TAP Blocks Flashcards
(35 cards)
What 4 structures compose Petits Triangle
ASIS
Intercostal margin
External oblique
Latissimus Dorsi
Indications for Midaxillary/Posterior TAP block
T10-L1 Unilateral does not cross midline C sections Inguinal hernia repairs Appendectomies Exparel is approved for it as well as interscalene blocks
What type of pain does Midaxillary TAP block help with?
Somatic only; no visceral pain
Landmarks for Midaxillary/posterior TAP block?
Midline between costal margin and superior iliac crest
What can cause femoral nerve block with Midaxillary/Posterior TAP blocks/
Unintentional injection into transversalis fascia which is continuous plane with fascia iliaca
Needling for Midaxillary/Posterior TAP block
Needle from anterior–> posterior approach
Go in between internal oblique and transversus abdominis
What lies just underneath the transversus abdominis muscle
Transversalis fascia
Things that can improve needle tip visualization in Midaxillary/posterior TAP block
Challenging in large patients
Use 18 g touhy needle
Can be VERY deep
Place on ventilator with controlled respirations
Hydrodissect with NS
Rocking helps keep eye on needle because more parallel and improves needle insonization
What can be done to get longer block duration with Midaxillary/Posterior TAP?
Can add epi 1:400,000
Decadron 4mg/side can be added
Place catheters when possible
Exparel FDA approved
Why do we want to be as posterior as possible for Posterior/Midaxillary TAP block?
To get the lateral cutaneous and anterior cutaneous nerves before they separate
Volume of LA for Midaxillary/Posterior TAP block
30-40mL each side; dilute LA to 0.25% bupivicaine or 0.375% ropivicaine
Indications for subcostal TAP block?
T7-T12 often spares T12-L1
Beneficial for upper abdominal surgical procedures
Ventral or incisional hernias
Maybe in laprascopic cases but probably not because only gets somatic pain/no visceral pain
Good for surgeries above umbilicus
Volume of LA for subcostal TAP block?
20-30mL
What muscle is very thin in older people and why do you have to be cautious?
Transversus abdominis is very thin and you can rupture bowel
Needling for Subcostal TAP block?
Come in from medial aspect through rectus abdominis muscle and inject between internal oblique and transversus abdominis
Want to be as close to rectus muscle as possible
Complications with Subcostal TAP block
Bowel hematoma Transient femoral block Infection Last because high volume 20-30 mL each side Liver lac on R side Hematoma
IIndications for Ilioinguinal/Iliohypogastric block
Inguinal hernia repair
Testicular or scrotal surgery; only innervates base of penis; dorsal n (branch of the pudenal) innervates the rest of the penis
Targets L1 root (ilioinguinal/iliohypogastric)
L1 and L2 form genitofemoral n
Where is the best place to target L1 nerve
Posterior aspect because catch the lateral cutaneous branch before it exits
Landmark approach for Ilioinguinal/iliohypogastric
ASIS 2 cm medial and 2 cm superior; use blunt needle to feel piercing of planes
Loss of resistance technique through fascia layer
10mL in between transverse abdominis and internal oblique muscle
Indications for Rectus Sheath Block
T7-T11
Ventral/incisional hernias
Exploratory lap
Anything within 6 pack region
What is the arcurate line?
Where rectus sheath thins out and all muscles; internal, external and transversus come together
Ends at T12
Make sure to do block above arcurate line b/c less chance of puncturing bowel
Needle placement for rectus sheath
Anterior cutaneous nerves exit on lateral aspect of rectus sheath come in from lateral aspect of rectus muscle
Where is LA placed in rectus sheath block?
Between the rectus muscle and posterior rectus sheath
Why should you apply Doppler before injecting with rectus sheath?
The inferior epigastric artery
