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Transversus Abdominis Plane Blocks: An Overview of Indication and Nursing Care
Original Article Transversus Abdominis Plane Blocks: An Overview of Indication and Nursing Care ---
-
Salima S. J. Ladak, RN(EC), BScN, MN, Jiao Jiang, RN(EC), BScN, MN, and Marie Ojha, RN(EC), BScN, MN
ABSTRACT:
Transversus abdominis plane (TAP) blocks are an evolving regional anesthesia technique used as part of postoperative pain management regimens after major abdominal surgery. This article reviews TAP block insertion techniques, commonly used local anesthetics, and recommends nursing care related to TAP blocks. Ó 2013 by the American Society for Pain Management Nursing
INTRODUCTION
From the University Health Network, Toronto General Hospital Acute Pain Service, Toronto, Ontario, Canada. Address correspondence to Salima S. J. Ladak, RN(EC), BScN, MN, University Health Network, Toronto General Hospital Acute Pain Service, Toronto, M5G 2C4 Ontario, Canada. E-mail: [email protected] Received January 4, 2012; Revised April 3, 2013; Accepted April 4, 2013. 1524-9042/$36.00 Ó 2013 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2013.04.005
Although knowledge about acute pain and technology associated with its management have increased, patients continue to experience significant pain after surgery. Approximately 50% of patients report moderate to severe pain within the first 5 postoperative days (Watt-Watson et al., 2010). Uncontrolled postoperative pain can result in deleterious effects in the quality of recovery, including pulmonary infections, myocardial ischemia and infarctions, thromboembolism, impaired immune function, paralytic ileus, and anxiety. Additionally, uncontrolled pain can lead to decreased patient satisfaction, increased recovery time, prolonged hospitalization, and additional cost to the healthcare system (Gandhi, Heitz & Viscusi, 2011; Polomano, Dunwoody, Krenzischek, & Rathmell, 2008). There is also a risk of developing persistent postsurgical pain long after the expected postoperative recovery period (Pasero, 2011). The use of multimodal therapy is the mainstay for preventing postoperative complications related to uncontrolled pain. Multimodal analgesia is the combination of different analgesics that work along different pathways and sites along the nervous system, which produces an additive or synergistic effect with lowered analgesia related side-effects compared with using individual analgesics alone (Buvanendran & Kroin, 2009; Joshi, 2005). For example, opioids remain the primary analgesic most suited for treating moderate-to-severe postoperative pain. However, when used as the sole analgesic, opioids can have significant doserelated side-effects such as nausea and vomiting, dizziness, drowsiness, urinary retention, and constipation, thereby delaying recovery (Joshi, 2005). Therefore, combining opioids with other analgesics that target different pain pathways may reduce such unwanted side-effects. Over the last two decades, regional anesthesia techniques have gained popularity and are often included when applicable as Pain Management Nursing, Vol -, No - (--), 2013: pp 1-5
2
Ladak, Jiang, and Ojha
part of the multimodal analgesia approach. Regional anesthesia is a type of pain management technique that results in sensory blockade to part of the body when local anesthesia is infused to a group of nerves that innervate that region of the body (Krenzischek, Dunwoody, Polomano & Rathmell, 2008). This paper describes the regional anesthesia technique, review of analgesic efficacy, and nursing care associated in the management of patients receiving transversus abdominis plane (TAP) blocks after surgery. Anatomy Initially described in 1993, the TAP block is an expanding regional anesthesia technique that provides analgesia to the parietal peritoneum as well as the skin and muscles of the anterior abdominal wall (Mukhtar, 2009; Young, Gorlin, Modest, & Quraishi, 2012). The goal of the TAP block is to deposit local anesthetic in the plane between the internal oblique and transversus abdominis muscle layers, resulting in the interruption to the innervation of the abdominal skin, muscles, and parietal peritoneum. Sensory blockade using the TAP block method can range between T7 to L1 (Mukhtar, 2009) (Fig. 1). Insertion Technique TAP blocks can be inserted by anesthesiologists utilizing surface anatomical landmarks, (i.e., ‘‘blind’’ or by using ultrasound guidance) or can be inserted by surgeons through direct visualization before the end of a surgical procedure. During the procedure, two ‘‘pops’’ (i.e., loss of resistance) are expected at entry into the plane between external and internal oblique muscles and at entry into the plane between internal
FIGURE 1. - Anatomy of the transversus abdominis plane, Copyright Ó 2008 Ultrasound for Regional Anesthesia, Toronto Western Hospital.
