TAP blockade - what's new? Jens Børglum - SSAI2017
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A talk by Jens Børglum at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All available content from SSAI2017: https://scanfoam.org/ssai2017/ Content delivered in collaboration between scanFOAM, SSAI & SFAI.
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TAP blockade - what's new? Jens Børglum - SSAI2017
- 1. TAP blockade – what’s new? by Ass. prof. Jens Børglum, MD, PhD Anaesthesiology, Zealand University Roskilde, Denmark
- 2. Conflict of interests: Supported by SECMA in Scandinavia
- 3. TAP blockade – what’s new? • Basically there is nothing new – a brief view of the history • What began as a so-called posterior TAP block initially evolved into new blocks – more anterior blocks • We are now again searching for various approaches that are more posterior • We now look more for visceral pain amelioration • Epidural block is on the decline in the Western world • Obstetric surgery is the exception • The holy grail is the thoracic paravertebral block – without actually being this!!! • We search for new approaches!
- 5. What about Abdominal Wall Blocks?
- 6. What about Abdominal Wall Blocks?
- 7. 4 kind of TAP block techniques currently in general use 1. Prof. O´Donnell & Prof. McDonnell (landmark based, triangle of Petit) • First movers, extensive dermatomal anaesthesia, long lasting effect • Primarily blind double pop technique, but also USG technique 2. Prof. Hebbard (oblique subcostal TAP block) • Aim: to anaesthetize all dermatomes Th6-Th12 • Insertion of catheters for continous pain management • Requires some time and extensive anatomical knowledge 3. Classical USG TAP block (anterior/middle axillary line) • Below the thoracic cage, above the iliac crest • Two injections, fast and easy • Primarily the lower abdomen Th10-Th12 • Perhaps the USG technique most frequently in clinical use today 4. Bilateral Dual TAP (BD-TAP) block (Børglum J & Jensen K) • 4 point ultrasound-guided strategy • Single-shot, fast and easy • Anaesthetizing all dermatomes from Th6-Th12 bilaterally
- 8. • Reg Anesth Pain Med. 2006 Jan-Feb;31(1):91. The transversus abdominis plane (TAP) block in open retropubic prostatectomy. O'Donnell BD, McDonnell JG, McShane AJ. • Reg Anesth Pain Med. 2007 Sep-Oct;32(5):399-404. Transversus abdominis plane block: a cadaveric and radiological evaluationMcDonnell JG, O'Donnell BD, Farrell T, Gough N, Tuite D, Power C, Laffey JG. • Anesth Analg. 2007 Jan;104(1):193-7. The analgesic efficacy of transversus abdominis plane block after abdominal surgery: a prospective randomized controlled trial. McDonnell JG, O'Donnell B, Curley G, Heffernan A, Power C, Laffey JG. • Anesth Analg. 2008 Jan;106(1):186-91, table of contents. The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial. McDonnell JG, Curley G, Carney J, Benton A, Costello J, Maharaj CH, Laffey JG. Prof. O’Donnell BD & Prof. McDonnell JG – Triangle of Petit • Two injections • Both blind, landmarked-based & USG blocks in the Triangle of Petit • Extensive scientific evidence for positive effects • Double pop technique • Extensive dermatomal anaesthesia • Long lasting effect
- 9. Prof. Hebbard PD – The Oblique Subcostal TAP block • Reg Anesth Pain Med. 2010 Sep-Oct;35(5):436-41. Ultrasound-guided continuous oblique subcostal transversus abdominis plane blockade: description of anatomy and clinical technique. Hebbard PD, Barrington MJ, Vasey C. • Disection technique • Ultrasound-guided technique • Aims to anaesthetize the entire abdominal wall (Th6-Th12(L1)) • Continuous anaesthesia • A catheter can be placed along the oblique subcostal line in the transversus abdominis plane for continuous infusion of local anesthetic. Multimodal analgesia and intravenous opioid are used in addition because visceral pain is not blocked. Continuous oblique subcostal transversus abdominis plane block is a new technique and requires both a detailed knowledge of sonographic anatomy and technical skill for it to be successful.
