TAP Block berbasiskan penyebaran obat anestetik lokal; jika digunakan utk blok neurolitik kimiawi???? cenderung high risk, blm ada evidence • analgesia rescue • blok diagnostik • nyeri inguinal (groin pain), ilioinguinal neuralgia, nerve entrapment dinding abdomen

1. TA P B L O C K :
C L I N I C A L A P P L I C AT I O N F O R PA I N
M A N A G E M E N T
d r. P r y a m b o d h o , S p A n K A R
D e p . A n e s t e s i o l o g i & Te r a p i I n t e n s i f , F K U I - R S C M , J a k a r t a

2. !

3. TA P B L O C K
• Transversus Abdominis Plane (TAP) Block
• injeksi obat anestetik lokal pada TAP
• ruang anatomik potensial antara otot internal oblique
dan otot transversus abdominis
• “RAFI = regional abdominal field infiltration” oleh Rafi
(2001)
• modifikasi menjadi TAP block oleh McDonnel (2004)

4. Transversus Abdominis Plane

5. Transversus Abdominis Plane

11. TA P B L O C K
• anestesia/analgesia dinding abdomen lateral s.d
anterior
• dermatom : T7-T12 + L1
• n. thorakal 7 - 12 + n. ilioingunal + n.iliohipogastrik
• blok unilateral sesuai lokasi injeksi
• tanpa anestesia/analgesia organ viseral abdomen

12. I N D I K A S I TA P B L O C K
• analgesia ajuvan/multimodal intraoperatif &
pascaoperatif
• posterior TAP Block :
• operasi abdomen bawah :
• sectio caesarea, histerektomi (ginekologi),
appendektomi, hernioplasti, radikal
prostatektomi, liposuction, abdominoplasti,dll
• subkosta TAP Block :
• operasi abdomen di atas umbilikus

13. K O N T R A I N D I K A S I TA P B L O C K
• Relatif :
• koagulopati
• operasi di area injeksi
• Absolut :
• pasien menolak
• alergi terhadap obat anestetik lokal
• infeksi lokal di area injeksi

14. K O M P L I K A S I
• blok gagal
• injeksi intraperitoneal
• cedera hepar
• cedera saluran cerna
• intoksikasi obat anestetik lokal

15. O B AT A N E S T E T I K L O K A L
• volume :
• ≥ 20 mL untuk satu sisi
• 0,3-0,6 ml/kg/sisi
• pilihan obat :
• Lidokain : 0,5 - 2 %
• Bupivakain & Levobupivakain: 0,125 - 0,5%
• Ropivakain : 0,2 - 0,5%
• pertimbangkan volume dan total dosis anestetik lokal, tidak melewati
batas dosis maksimal yg direkomendasikan :
• Lidokain : 5-7 mg/kgBB
• Bupivakain & Levobupivakain: 3-5 mg/kgBB
• Ropivakain : 3-5 mg/kgBB

16. P E R A L ATA N
• Troley/set resusitasi
• Monitor bedside (EKG, pulse oksimeter, TD)
• Antiseptik kulit dan sarung tangan steril
• Jarum blok/bevel pendek (30o
) kaliber 21-24G, 50 – 100 mm,
atau jarum Tuohy 16-G needle
• Kateter ekstensi jarum
• 20 ml syringe
• USG + probe high freq (bila ada)

17. T E K N I K L A N D M A R K
( B L I N D )

18. T E K N I K L A N D M A R K
( B L I N D )
• Triangular of Petit (TOP)

19. T E K N I K L A N D M A R K
( B L I N D )
• Triangular of Petit (TOP)
• Rafi (2001) : dalam TOP,
“single pop”

20. T E K N I K L A N D M A R K
( B L I N D )
• Triangular of Petit (TOP)
• Rafi (2001) : dalam TOP,
“single pop”
• McDonnel (2004) :
cephalad dari krista iliaka
di TOP, “double pop”

21. T E K N I K L A N D M A R K
( B L I N D )

22. T E K N I K L A N D M A R K
( B L I N D )
Jankovic Z. Transversus abdominis plane block: The
Holy Grail of anaesthesia for (lower) abdominal
surgery. Period Biol, Vol 111, No 2, 2009; 203-8.