oblique and transversus abdominis muscles (i.e., the TAP plane) (Ultrasound for Regional Anesthesia, 2008). A blunt needle will make such pops more apparent, especially during a ‘‘blind’’ insertion. With ultrasound guidance the deposition of local anesthetic can be accurately placed in the correct neurovascular plane (Ultrasound for Regional Anesthesia, 2008). To extend the analgesia beyond the duration of a single shot of local anesthetic, an indwelling catheter can be placed (Mukhtar, 2009). Such catheters can be placed either with ultrasound by anesthesiologists or under direct vision by the surgeon prior to the completion of surgery. The catheter(s) can be covered with transparent dressing so that the insertion site can be assessed, or be secured with steri-strips, sutures, or through a tunnelled technique. Approximately 10% of catheters may migrate out; however, no significant difference has been previously reported in the three securing methods in relation to accidental catheter migration. However, catheters may migrate out more readily if they are in situ for a prolonged period of time (i.e., 4 or more days). Additional abdominal binders prevent migration in some procedures, such as deep inferior epigastric perforator incisions, but are not practical for other procedures such as liver resection. Local Anesthetic Administration Using TAP Blocks Although local anesthetic agent, volume, concentration, and delivery method are different among studies (Young, Gorlin, Modest & Quraishi, 2012), bupivacaine, ropivacaine, and levobupivacaine have been commonly used for the TAP blocks (Barash et al., 2009). For instance, 0.25% bupivacaine can be administered at 0.5 mg/kg per TAP catheter every 12 hours in patients who have normal hepatic function. While the maximum recommended dose of bupivacaine for peripheral nerve blocks is 400 mg/day (Lexicomp Online, 2013), lower doses are administered in clinical practice, ranging from 0.5 mg to 1 mg/kg with a maximum dose of 100 mg every 12 hours, and are well below the toxic range. Furthermore, in patients undergoing liver resection or those with impaired liver function, bupivacaine is administered every 12 hours with a diluted concentration of 0.125% resulting in 0.25 mg/ kg per TAP catheter. The lower dose in patients with liver dysfunction accommodates for decreased liver enzymatic activity. Bupivacaine is an amino-amide local anesthetic which effectively blocks sodium channels thereby reducing the production and generation of nerve impulses (Stoelting & Miller, 2007). Distribution is 95 % protein bound and plasma concentration may accumulate with repeated doses. Metabolism is mainly
Transversus Abdominis Plane Blocks
in the liver by microsomal P-450 enzymes, and it is renally excreted with 5% unchanged. The elimination half life is 2.7 hours for adults (Lexicomp Online, 2013). The measurement of duration of analgesia of local anesthetics has been challenging to determine (Young, Gorlin, Modest, & Quraishi, 2012), and administration frequency is based on knowledge of its half life. The bupivacaine bolus doses are administered using syringe injection by the acute pain service physicians and nurse practitioners. While doses can be below the published toxic ranges, all patients must be assessed for early signs of local anesthetic toxicity such as perioral numbness and tingling, metallic taste, tinnitus, blurred vision, tremors, restlessness, and light-headedness (Lexicomp Online, 2013) minutes after each TAP bolus delivery and as needed. Although studies have not shown significant advantage of continuous infusions versus intermittent bolus dose administration, (Young, Gorlin, Modest & Quraishi, 2012), continuous infusions for TAP catheters may be more feasible for clinical practice. Multimodal Analgesia Using Transversus Abdominis Plane (TAP) Blocks Several studies have used a combination of morphine intravenous (IV) patient-controlled analgesia (PCA) with or without adjuncts such as acetaminophen and/or