- 10. Oblique Subcostal TAP block
- 11. Oblique Subcostal TAP block
- 12. The Classical TAP block • Br J Anaesth. 2009 Jun;102(6):763-7. Epub 2009 Apr 17. Ultrasound-guided transversus abdominis plane block: description of a new technique and comparison with conventional systemic analgesia during laparoscopic cholecystectomy. El-Dawlatly AA, Turkistani A, Kettner SC, Machata AM, Delvi MB, Thallaj A, Kapral S, Marhofer P. • Anesth Analg. 2007 Sep;105(3):883; author reply 883. Transversus abdominis plane block. Shibata Y, Sato Y, Fujiwara Y, Komatsu T. • Ultrasound-guided technique • Above the pelvic crest and below the costal margin • Anterior/medial axillary line • Aim to anaesthetize as much of the abdominal wall as possible • Simple to understand, simple to execute • Probably the technique preferred by most physicians • Anatomical structures are clearly visible • Two injections
- 13. Bilateral Dual - Transversus abdominis plane (TAP) block Katrina Webster; Royal Hobart Hospital, Australia: The Transversus Abdominis Plane (TAP) block: Abdominal Plane Regional Anaesthesia
- 15. The Bilateral Dual TAP (BD-TAP) block • Large branch communications anterolaterally (intercostal plexus) – Th6-Th9 • Large branch communications in plexuses that run with the deep circumflex iliac artery (DCIA) (TAP plexus) – lower lateral abdomen – Th10-Th12 (L1) • Large brance communications that run with the deep inferior epigastric artery (DIEA) (rectus sheath plexus). Th6-Th12 (L1)
- 16. The Bilateral Dual TAP (BD-TAP) block (Børglum J et al. Reg Anesth Pain Med. 2012 May-Jun;37(3):294-301)
- 17. Upper Intercostal TAP block (Th6-Th9)
- 18. Lateral Classical TAP block (Th10-Th12)
- 19. (Børglum J et al. Reg Anesth Pain Med. 2012 May-Jun;37(3):294-301) The Bilateral Dual TAP (BD-TAP) block
- 23. TEQUILA BLOCK: The Transmuscular Quadratus Lumborum (TQL) block – Where, When, Why and How?
- 25. Source: LSORA > The Blanco block: a Quadratus lumborum block The Blanco block – the first QL block
- 26. Carney et al – the ”posterior approach”
- 30. The Quadratus Lumborum muscle
- 31. The Quadratus Lumborum muscle
- 32. The Quadratus Lumborum muscle
- 33. Transmuscular Quadratus Lumborum Block = TQL Block = Tequila Block
- 34. Transmuscular Quadratus Lumborum (TQL) Block
- 35. Transmuscular Quadratus Lumborum (TQL) Block
- 40. Transmuscular Quadratus Lumborum (TQL) Block
- 43. Posterior Anterior Transverse Oblique Paramedian = TOP TQL block
- 44. Anterior Posterior Transverse Oblique Paramedian = TOP TQL block
- 51. L4
- 52. L4
- 53. • WHEN: Indicated for abdominal and retroperitoneal surgery • WHERE: Administered between QL and PMM • WHY: Spreads to the Thoracic Paravertebral Space • WHY: Alleviates visceral pain • WHY: Long lasting effect > 24 hours • HOW: It’s obvious – the TEQUILA way!
- 54. Thank you for listening…… any questions?
Editor's Notes
- Most of us first read about the Blanco block, Rafa´s block or the QL block from the LSORA website. Dr Blanco had in oral presentations described how he had begun to administer a USG QL block at the lateral border of the QL muscle when he examinied the possible effect of the landmark based double-pop technique at the triangle of Petit as the first TAP block was described. Blanco found the block to be very effective and longlasting.
- The Blanco block – or as Carney et al named it – the posterior approach described the spread of local anaesthetic using MRI. The spread was predominantly posterior with contrast found in the paravertebral space as high as Th5 and caudad to L1.
- Most of us first read about the Blanco block, Rafa´s block or the QL block from the LSORA website. Dr Blanco had in oral presentations described how he had begun to administer a USG QL block at the lateral border of the QL muscle when he examinied the possible effect of the landmark based double-pop technique at the triangle of Petit as the first TAP block was described. Blanco found the block to be very effective and longlasting.
