Transversus Abdominis Plane (TAP) Block
: Primarily used for acute postoperative abdominal pain with bilateral blocks covering midline surgical site. Best for incisional pain with unilateral coverage of the abdominal wall from dermatome T7 to L1 (most consistently T10 to L1) with each block. Ca
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David Ende and Jose Luis Zeballos
Indications: Primarily used for acute postoperative abdominal pain with bilateral blocks covering midline surgical site. Best for incisional pain with unilateral coverage of the abdominal wall from dermatome T7 to L1 (most consistently T10 to L1) with each block. Can be single shot or with catheter deployment for continuous pain control. May also be used as both treatment modality and diagnostic maneuver for anterior cutaneous nerve entrapment syndrome (ACNES). Equipment/Materials: Ultrasound with long linear high-frequency probe and sterile cover, skin antiseptic, sterile drape, 50 or 100 mm needle, 20 cc syringe, 25–30 cc local anesthetic (bupivacaine/ropivacaine) (0.25–0.5 % is a typical choice), +/− catheter, +/− Tegaderm, +/− tape (to secure catheter), and +/− steroid (methylprednisolone 40 mg).
CPT TAP block unilateral: 64486 TAP block unilateral with catheter: 64487 TAP block bilateral: 64488 TAP block bilateral with catheter: 64489 Ultrasound guidance: 76942 Professional service component modifier: 26 D. Ende, MD (*) • J.L. Zeballos, MD Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA, USA e-mail: [email protected]; [email protected]
Procedure Position: Supine IV: Required for risk of local anesthetic toxicity Antibiotics: Not required Steps 1. With the patient in supine position, expose the abdomen, and using skin antiseptic prep abdominal area from costal margin to the iliac crest extending all the way posteriorly to where patient’s flank meets the bed. 2. Place long linear ultrasound probe-oriented transverse to rectus muscles on the flank of the patient just above where patient’s flank meets the bed between the iliac crest and costal margin. 3. Identify the three typically well-defined muscular layers of the abdominal wall from superficial to deep: external oblique (EO), internal oblique (IO), and transversus abdominis (TA). Below the TA is the peritoneum and loops of bowel may be visualized. If having difficulty identifying all three layers, scan medially to the rectus muscle or posterolaterally to the quadratus lumborum to visualize origin of three layers as they separate and track back to injection site. 4. Once muscular layers are identified, identify target injection site. We find the best injection site is just medial to muscle layer origin coming off and separating from the quadratus lumborum.
© Springer International Publishing Switzerland 2017 R.J. Yong et al. (eds.), Pain Medicine, DOI 10.1007/978-3-319-43133-8_86
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5. Insert needle medially but in plane with ultrasound probe, and direct the tip posteriorly under probe and into the field of view, keeping the tip visualized throughout. Advance the tip to plane between the IO and TA (second and third muscle layers). 6. Aspirate from needle and if negative for blood, slowly inject total volume of chosen local anesthetic, watching spread on ultrasound. Ideal spread is to see TA “peel” off t
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