a nonsteroidal anti-inflammatory drug (NSAID) to complement local anesthetics delivered through a TAP block. In these studies, surgical procedures where a TAP block was utilized generally involved the abdominal area and included (although not limited to) large bowel resections, total abdominal hysterectomies, caesarean sections, laparoscopic cholecystectomies, autologous breast reconstruction by deep inferior epigastric perforator (DIEP), and renal transplantation (Bharti, Kumar, Bala, & Gupta, 2011; Hivelin, Wyniecki, Plaud, Marty, & Lantieri, 2011; Jankovic, Pollard, & Nachiappan, 2009; Petersen, Mathiesen, Torup, & Dahl, 2010; McDonnell et al., 2007; Petersen, Mathiesen, Torup, & Dahl, 2010; Siddiqui, Sajid, Uncles, Cheek, & Baig, 2011; Young, Gorlin, Modest, & Quraishi, 2012; Zhong et al., 2012). The type of local anesthetic, concentration, and volume used as well as the delivery method within the TAP (i.e., single shot injection versus having an indwelling TAP catheter[s] left in situ) differed among studies; however, most reports were able to highlight a finding of analgesic efficacy. Results of reduced postoperative opioid requirement (Bharti, Kumar, Bala, & Gupta, 2011; Hivelin, Wyniecki, Plaud, Marty, & Lantieri, 2011; Jankovic, Pollard, & Nachiappan, 2009; McDonnell et al., 2007; Zhong et al., 2012), lower pain scores (Bharti, Kumar, Bala, & Gupta,
3
2011; McDonnell et al., 2007), in addition to reduced opioid related side-effects particularly with sedation (Bharti, Kumar, Bala, & Gupta, 2011; McDonnell et al., 2007) make the TAP block a viable option in postoperative multimodal analgesia regimens after abdominal surgery.
NURSING ASSESSMENT AND MONITORING Nursing accountability related to assessment, monitoring, and documentation of TAP blocks may be guided by individual institutions. This section reviews general nursing practice. Assessment In addition to the efficacy of analgesia, the insertion sites, dressings, and caps should be monitored and part of the overall nursing assessment. TAP catheters are generally inserted into the abdomen using marked tubing, which indicates the depth of the catheter (Fig. 2). Typically, such catheters are placed between 15 to 20 cm under the dermis. The distal end of the catheter is sealed with a lure-lock cap, which is removed to allow for local anesthetic administration via syringe injection, and then replaced. Guidelines pertaining to the length of time catheters may remain in situ have not previously published. Such catheters have remained in situ up to 5 days after insertion, without any signs of infection. Generally, patients are able to tolerate oral analgesics by the fifth postoperative day after abdominal surgeries and no longer require analgesic administration through the TAP catheters. The catheters may removed by nurse practitioners or anesthesiologists of the acute pain service. After removal of
FIGURE 2.
-
Sample dressing of TAP catheter insertion site.
4
Ladak, Jiang, and Ojha
the TAP catheters, the insertion site should be assessed at least once in the following 24 hours for any new erythema or fluid discharge. Monitoring After administration of local anesthetic, patients should be monitored for pain relief and any toxic side effects of the local anesthetic. Analgesic effect from the local anesthetic should be felt within the first 30 minutes after administration. Pain should be assessed at least once per shift. Local anesthetic toxicity is infrequent, but can occur when there is a high local anesthetic concentration in the bloodstream caused by either accidental injection of local anesthetic into small veins or arteries, or by administration of large volumes to older adults and frail patients such as those with decreased hepatic function. The American Society of Regional Anesthesia practice advisory on local anesthetic systemic toxicity recommend that patients be monitored for at least 30 minutes after high concentration of local anesthetic is administered (Neal et al., 2010).