- Most of us first read about the Blanco block, Rafa´s block or the QL block from the LSORA website. Dr Blanco had in oral presentations described how he had begun to administer a USG QL block at the lateral border of the QL muscle when he examinied the possible effect of the landmark based double-pop technique at the triangle of Petit as the first TAP block was described. Blanco found the block to be very effective and longlasting.
- Most of us first read about the Blanco block, Rafa´s block or the QL block from the LSORA website. Dr Blanco had in oral presentations described how he had begun to administer a USG QL block at the lateral border of the QL muscle when he examinied the possible effect of the landmark based double-pop technique at the triangle of Petit as the first TAP block was described. Blanco found the block to be very effective and longlasting.
- The quadratus lumborum muscle has given the name to this new block. Many physicians I know have forgotten that the muscle actually exists. It has its embryonic origien in the thoracic cage as it springs from the 12th costa. This fact is rather important as I will explain later, and it is also important that the muscle attachs medially at the transverse processes L1-L4. The quadratus lumborum can perform four actions: Lateral flexion of vertebral column, with ipsilateral contraction Extension of lumbar vertebral column, with bilateral contraction Fixes the 12th rib during forced expiration Elevates the Ilium (bone), with ipsilateral contraction
- The quadratus lumborum muscle has given the name to this new block. Many physicians I know have forgotten that the muscle actually exists. It has its embryonic origien in the thoracic cage as it springs from the 12th costa. This fact is rather important as I will explain later, and it is also important that the muscle attachs medially at the transverse processes L1-L4. The quadratus lumborum can perform four actions: Lateral flexion of vertebral column, with ipsilateral contraction Extension of lumbar vertebral column, with bilateral contraction Fixes the 12th rib during forced expiration Elevates the Ilium (bone), with ipsilateral contraction
- The quadratus lumborum muscle has given the name to this new block. Many physicians I know have forgotten that the muscle actually exists. It has its embryonic origien in the thoracic cage as it springs from the 12th costa. This fact is rather important as I will explain later, and it is also important that the muscle attachs medially at the transverse processes L1-L4. The quadratus lumborum can perform four actions: Lateral flexion of vertebral column, with ipsilateral contraction Extension of lumbar vertebral column, with bilateral contraction Fixes the 12th rib during forced expiration Elevates the Ilium (bone), with ipsilateral contraction
- Most of us first read about the Blanco block, Rafa´s block or the QL block from the LSORA website. Dr Blanco had in oral presentations described how he had begun to administer a USG QL block at the lateral border of the QL muscle when he examinied the possible effect of the landmark based double-pop technique at the triangle of Petit as the first TAP block was described. Blanco found the block to be very effective and longlasting.
- Most of us first read about the Blanco block, Rafa´s block or the QL block from the LSORA website. Dr Blanco had in oral presentations described how he had begun to administer a USG QL block at the lateral border of the QL muscle when he examinied the possible effect of the landmark based double-pop technique at the triangle of Petit as the first TAP block was described. Blanco found the block to be very effective and longlasting.
- Most of us first read about the Blanco block, Rafa´s block or the QL block from the LSORA website. Dr Blanco had in oral presentations described how he had begun to administer a USG QL block at the lateral border of the QL muscle when he examinied the possible effect of the landmark based double-pop technique at the triangle of Petit as the first TAP block was described. Blanco found the block to be very effective and longlasting.
- Most of us first read about the Blanco block, Rafa´s block or the QL block from the LSORA website. Dr Blanco had in oral presentations described how he had begun to administer a USG QL block at the lateral border of the QL muscle when he examinied the possible effect of the landmark based double-pop technique at the triangle of Petit as the first TAP block was described. Blanco found the block to be very effective and longlasting.
- Most of us first read about the Blanco block, Rafa´s block or the QL block from the LSORA website. Dr Blanco had in oral presentations described how he had begun to administer a USG QL block at the lateral border of the QL muscle when he examinied the possible effect of the landmark based double-pop technique at the triangle of Petit as the first TAP block was described. Blanco found the block to be very effective and longlasting.
- The local anaesthetic is deposited between the QL and PM muscles. It then spreads cranially below the transversalis fascia up to the lateral and medial acuate ligamnents. It further spreads cranially to the thoracic paravertebral place. This is possible since the QL and PM muscles have their embryonic origin in the thoracic cage and since the transversalis fascia is continuous with the endothoracic fascia.