WholeLottaGame7]

why not just give her opiate through her IV? Seems like an unneccessary spinal. ALso would not do a TAP block for a laparoscopic procedure. Also TAP blocks only help with somatic pain. Unless your going to do a celiac plexus block for this lady, the only thing that will truly help her "visceral" pain is opiate, tylenol, nsaids. Maybe a little ketamine but I wouldnt in this population. Like i said i see no reason to put the MSO4 in her Csf rather than her bloodstream.

I was also skeptical about TAP blocks and laparoscopy until recently, and discovered there's a fair number of studies supporting it's use: http://www.ncbi.nlm.nih.gov/pubmed/?term=tap+block+and+laparoscopy

 

[BLADEMDA]

Tap blocks for Laparoscopic surgery are useful for those patients wanting or needing to avoid narcotics postop. Honestly, they help some but if you can tolerate a little morphine or a pain pill they aren't essential most of the time. That said, I do TAP blocks on about 1/3 of all patients presenting for some type of Laparoscopic surgery. The feedback from patients and surgeons is positive.

 

[Hoya11]

I was also skeptical about TAP blocks and laparoscopy until recently, and discovered there's a fair number of studies supporting it's use: http://www.ncbi.nlm.nih.gov/pubmed/?term=tap+block+and+laparoscopy

Those studies are pretty weak, but I did look at them as I am trying to be open minded about TAP blocks. It just doesnt make sense in my mind that a small little hole infiltrated with local would be worth the block. What makes more sense to me is that certain anesthesiologists/institutions are looking to build a case for doing more of these blocks for billing reasons. Thus "studies" are evolving. I think the TAP block is the facet block of anesthesia (meaning its easy to make a case for it but in reality very low yield and difficult to assess the efficacy). We need to be careful to do the right thing for the patient as sleazy money making practices are becoming more prevalent and scientists are looking to justify these procedures. I am starting to do them for post CS though. Hernia repair is a no-brainer since the abdominal wall is where the pain is. I have done a lot with great success for chronic abdominal pain related to the abdominal wall (scar issues after open lap surgery)

 

[Arch Guillotti]

That said, I do TAP blocks on about 1/3 of all patients presenting for some type of Laparoscopic surgery.

That number seems incredibly high.

I do think TAP blocks can be helpful in certain situations though.

 

[fakin' the funk]

Intrathecal morphine for a lap hyst BSO is totally overkill.

Pt ought to do fine with a little bit of IV opioid, APAP, ketorolac, local in the port sites, maybe TAP blocks.

 

[lakersbaby]

Intrathecal morphine for a lap hyst BSO is totally overkill.

Pt ought to do fine with a little bit of IV opioid, APAP, ketorolac, local in the port sites, maybe TAP blocks.

That is overkill as well. IT morphine arguably takes much less time to place than doing bilateral tap blocks. Both of which are unnecessary. The OP only seems to have considered this given the patients low threshold and fear of pain

 

[Random Anesthesiologist]

It's a small little hole but the muscle and fascia around it are so abused. Watch how much it gets torqued sometime, esp by residents that don't know how to drive a camera.

 

[narcusprince]

This may sound like overkill. My surgeons have had some higher pain scores for their bariatric patients. We started doing it morphine and the patients love it. Dropped his pain scores down to 2-3 for the first 24 hrs. Our patients go to the icu for the first 24 hrs. The spinal is placed 2-3 hrs before surgery due to the lovenox. Last patient transferred herself from the or table to the gurney. Remi/des acetaminophen, iv fentanyl 75-100mcg at end of case, exparel at trochar sites.

 

[deleted162650]

The CO2 for insufflation also gets absorbed and converted to carbonic acid by the peritoneum causing a mild peritonitis. This isanother reason why, despite excellent infiltration of port sites, pts can have a good bit of abdominal pain after laparoscopy.

 

[urge]

This may sound like overkill. My surgeons have had some higher pain scores for their bariatric patients. We started doing it morphine and the patients love it. Dropped his pain scores down to 2-3 for the first 24 hrs. Our patients go to the icu for the first 24 hrs. The spinal is placed 2-3 hrs before surgery due to the lovenox. Last patient transferred herself from the or table to the gurney. Remi/des acetaminophen, iv fentanyl 75-100mcg at end of case, exparel at trochar sites.

You are putting intrathecal morphine in bariatric patients?

I get visceral pain thinking about it.

 

[Pooh & Annie]

Intrathecal morphine for a lap hyst BSO is totally overkill.

Pt ought to do fine with a little bit of IV opioid, APAP, ketorolac, local in the port sites, maybe TAP blocks.

Agreed, with TAPs required RARELY.