Documentation Essential components of documentation related to the care of patients with TAP blocks should include the patient’s pain intensity, efficacy of medication, appearance of the catheter sites, and any side effects related to medication administration. Dressing Generally the TAP catheter dressings and caps on the end of the catheters do not need to be replaced, unless the dressing has become soiled or removed.
CONCLUSION Novel approaches to pain management are emerging as part of multimodal therapy to optimize pain relief. The TAP block is a regional anesthetic technique that provides analgesia after major abdominal surgery. Summarized within this paper is a description of the TAP block, the medications used, along with the nursing care associated for patients who may have this modality of pain management.
REFERENCES Barash, P., Cullen, B., Stoelting, R., Cahalan, M., & Stock, M. (2009). Clinical Anesthesia, (6th edition). Philadelphia: Lippincott Williams & Wilkins. Bharti, N., Kumar, P., Bala, I., & Gupta, V. (2011). The efficacy of a novel approach to transversus abdominis plan block for postoperative analgesia after colorectal surgery. Anesthesia & Analgesia, 112(6), 1504–1508. Buvanendran, A., & Kroin, J. S. (2009). Multimodal analgesia for controlling acute postoperative pain. Current Opinion in Anaesthesiology, 22, 588–593. Gandhi, K., Heitz, J. W., & Viscusi, E. R. (2011). Challenges in acute pain management. Anesthesiology Clinics, 29, 291– 309. Hivelin, M., Wyniecki, A., Plaud, B., Marty, J., & Lantieri, L. (2011). Ultrasound-guided bilateral transversus abdominis plane block for postoperative analgesia after breast reconstruction by DIEP flap. Plastic and Reconstructive Surgery Journal, 128(1), 44–55. Jankovic, Z. B., Pollard, S. B., & Nachiappan, M. M. (2009). Continuous transversus abdominis plane block for renal transplant recipients. Anesthesia & Analgesia, 109(5), 1710–1711. Joshi, G. P. (2005). Multimodal analgesia techniques and postoperative rehabilitation. Anesthesiology Clinics of North America, 23, 185–202. Krenzischek, D. A., Dunwoody, C. J., Polomano, R. C., & Rathmell, J. P. (2008). Pharmacotherapy for acute pain: Implications for practice. Pain Management Nursing, 9(1), S22–S32. Lexicomp Online. (2013). Bupivacaine (Lexi-Drugs). Retrieved March 15, 2013, from http://online.lexi.com/lco/ action/doc/retrieve/docid/patch_f/6481
McDonnell, J. G., O’Donnell, B., Curley, G., Heffernan, A., Power, C., & Laffey, J. G. (2007). The analgesic efficacy of transversus abdominis plane block after abdominal surgery: A prospective randomized controlled trial. Anesthesia and Analgesia, 104, 193–197. Mukhtar, K. (2009). Transversus abdominis plane (TAP) block. The Journal of New York School of Regional Anesthesia, 12, 28–33. Neal, J. M., Bernards, C. M., Butterworth J. F. 4th, Gregorio, G., Drasner, K., Hejtmanek, M. R., Mulroy, M. F., Rosenquist, R. W., & Weinberg, G. L. (2010). ASRA practice advisory on local anesthetic systemic toxicity. Regional Anesthesia Pain Medicine, 35, 152–161. Pasero, C. (2011). Persistent postsurgical and posttrauma pain. Journal of Perianesthesia Nursing, 26(1), 38–42. Petersen, P. L., Mathiesen, O., Torup, H., & Dahl, J. B. (2010). The transversus abdominis plane block: A valuable option for postoperative analgesia? A topical review. Acta Anaesthesiologica Scandinavica, 54, 529–535. Polomano, R. C., Dunwoody, C. J., Krenzischek, D. A., & Rathmell, J. P. (2008). Perspective on pain management in the 21st century. Pain Management Nursing, 9(1), S3–S10. Siddiqui, M. R. S., Sajid, M. S., Uncles, D. R., Cheek, L., & Baig, M. K. (2011). A meta-analysis on the clinical effectiveness of transversus abdominis plane block. Journal of Clinical Anesthesia, 23, 7–14. Stoelting, R., & Miller, R. (2007). Basics of Anesthesia, (5th edition). Philadelphia: Churchill Living Stone Elsevier. Ultrasound for Regional Anesthesia, Toronto Western Hospital. (2008). Transversus Abdominis Plane (TAP) Block. Retrieved March 1, 2013, from http://www.usra.ca/ tapgeneral.php
