Should we stop TAP blocks?

Prospective blinded study To evaluate with US the placement of the needle tip and LA during TAP blocks using landmark-based double pop technique

TAP blocks
One of the techniques of abdominal wall nerve blocks Abdominal wall nerve blocks have been used in anaesthesia for surgery involving the anterior abdominal wall for several decades.

History
1980s A technique involving multiple injections of local anaesthetic in the abdominal wall was used
Atkinson R, Rushman G, Lee J. A synopsis of anaesthesia, 10th ed. Bristol: Wright, 1987: 637-640.

Blind landmark - lumbar triangle of Petit

Rafi AN. Abdominal field block: a new approach via the lumbar triangle. Anaesthesia 2001; 56: 10246

blunt needle make the loss of resistance more appreciable

st 1

pop
pop

20 30ml LA (any %) This block relies on LA spread rather than concentration

nd 2

TAP blocks
Provide excellent intra-op & post-op analgesia, decrease opioid requirement, allow patients to breathe and cough more comfortably, and facilitate early mobilization & discharge

TAP blocks

TAP blocks

TAP blocks
Is particularly useful for cases when an epidural is contraindicated or refused Can be performed unilaterally (e.g. appendicectomy), or bilaterally when the incision crosses the midline (e.g. Pfannenstiel) Single injection or catheter

Rescue analgesia

TAP block - Indications

Any surgery involves lower abdominal wall

bowel surgery
appendicectomy caesarean section hernia repair umbilical surgery gynaecological surgery

Concern regarding blind technique

Accuracy of placement of needle & LA

Potential damage to adjacent structure

TAP block - Complications

block failure intravascular injection injection into peritoneal cavity, with

associated risks of damage to bowel and other abdominal viscera

TAP block - Complications

Liver puncture

Colonic puncture

Methods
hospital ethic committee written informed consent Enrolment: 60 adult patients undergoing elective abdominal surgery
Exclusion criteria: infection at the proposed site of injection, coagulation disorders, allergy to bupivacaine, pregnancy, BMI > 35 & planned postoperative ICU care admission

Methods
All patients had standard monitoring & IV induction of GA Before placement of block, the area was prepared with chlorhexidine

An initial US scan of the area was performed by an experienced anaesthetic ultrasonographer

SonoSite 6 13 MHz linear probe (sterile sheath)

Methods
All TAP blocks were performed bilaterally by one of the six investigators
(3 consultant anaesthetist & 3 anaesthetist in training) Each of whom had performed a minimum of 50 landmark based TAP block

Double pop landmark technique

(mid point of the iliac crest & the costal margin in the mid-axillary line)

Blunt needle Plexufix 22g

Methods
After careful aspiration, 20ml of bupivacaine 0.25% was injected bilaterally

under real-time ultrasound imaging (out of plane technique) To detect the position of needle & spread of LAs

Methods
The ultrasonographer recorded

Images of pre and post injection of LA

Anatomical site of injection

subcutaneous tissue, external oblique muscle, plane between the external and internal oblique muscle, internal oblique muscle, TAP, transversus abdominis muscle, peritoneum

Methods

the anaesthetist performing the block was blinded to the ultrasound image

If the needle was in the peritoneum, the anaesthetist performing the block was alerted by the ultrasonographer and the procedure was repeated

Post op pain scores were not assessed

Statistical analysis
Logistic regression analysis
to explore the influence of patient age, sex, BMI, presence of stoma, and the level of experience of the anaesthetist performing the block (consultant vs trainee) on the likelihood of correct placement of the needle tip and local anaesthetic and the likelihood of

peritoneal placement.

Statistical analysis
Mann-Whitney & Fishers exact test
data analysis

Logistic regression analysis

to determine both patient and operator factors contributing to inaccurate needle placement

Results

Results
17 (23.6%)

13 (18%)

Results 32
15 VS 2

72 injections

40
13

Results
The only factor that predicted peritoneal injection was age after adjusting for training (consultant or not).

(P = 0.04), (OR = 1.13), 95% confidence interval (1.01, 1.26)

Patient BMI no effect on successful or BMI block-related complications were No and thickness of muscle layers or peritoneal placement ofrelationshiptip. peritoneal depth - no the needle noted.

Discussion
The placement of the needle tip and LA using the standard landmark-based approach to the TAP block is

inaccurate

The incidence of peritoneal placement

is unacceptably

high

Discussion

All trainees involved in the trial had performed > 50 blocks each

33 % peritonal injection rate

Discussion

Solution

Cost price

RM 35 / set

Polymedic Stimuplex

RM 38 / set RM 28 / set
Courtesy from Mr Asnan

Cost price
Locoplex Contiplex Tuohy
Ropi 0.75% Chirocaine 0.5% Marcaine 0.5%
RM 50 / set RM 121 / set RM 25 / amp RM 14.50 / amp RM 8.20 / vial

Cost price
DRUGS

Courtesy from Ching Ching, pharmacist Hospital Selayang 2010

PRICE (RM)
0.03 per tablet 0.20 per supp 0.20 per supp 1.77 per bottle 0.07 per tablet 0.79 per vial 1.50 per tube 0.57 per supp 0.03 per tablet 0.11 per tablet 0.03 per tablet 1.55 per bottle 4.40 per tube 0.60 per piece 0.07 per tablet 0.04 per capsule 1.70 per capsule 3.32 per tablet 1.87 per tablet 0.07 per capsule 0.95 per vial

T. PCM 500mg Supp PCM 125mg Supp PCM 250mg Syrup PCM 120mg/5ml (60ml) Aspirin 300mg solutablet Diclofenac injection 75mg/3ml Diclofenac acid gel 20g (Voren) Diclofenac sodium 25mg supp Diclofenac sodium 50mg tablet Meloxicam 7.5mg tablet Ibuprofen 200mg tablet Ibuprofen syrup 100mg/5ml (60ml) Ketoprofen 2.5% gel 30g Ketoprofen 30mg plaster Naproxen tablet 250mg Mefenamic acid 250mg capsule Celecoxib 200mg capsule Etoricoxib 120mg tablet Etoricoxib 90mg tablet Tramadol 50mg capsule Tramadol HCL 50mg/ml injection