So today I'll be particularly talking about on transversus abdominus plane blocks used in the ICU. I have no financial disclosure pertinent to this presentation, however, I have multiple grants for my research project funded by NIH and IEA, Reliant, and then GEMSTAR. So the learning objective of this talk is today we will identify critically ill surgical patients which can be considered for TAB blocks and then we will learn different TAB block techniques. It doesn't matter if you're an anesthesiologist or surgeons or pulmonary critical care physician, anyone can learn it. And then we will discuss real data which is available out there on the clinical utility of TAB blocks performed by any other specialty. So as you all know that acute pain management has remained challenging both for anesthesiologists and surgeons and we all know that severe postoperative pain is associated with increased morbidity and mortality because of multiple reasons such as poor wound healing, excessive use of opioids, and which is related to alias urinary retention, that leading to delayed recovery and rehabilitation. And as we all know that the thoracic epidural analgesia remain the gold standard treatment for the analgesic options after surgery because it provides excellent pain relief, however, it is associated with delayed rehabilitation and discharge because it can cause severe hypotension which subsequently requires vasopressor support and epidural analgesia sometimes can cause profound motor blockade that can lead to the immobility and urinary retention and there are like, you know, not significant, insignificant risk of neurological damage if it is performed by not well-trained person. So therefore various analgesia techniques are emerging and one of them is ultrasound guided tab block performed by different specialties physician. So the transversus abdominis plane block was described in 2001 which is actually block when you perform transversus abdominis plane block is block the nerves that lies between T6 to L1 dermatomal distribution that usually present in the transversus abdominis plane. In the past it has been performed by anatomically using the number triangle of patent but because of the ultrasound techniques are emerging and it has become the preferred option because it improved the efficacy of the nerve block so we all are doing this blocks nowadays with the ultrasound. There are multiple approaches we will talk about in couple more slides about it. So the indication for tab block if you have a patient come to you and having pain in the ICU I perform these block in anyone who comes to us after lower abdominal surgeries even cesarean deliveries, colectomies, hernia repair, any abdominal procedures I do frequently perform these blocks if it's not performed by anesthesiologist in the operating room because of the time or lack of resources so I do it in our ICU all the time. So there are different kind of tab blocks that you should know before you are performing there is a first one that we perform is called classical tab block which cover the nerve that is located in the dermatomes between T10 to L1 as you can see the picture with the yellow circle here it covers this area so basically C-section any lower abdominal incision below the umbilicus we perform this classical tab block how we do perform like you know you just place the probe find this anatomy you will see external oblique, internal oblique and transversus abdominis and then you will place the so you will use the needle under the ultrasound guidance and then inject the local anesthetic between internal oblique and transversus abdominis and you will see this plane will be spreading apart and then in 10 to 15 minutes patient will say oh yeah I got good pain relief. So this is called classical tab block then you have another tab block that called sub costal tab block which cover the nerve that involved in the dermatomal distribution between T6 to T10 particularly if patient is coming with the hypotectomy any kind of cocker incision what you do you put the ultrasound under the sub costal area find out this picture where you see the rectus abdominis like a big bulky muscle below is a transversus abdominis if you inject between rectus and transversus abdominis you will see the local anesthetic spreading in this area and that's give the sub costal tab block very easy to perform very few side effect I will tell you and then if you have a patient with expiratory leprotomy complaining of severe pain then you need to consider giving four bilateral four point tab block which were like you know it's a combination of sub costal and classical tab block it covers the nerves between T6 to T12 same thing is you will put the ultrasound probe just beside the patient's umbilicus you will identify this anatomy and then you will inject like you know between the internal oblique and transversus abdominis muscles here on the left side and on the right side and patient will get the four point tab block so now the next thing is is it safe to be performed by non anesthesia faculty yes it has been already performed by many different specialty particularly surgical there are very few reports of complications there are only one or two case report of intra hepatic injections if you are performing sub costal tab block on the right side there are a port of intraperitoneal injection usually with the blinded procedures but we use ultrasound bowel hematoma and then local anesthetic toxicity is also a very important thing that you need to keep in mind if you are learning to do this block in the ICU and so that's why it's very important to follow the guidelines that are published to use how much the dosing how much the volume because it's a fascial plane block so volumes matters so the doses and volume varies whatever your facilities have we have bupivacaine that can 0.25 to 0.45 percent you can use ranging between 20 to 30 mils on each side if you have ropivacaine in your facilities which most community hospital has it use 0.2 percent ropivacaine with 30 mils 20 to 30 mils on each side we use experil we consider to be rich hospitals so we have experil liberally available I take one while off experil 20 mils mix with the another while of bupivacaine which is 0.25 percent and then mix with the 20 mils of normal saline I dilute everything in 60 mils range divided into the 30 and inject on both side so you have all these three options available based on your facility you're located and availability so then I want to bring your attention to some data which is out there regarding utility of the tab block this study was performed by Shaker and colleague regarding efficacy and safety of tab block versus epidural what they found there was no difference in the 48 0 to 48 hours fluid balance their overall pain scores and worst pain scores so if you do it right tab block works like epidural and then what they also found patients with the tab block has less morphine or opioid consumption on post-op day one as you can see 24.5 milliequivalent then 120 with the epidural same thing they notice on post-op day two their opioid consumption as compared to epidural group was lower and then same thing they noticed on post-op day three so then the the other thing is there a lot of discussion going around a guy regarding surgeon administered tab block this study was published one of the OBGYN doctor they they their group evaluated surgeon administered intraoperative transverse abdominus plane block with the anesthesiologist administered tab block what they found the time taken to perform the block was 2.4 minute for the surgeons as compared to the anesthesiologist I think it's just because we have to do it in the pre-op area we have to have a nurse I think in the intra they all are prepared to just go and find the anatomy in place in our block but that was a significant time to perform the tab block was very less and they found no difference in 24 hours morphine consumption and post-operative pain score so that was good it was working and then this study was performed at our facility at Houston Methodist Hospital by Eric has who's a colorectal surgeon they wanted to evaluate the learning curve of transverse abdominus plane block done by surgeon what they found on the fourth attempt the operator reaches appropriate speeds of placement of the tab block they didn't require any supervision and then tab block was easy to perform on the fourth attempt I'm sorry this is really hazy slide I did not realize but I just wanted to let you know that data shows the same thing that operator on the fourth attempt was able to successfully place a plane block so you just need four attempt under supervision and then you will learn it and this is study done at our Center by me and my colleague what we wanted to see how quickly the resident can perform the tab lock so what we did we divided our residents in two groups one that learned the technique through the simulation based technique and one with the YouTube video and then they performed the tab lock on the pig model and what we found that simulation based group who learned the technique of tab lock did very well that as compared to people who learn on the YouTube group in terms of alert ultrasound setting accurate anatomic identification probe manipulation proper needle alignment all the numbers were better for the people who learn or simulation based then compare with the YouTube or any other nice or as you will see this paper coming out soon it is already submitted for publication so my take-home point here I would say or your take-home point is like tab lock lower post-operative pain scores and consumption of opioids with minimal no adverse effect traditionally it is performed by anesthesiologists but there is increasing interest in surgeon administered facial plane block because they are safe there is minimal literature out there in regards to that what surgeons needs to do can they do this tab lock using the YouTube videos or the other nerve block videos or they need to undergo a training so we recommend there like a lot of research needs to be done to develop the best practice for education and implementation of these kind of tab lock performed by the surgeon

TAP blocks

ICU

acute pain management

transversus abdominis plane

local anesthetic