Best Infiltration Practices - local analgesic techniques for abdominal and orthopedic surgery
Issue link: https://eguideline.guidelinecentral.com/i/73209
Infiltration Technique Descriptions Transversus Abdominis Plane Field Infiltration or Block (TAP Block) Infiltration Technique Infiltration Target Local Analgesic Volume 1) Administration of local analgesic between the transversus abdominis and internal oblique muscles can provide pain relief for a range of abdominal surgical procedures.21-25 With a laparoscope in place, the mid-axillary line is defined. The laparoscopic version of the block is not infiltrated as far posteriorly as the triangle of Petit, the traditional site of an anesthesiologist- placed TAP block. Insert a blunt-tipped needle attached to a 20-cc syringe in the mid-axillary line, two fingerbreadths above the iliac crest. Advance the needle at right angles to the dermis in a coronal plane until resistance is encountered at the external oblique muscle. A "pop" indicates the needle has entered the plane between the external and internal oblique fascial layers. Further advance the needle until a second "pop" indicates the needle has entered the transversus abdominis fascial plane. Through the laparoscope, observe a diffuse bulge under the peritoneum. After aspiration to exclude vascular puncture, infiltrate approximately 5 cc local analgesic to ensure the needle is in the correct position and plane (Figure 7). Then inject an additional 10-15 cc of local analgesic. Repeat the procedure on the opposite side. For open abdominal procedures, TAP block can be performed from inside the abdominal wall by inserting a 22-gauge needle at the mid-axillary line at the level of the umbilicus and injecting local analgesic once a loss of resistance is achieved (i.e., the transversus abdominis muscle is pierced).22 The conventional TAP block described above benefits patients undergoing infra-umbilical procedures and may not provide upper abdominal wall blockade.23,24 lower TAP compartment does not communicate with the upper intercostal compartment. Therefore, it may be necessary to perform injections in both compartments to affect the entire anterior wall. If upper abdominal wall blockade is desired, there is anecdotal evidence that a second, "upper" block may be warranted. However, to date, no studies have been done to validate the benefit versus risk (e.g., liver puncture) of the upper TAP block. Recent reports suggest that the TOTAL: 30-40 cc 10 T11-L1 cutaneous, myofascial and peritoneal nerves and iliohypogastric nerves infiltration, and cumulative dose toxicity needs to be considered if used together): (Infiltration of local analgesic by TAP may replace local 15-20 cc per side