Transversus Abdominis Plane Blocks
Watt-Watson, J., Choiniere, M., Costello, J., Feindel, C., Guerriere, D., Carrier, M., Cogan, J., Guertin, M., Lesperance, F., Bussieres, J., Baskett, R., McFetridgeDurdle, J., & Sullivan, J. (2010). ‘‘Prevalence, characteristics and risk factors of persistent post-operative pain after cardiac surgery.’’ World Congress on Pain. Montreal: Abstract. Young, M. J., Gorlin, A. W., Modest, V. E., & Quraishi, S. A. (2012). Clinical implications of the transversus abdominis
5
plane block in adults. Anesthesiology Research and Practice, 2012, 11. Article ID: 731645. Zhong, T., Wong, K. W., Cheng, H., Ojha, M., Srinivas, C., McCluskey, S. A., Clarke, H., Jacks, L., & Hofer, S. O. (2012). Transversus abdominis plane (TAP) catheters inserted under direct vision in the donor site following free DIEP and MSTRAM breast reconstruction: A prospective cohort study of 45 patients. Journal of Plastic, Reconstructive and Aesthetic Surgery, 66(3), 329–336.
-
Salima S. J. Ladak, RN(EC), BScN, MN, Jiao Jiang, RN(EC), BScN, MN, and Marie Ojha, RN(EC), BScN, MN
ABSTRACT:
Transversus abdominis plane (TAP) blocks are an evolving regional anesthesia technique used as part of postoperative pain management regimens after major abdominal surgery. This article reviews TAP block insertion techniques, commonly used local anesthetics, and recommends nursing care related to TAP blocks. Ó 2013 by the American Society for Pain Management Nursing
INTRODUCTION
From the University Health Network, Toronto General Hospital Acute Pain Service, Toronto, Ontario, Canada. Address correspondence to Salima S. J. Ladak, RN(EC), BScN, MN, University Health Network, Toronto General Hospital Acute Pain Service, Toronto, M5G 2C4 Ontario, Canada. E-mail: [email protected] Received January 4, 2012; Revised April 3, 2013; Accepted April 4, 2013. 1524-9042/$36.00 Ó 2013 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2013.04.005
Although knowledge about acute pain and technology associated with its management have increased, patients continue to experience significant pain after surgery. Approximately 50% of patients report moderate to severe pain within the first 5 postoperative days (Watt-Watson et al., 2010). Uncontrolled postoperative pain can result in deleterious effects in the quality of recovery, including pulmonary infections, myocardial ischemia and infarctions, thromboembolism, impaired immune function, paralytic ileus, and anxiety. Additionally, uncontrolled pain can lead to decreased patient satisfaction, increased recovery time, prolonged hospitalization, and additional cost to the healthcare system (Gandhi, Heitz & Viscusi, 2011; Polomano, Dunwoody, Krenzischek, & Rathmell, 2008). There is also a risk of developing persistent postsurgical pain long after the expected postoperative recovery period (Pasero, 2011). The use of multimodal therapy is the mainstay for preventing postoperative complications related to uncontrolled pain. Multimodal analgesia is the combination of different analgesics that work along different pathways and sites along the nervous system, which produces an additive or synergistic effect with lowered analgesia related side-effects compared with using individual analgesics alone (Buvanendran & Kroin, 2009; Joshi, 2005). For example, opioids remain the primary analgesic most suited for treating moderate-to-severe postoperative pain. However, when used as the sole analgesic, opioids can have significant doserelated side-effects such as nausea and vomiting, dizziness, drowsiness, urinary retention, and constipation, thereby delaying recovery (Joshi, 2005). Therefore, combining opioids with other analgesics that target different pain pathways may reduce such unwanted side-effects. Over the last two decades, regional anesthesia techniques have gained popularity and are often included when applicable as Pain Management Nursing, Vol -, No - (--), 2013: pp 1-5
