dr. Pry - Tap Block: CLINICAL APPLICATION FOR PAIN MANAGEMENT_ISAPM Manado 2015

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 Td 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

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)

Transversus Abdominis Plane

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

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

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

K O M P L I K A S I

• blok gagal

• injeksi intraperitoneal

• cedera hepar

• cedera saluran cerna

• intoksikasi obat anestetik lokal

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

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)

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”



• Rafi (2001) : dalam TOP,“single pop”

• McDonnel (2004) :cephalad dari krista iliakadi TOP, “double pop”


Jankovic Z. Transversus abdominis plane block: The Holy Grail of anaesthesia for (lower) abdominal surgery. Period Biol, Vol 111, No 2, 2009; 203-8.

• Success rate : 23,6 - 85%




• Posisi TOP antar individusangat bervariasi





• Ukuran TOP relatif kecil





• Ukuran TOP relatif kecil

• Landmark alternatif ygdisarankan : posterior darigaris mid-aksilar pada areacephalad dari krista iliakaatau di LIP (latissimo-iliacpoint)



T E K N I K D I PA N D U U S G

• Pendekatan Posterior

• studi cadaver : penyebaran obat T10 - L1

EOM

IOM

TAM

RAM

TAM

IOM

EOM

EOM

IOM

TAM

RAM

EOM

IOM

TAM

T E K N I K D I PA N D U U S G

• Pendekatan subkosta

• penyebaran obat T7-T11

TAM

PC

RAM

TAM

PC

RAM

RAM

TAM

OEMLS

PC

TAM

PC

RAM

RAM

TAM

OEMLS

PC

TAM

IOM

EOM

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

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

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

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

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

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.

T E R I M A K A S I H

dr. Pry - Tap Block: CLINICAL APPLICATION FOR PAIN MANAGEMENT_ISAPM Manado 2015

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