23. • Success rate : 23,6 - 85%
T E K N I K L A N D M A R K
( B L I N D )
Jankovic Z. Transversus abdominis plane block: The
Holy Grail of anaesthesia for (lower) abdominal
surgery. Period Biol, Vol 111, No 2, 2009; 203-8.

24. • Success rate : 23,6 - 85%
• Posisi TOP antar individu
sangat bervariasi
T E K N I K L A N D M A R K
( B L I N D )
Jankovic Z. Transversus abdominis plane block: The
Holy Grail of anaesthesia for (lower) abdominal
surgery. Period Biol, Vol 111, No 2, 2009; 203-8.

25. • Success rate : 23,6 - 85%
• Posisi TOP antar individu
sangat bervariasi
• Ukuran TOP relatif kecil
T E K N I K L A N D M A R K
( B L I N D )
Jankovic Z. Transversus abdominis plane block: The
Holy Grail of anaesthesia for (lower) abdominal
surgery. Period Biol, Vol 111, No 2, 2009; 203-8.

26. • Success rate : 23,6 - 85%
• Posisi TOP antar individu
sangat bervariasi
• Ukuran TOP relatif kecil
• Landmark alternatif yg
disarankan : posterior dari
garis mid-aksilar pada area
cephalad dari krista iliaka
atau di LIP (latissimo-iliac
point)
T E K N I K L A N D M A R K
( B L I N D )
Jankovic Z. Transversus abdominis plane block: The
Holy Grail of anaesthesia for (lower) abdominal
surgery. Period Biol, Vol 111, No 2, 2009; 203-8.

27. • Success rate : 23,6 - 85%
• Posisi TOP antar individu
sangat bervariasi
• Ukuran TOP relatif kecil
• Landmark alternatif yg
disarankan : posterior dari
garis mid-aksilar pada area
cephalad dari krista iliaka
atau di LIP (latissimo-iliac
point)
T E K N I K L A N D M A R K
( B L I N D )
Jankovic Z. Transversus abdominis plane block: The
Holy Grail of anaesthesia for (lower) abdominal
surgery. Period Biol, Vol 111, No 2, 2009; 203-8.

28. • Success rate : 23,6 - 85%
• Posisi TOP antar individu
sangat bervariasi
• Ukuran TOP relatif kecil
• Landmark alternatif yg
disarankan : posterior dari
garis mid-aksilar pada area
cephalad dari krista iliaka
atau di LIP (latissimo-iliac
point)
T E K N I K L A N D M A R K
( B L I N D )
Jankovic Z. Transversus abdominis plane block: The
Holy Grail of anaesthesia for (lower) abdominal
surgery. Period Biol, Vol 111, No 2, 2009; 203-8.