2
Ladak, Jiang, and Ojha
part of the multimodal analgesia approach. Regional anesthesia is a type of pain management technique that results in sensory blockade to part of the body when local anesthesia is infused to a group of nerves that innervate that region of the body (Krenzischek, Dunwoody, Polomano & Rathmell, 2008). This paper describes the regional anesthesia technique, review of analgesic efficacy, and nursing care associated in the management of patients receiving transversus abdominis plane (TAP) blocks after surgery. Anatomy Initially described in 1993, the TAP block is an expanding regional anesthesia technique that provides analgesia to the parietal peritoneum as well as the skin and muscles of the anterior abdominal wall (Mukhtar, 2009; Young, Gorlin, Modest, & Quraishi, 2012). The goal of the TAP block is to deposit local anesthetic in the plane between the internal oblique and transversus abdominis muscle layers, resulting in the interruption to the innervation of the abdominal skin, muscles, and parietal peritoneum. Sensory blockade using the TAP block method can range between T7 to L1 (Mukhtar, 2009) (Fig. 1). Insertion Technique TAP blocks can be inserted by anesthesiologists utilizing surface anatomical landmarks, (i.e., ‘‘blind’’ or by using ultrasound guidance) or can be inserted by surgeons through direct visualization before the end of a surgical procedure. During the procedure, two ‘‘pops’’ (i.e., loss of resistance) are expected at entry into the plane between external and internal oblique muscles and at entry into the plane between internal
FIGURE 1. - Anatomy of the transversus abdominis plane, Copyright Ó 2008 Ultrasound for Regional Anesthesia, Toronto Western Hospital.
oblique and transversus abdominis muscles (i.e., the TAP plane) (Ultrasound for Regional Anesthesia, 2008). A blunt needle will make such pops more apparent, especially during a ‘‘blind’’ insertion. With ultrasound guidance the deposition of local anesthetic can be accurately placed in the correct neurovascular plane (Ultrasound for Regional Anesthesia, 2008). To extend the analgesia beyond the duration of a single shot of local anesthetic, an indwelling catheter can be placed (Mukhtar, 2009). Such catheters can be placed either with ultrasound by anesthesiologists or under direct vision by the surgeon prior to the completion of surgery. The catheter(s) can be covered with transparent dressing so that the insertion site can be assessed, or be secured with steri-strips, sutures, or through a tunnelled technique. Approximately 10% of catheters may migrate out; however, no significant difference has been previously reported in the three securing methods in relation to accidental catheter migration. However, catheters may migrate out more readily if they are in situ for a prolonged period of time (i.e., 4 or more days). Additional abdominal binders prevent migration in some procedures, such as deep inferior epigastric perforator incisions, but are not practical for other procedures such as liver resection. Local Anesthetic Administration Using TAP Blocks Although local anesthetic agent, volume, concentration, and delivery method are different among studies (Young, Gorlin, Modest & Quraishi, 2012), bupivacaine, ropivacaine, and levobupivacaine have been commonly used for the TAP blocks (Barash et al., 2009). For instance, 0.25% bupivacaine can be administered at 0.5 mg/kg per TAP catheter every 12 hours in patients who have normal hepatic function. While the maximum recommended dose of bupivacaine for peripheral nerve blocks is 400 mg/day (Lexicomp Online, 2013), lower doses are administered in clinical practice, ranging from 0.5 mg to 1 mg/kg with a maximum dose of 100 mg every 12 hours, and are well below the toxic range. Furthermore, in patients undergoing liver resection or those with impaired liver function, bupivacaine is administered every 12 hours with a diluted concentration of 0.125% resulting in 0.25 mg/ kg per TAP catheter. The lower dose in patients with liver dysfunction accommodates for decreased liver enzymatic activity. Bupivacaine is an amino-amide local anesthetic which effectively blocks sodium channels thereby reducing the production and generation of nerve impulses (Stoelting & Miller, 2007). Distribution is 95 % protein bound and plasma concentration may accumulate with repeated doses. Metabolism is mainly
Transversus Abdominis Plane Blocks
in the liver by microsomal P-450 enzymes, and it is renally excreted with 5% unchanged. The elimination half life is 2.7 hours for adults (Lexicomp Online, 2013). The measurement of duration of analgesia of local anesthetics has been challenging to determine (Young, Gorlin, Modest, & Quraishi, 2012), and administration frequency is based on knowledge of its half life. The bupivacaine bolus doses are administered using syringe injection by the acute pain service physicians and nurse practitioners. While doses can be below the published toxic ranges, all patients must be assessed for early signs of local anesthetic toxicity such as perioral numbness and tingling, metallic taste, tinnitus, blurred vision, tremors, restlessness, and light-headedness (Lexicomp Online, 2013) minutes after each TAP bolus delivery and as needed. Although studies have not shown significant advantage of continuous infusions versus intermittent bolus dose administration, (Young, Gorlin, Modest & Quraishi, 2012), continuous infusions for TAP catheters may be more feasible for clinical practice. Multimodal Analgesia Using Transversus Abdominis Plane (TAP) Blocks Several studies have used a combination of morphine intravenous (IV) patient-controlled analgesia (PCA) with or without adjuncts such as acetaminophen and/or a nonsteroidal anti-inflammatory drug (NSAID) to complement local anesthetics delivered through a TAP block. In these studies, surgical procedures where a TAP block was utilized generally involved the abdominal area and included (although not limited to) large bowel resections, total abdominal hysterectomies, caesarean sections, laparoscopic cholecystectomies, autologous breast reconstruction by deep inferior epigastric perforator (DIEP), and renal transplantation (Bharti, Kumar, Bala, & Gupta, 2011; Hivelin, Wyniecki, Plaud, Marty, & Lantieri, 2011; Jankovic, Pollard, & Nachiappan, 2009; Petersen, Mathiesen, Torup, & Dahl, 2010; McDonnell et al., 2007; Petersen, Mathiesen, Torup, & Dahl, 2010; Siddiqui, Sajid, Uncles, Cheek, & Baig, 2011; Young, Gorlin, Modest, & Quraishi, 2012; Zhong et al., 2012). The type of local anesthetic, concentration, and volume used as well as the delivery method within the TAP (i.e., single shot injection versus having an indwelling TAP catheter[s] left in situ) differed among studies; however, most reports were able to highlight a finding of analgesic efficacy. Results of reduced postoperative opioid requirement (Bharti, Kumar, Bala, & Gupta, 2011; Hivelin, Wyniecki, Plaud, Marty, & Lantieri, 2011; Jankovic, Pollard, & Nachiappan, 2009; McDonnell et al., 2007; Zhong et al., 2012), lower pain scores (Bharti, Kumar, Bala, & Gupta,
3
2011; McDonnell et al., 2007), in addition to reduced opioid related side-effects particularly with sedation (Bharti, Kumar, Bala, & Gupta, 2011; McDonnell et al., 2007) make the TAP block a viable option in postoperative multimodal analgesia regimens after abdominal surgery.