29. T E K N I K
D I PA N D U U S G
• Pendekatan Posterior
• studi cadaver : penyebaran
obat T10 - L1

30. T E K N I K
D I PA N D U U S G
• Pendekatan Posterior
• studi cadaver : penyebaran
obat T10 - L1

31. T E K N I K
D I PA N D U U S G
• Pendekatan Posterior
• studi cadaver : penyebaran
obat T10 - L1

33. EOM
IOM
TAM
RAM

34. EOM
IOM
TAM
RAM

35. TAM
IOM
EOM
EOM
IOM
TAM
RAM

36. EOM
IOM
TAM

37. EOM
IOM
TAM

38. EOM
IOM
TAM

39. T E K N I K
D I PA N D U U S G
• Pendekatan subkosta
• penyebaran obat T7-T11

40. TAM
PC
RAM

41. TAM
PC
RAM

42. TAM
PC
RAM

43. TAM
PC
RAM
RAM
TAM
OEM
LS
PC

44. TAM
PC
RAM
RAM
TAM
OEM
LS
PC

45. TAM
PC
RAM
RAM
TAM
OEM
LS
PC

46. TAM
PC
RAM
RAM
TAM
OEM
LS
PC
TAM
IOM
EOM

47. TAM
PC
RAM
RAM
TAM
OEM
LS
PC
TAM
IOM
EOM

48. TAM
PC
RAM
RAM
TAM
OEM
LS
PC
TAM
IOM
EOM

49. TAM
PC
RAM
RAM
TAM
OEM
LS
PC
TAM
IOM
EOM

50. TAM
PC
RAM
RAM
TAM
OEM
LS
PC
TAM
IOM
EOM

51. TAP injections could be classified as follows : (Hebbard P, 2014)
• Upper subcostal TAP
• deep to the rectus
• mainly covering T7 and T8
• Lower subcostal TAP
• lateral to rectus
• mainly covering T9, T10 and T11
• Lateral TAP
• midway between costal margin and iliac crest in
the mid-clavicular line
• mainly covering T11 and T12
• Ilio-inguinal TAP
• near the iliac crest lateral to the anterior superior
iliac spine
• mainly covering T12 and L1
• Posterior TAP
• injections in the TAP in the area of the triangle of
Petit

52. TA P B L O C K K O N T I N Y U
( D E N G A N K AT E T E R )
• evidence: variasi hasil pro & kontra
• kateter bilateral/unilateral
• bagian dari multimodal analgesia pascaoperatif
• kecepatan infus anestetik lokal yg pernah dilaporkan
dlm jurnal: 2 - 10mL/jam/kateter

53. E V I D E N C E B A S E D
• teknik single shot - menghasilkan analgesia
(multimodal) yg baik dlm 24 s.d 48 jam pascaoperatif
• mengurangi kebutuhan opioid pascaoperatif, dan ES
terkait opioid (PONV, sedasi)
• tidak inferior dibandingkan epidural kontinyu;
analgesia baik dinding abdomen, tidak pengaruhi
fungsi berkemih dan fungsi motorik tungkai bawah

54. TA P B L O C K U N T U K N Y E R I K R O N I K ?
• TAP Block berbasiskan penyebaran obat anestetik
lokal; jika digunakan utk blok neurolitik kimiawi????
cenderung high risk, blm ada evidence
• analgesia rescue
• blok diagnostik
• nyeri inguinal (groin pain), ilioinguinal neuralgia, nerve
entrapment dinding abdomen

55. TA K E H O M E M E S S A G E S

56. R E F E R E N S I
1. Townsley P, French J. Transversus Abdominis Plane Block Anaesthesia Tutorial Of The Week 239. Updated September 5th,
2011. Available at https://www.aagbi.org/sites/default/files/239%20Transversus%20Abdominus%20Plane%20Block.pdf
2. Rafi AN. Abdominal Field Block: a New Approach Via The Lumbar Triangle. Anaesthesia 2001;56:1024-6
3. Rafi AN. Abdominal field block via the lumbar triangle revisited. Anaesthesia 2012;67:1399-1401
4. McDonnell JG, O’Donnell BD, Tuite D, et al. The Regional Abdominal Field Infiltration Technique Computerised
Tomographic and Anatomical Identification of a Novel Approach to the Transversus Abdominis Neuro-Vascular Fascial
Plane. Anaesthesiology, 2004; 101: A899
5. Jankovic Z. Transversus abdominis plane block: The Holy Grail of anaesthesia for (lower) abdominal surgery. Period Biol,
Vol 111, No 2, 2009; 203-8.
6. Børglum J, Abdallah FW, McDonnell JG, Moriggl B, Bendtsen TF. TAP block terminology, Anaesthesia, 2014; 69: 1055-6
7. McDermott G, Korba E, Mata U, et al. Should we stop doing blind transversus abdominis plane blocks? Br J Anaesth
2012;108:499-502.
8. Charlton S, Cyna AM, Middleton P, Griffiths JD. Perioperative transversus abdominis plane (TAP) blocks for analgesia after
abdominal surgery. Cochrane Database of Systematic Reviews 2010, Issue 12. Art. No.: CD007705. DOI:
10.1002/14651858.CD007705.pub2.
9. Young, M.J., Gorlin, A.W., Modest, V.E., Quraishi, S.A. Clinical implications of the transversus abdominis plane block in
adults. Anesthesiology Research and Practice. 2012;2012:11 (Article ID: 731645).
10. De Oliveira, G.S., Castro-Alves, L.J., Nader, A. et al, Transversus abdominis plane block to ameliorate postoperative pain
outcomes after laparoscopic surgery: a meta-analysis of randomized controlled trials. Anesth Analg. 2014;118:454–463.

57. T E R I M A K A S I H