NURSING ASSESSMENT AND MONITORING Nursing accountability related to assessment, monitoring, and documentation of TAP blocks may be guided by individual institutions. This section reviews general nursing practice. Assessment In addition to the efficacy of analgesia, the insertion sites, dressings, and caps should be monitored and part of the overall nursing assessment. TAP catheters are generally inserted into the abdomen using marked tubing, which indicates the depth of the catheter (Fig. 2). Typically, such catheters are placed between 15 to 20 cm under the dermis. The distal end of the catheter is sealed with a lure-lock cap, which is removed to allow for local anesthetic administration via syringe injection, and then replaced. Guidelines pertaining to the length of time catheters may remain in situ have not previously published. Such catheters have remained in situ up to 5 days after insertion, without any signs of infection. Generally, patients are able to tolerate oral analgesics by the fifth postoperative day after abdominal surgeries and no longer require analgesic administration through the TAP catheters. The catheters may removed by nurse practitioners or anesthesiologists of the acute pain service. After removal of
FIGURE 2.
-
Sample dressing of TAP catheter insertion site.
4
Ladak, Jiang, and Ojha
the TAP catheters, the insertion site should be assessed at least once in the following 24 hours for any new erythema or fluid discharge. Monitoring After administration of local anesthetic, patients should be monitored for pain relief and any toxic side effects of the local anesthetic. Analgesic effect from the local anesthetic should be felt within the first 30 minutes after administration. Pain should be assessed at least once per shift. Local anesthetic toxicity is infrequent, but can occur when there is a high local anesthetic concentration in the bloodstream caused by either accidental injection of local anesthetic into small veins or arteries, or by administration of large volumes to older adults and frail patients such as those with decreased hepatic function. The American Society of Regional Anesthesia practice advisory on local anesthetic systemic toxicity recommend that patients be monitored for at least 30 minutes after high concentration of local anesthetic is administered (Neal et al., 2010).
Documentation Essential components of documentation related to the care of patients with TAP blocks should include the patient’s pain intensity, efficacy of medication, appearance of the catheter sites, and any side effects related to medication administration. Dressing Generally the TAP catheter dressings and caps on the end of the catheters do not need to be replaced, unless the dressing has become soiled or removed.
CONCLUSION Novel approaches to pain management are emerging as part of multimodal therapy to optimize pain relief. The TAP block is a regional anesthetic technique that provides analgesia after major abdominal surgery. Summarized within this paper is a description of the TAP block, the medications used, along with the nursing care associated for patients who may have this modality of pain management.
REFERENCES Barash, P., Cullen, B., Stoelting, R., Cahalan, M., & Stock, M. (2009). Clinical Anesthesia, (6th edition). Philadelphia: Lippincott Williams & Wilkins. Bharti, N., Kumar, P., Bala, I., & Gupta, V. (2011). The efficacy of a novel approach to transversus abdominis plan block for postoperative analgesia after colorectal surgery. Anesthesia & Analgesia, 112(6), 1504–1508. Buvanendran, A., & Kroin, J. S. (2009). Multimodal analgesia for controlling acute postoperative pain. Current Opinion in Anaesthesiology, 22, 588–593. Gandhi, K., Heitz, J. W., & Viscusi, E. R. (2011). Challenges in acute pain management. Anesthesiology Clinics, 29, 291– 309. Hivelin, M., Wyniecki, A., Plaud, B., Marty, J., & Lantieri, L. (2011). Ultrasound-guided bilateral transversus abdominis plane block for postoperative analgesia after breast reconstruction by DIEP flap. Plastic and Reconstructive Surgery Journal, 128(1), 44–55. Jankovic, Z. B., Pollard, S. B., & Nachiappan, M. M. (2009). Continuous transversus abdominis plane block for renal transplant recipients. Anesthesia & Analgesia, 109(5), 1710–1711. Joshi, G. P. (2005). Multimodal analgesia techniques and postoperative rehabilitation. Anesthesiology Clinics of North America, 23, 185–202. Krenzischek, D. A., Dunwoody, C. J., Polomano, R. C., & Rathmell, J. P. (2008). Pharmacotherapy for acute pain: Implications for practice. Pain Management Nursing, 9(1), S22–S32. Lexicomp Online. (2013). Bupivacaine (Lexi-Drugs). Retrieved March 15, 2013, from http://online.lexi.com/lco/ action/doc/retrieve/docid/patch_f/6481
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Transversus Abdominis Plane Blocks
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