Transversus Abdominis Plane (TAP) block

Indications and Technique

Figure 1. Biomed Res Int. 2017; 2017: 8284363.
Figure 1. Anesthesiol Res Pract. 2012; 2012: 731645.
Figure 5. Anesthesiol Res Pract. 2012; 2012: 731645.
Figure 6. Biomed Res Int. 2017; 2017: 8284363.

Pros & Cons

The Effect of Transversus Abdominis Plane Blocks on Postoperative Pain in Laparoscopic Colorectal Surgery: A Prospective, Randomized, Double-Blind Trial. Diseases of the Colon & Rectum: November 2014 – Volume 57 – Issue 11 – p 1290-1297


How to perform a TAP block?

YouTube: U/S guided TAP block

YouTube: RAUKvideos U/S guided TAP block Fast forward to 0:39

YouTube: 3D How-To U/S Guided TAP block Fast forward to 1:00

YouTube: 2012 ISURA TAP block lecture Fast forward to 16:55 for summary.

YouTube: ASRA Society Fast forward to 0:55. Sound off.

YouTube: Pajunk TAP block


Current mix:

  • July 2020
    • 0.25% bupi + epi + 1 mcg/kg dexmedetomidine (roughly 30 ml per side)

Methadone: perioperative pain use

Methadone for perioperative pain #methadone #pain #ERAS

There’s a lot of great data that methadone use decreases postoperative narcotics use in cardiac surgery patients, and I believe it would really be a beneficial drug in an ERAS pathway for early extubation, decreased LOS in ICU and hospital, and better patient satisfaction.  Please see the articles below/attached for references.

Methadone for cardiac surgery: 0.2-0.3 mg/kg prior to incision – perhaps different metabolism on CPB so consider split dosing pre-pump and post-pump. Dose adjustment with age and other co-morbidities. At induction, one half of the study opioid (either 0.15 mg/kg of methadone or 6 μg/kg of fentanyl) was administered via an infusion pump over 5 min. The remainder of the study opioid (0.15 mg/kg of methadone or 6 μg/kg of fentanyl) was infused over the next 2 h. Either 0.3 mg/kg of methadone (maximum dose of 30 mg) or 12 μg/kg of fentanyl (maximum dose of 1200 μg) was added to 100-ml bags of normal saline (total volume 100 ml).

Methadone for non-cardiac surgery: 0.2mg/kg prior to incision. REVIEW: Intraoperative Methadone in Surgical Patients: A Review of Clinical Investigations. Anesthesiology 9 2019, Vol.131, 678-692.

Methadone for obesity: 0.15 mg/kg IBW+20% at induction. J Pain Res. 2018; 11: 2123–2129. Intraoperative use of methadone improves control of postoperative pain in morbidly obese patients: a randomized controlled study.

Methadone for outpatient surgery: 0.15 mg/kg ideal body weight. Anesth Analg. 2019 Apr; 128(4): 802–810. Intraoperative Methadone in Same-Day Ambulatory Surgery: A Randomized, Double-Blinded, Dose-Finding Pilot Study.

OVERALL: A variety of doses have been used in clinical trials, ranging from 0.1 to 0.3 mg/kg, with the majority of studies using a dose of either 0.2 mg/kg or a fixed dose of 20 mg.

Methadone has a long elimination half-life (1–2 days). It is cleared predominantly by hepatic metabolism, primarily via N-demethylation to 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP), which is pharmacologically inactive, and thence secondarily to 2-ethyl-5-methyl-3,3-diphenylpyrroline (EMDP).

Together these investigations established that a) CYP3A has no influence on single-dose intravenous or oral methadone plasma concentrations, b) CYP3A plays a minimal (if any) role clinically in single-dose methadone N-demethylation and clearance, c) methadone is not a clinical CYP3A substrate, and d) clinical guidelines stating that methadone is a CYP3A4 substrate and warning about CYP3A4 drug interactions needed revision. In addition, CYPs 2C9, 2C19, and 2D6 do not appear to contribute materially to clinical methadone N-demethylation and clearance.

In summary, it is now obvious that CYP2B6 a) is a predominant catalyst of methadone metabolism in vitro; b) mediates clinical methadone metabolism, clearance, stereoselective disposition, and drug-drug interactions; and c) genetic polymorphisms influence methadone disposition. Thus, both constitutive variability due to CYP2B6 genetics, and CYP2B6-mediated drug interactions, can alter methadone disposition, clinical effect, and drug safety. Rewritten clinical guidelines stating that methadone is a CYP2B6 substrate and warning about CYP2B6 drug interactions may improve methadone use, treatment of pain and substance abuse, and patient safety.

FDA Drug Datasheet

From Anesthesiology 5 2015, Vol.122, 1112-1122.
From Anesth Analg. 2019 Apr; 128(4): 802–810.

What I’m doing these days:

  • July 2020


Adult Cardiothoracic

Adult Non-Cardiac

Adult Outpatient

Pediatric Surgery

Methadone Pharmacology & Effects

Updated July 2020

Prescription of Controlled Substances: Benefits and Risks. [Updated 2020 Jun 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537318/

The role of methadone in opioid rotation-a Polish experience. Support Care Cancer. 2009 May;17(5):607-12.

Project Hands OR 1

The experience is one I’ll truly cherish. I’ll have to go at least yearly. These people need so much and it’s really an honor to be able to reach out to them. Had 3 cases today. All pedi burns..6y, 14y, 6y. First case, the 6y old was so brave. We did a right axillary contracture release with skin graft lasted about 2h. 2nd case was the toughest anesthetically. She had burns to her face and had a mouth opening of barely 2 of my fingers. I barely got a 2.5 Lma thru. They released contractures on her neck and eyelids. She coughed in the middle of the case as one of surgeons was putting stitch in neck. She laryngospasmed….oy! Sat went down to 70s…had to give prop to break it. That, I could’ve lived without. Last case was a screaming, crying 6y. Had to tackle mask him down…luckily, he went down nicely. They did a left hand/thumb release. All the pts did well in the pacu. 🙂 so far so good…. now for dinner, drinks, and hanging with the group.

 

Free day in Antigua

I´m currently in Antigua.  ´It´s a cute, beautiful city that used to be the ancient capitol of Guatemala.  We´ve walked around the city, which reminded me of San Juan, Puerto Rico.  Cute city blocks with very colorful buildings.  The people are extremely friendly.  Heading out to a Spanish class at 1:30p for a refresher.  My Project HANDS family is very nice, helpful and I can definitely see this trip being a great one!  More to follow…

Project hands day 1

image

Back in December, I found a group on the internet called Project Hands. It’s a Vancouver based group who puts together a healthcare team composed of doctors, nurses, techs, administrators, and engineers to send over to Guatemala to deliver surgical care. I’m part of the May 2011 team. I’ve never done a medical mission trip, but I think they’re important to see how others live life and deal with medical problems. I love experiencing new cultures!  Today, I leave for Guatemala and am quite excited to get going on the trip. Now, as an anesthesiologist, I wonder about the equipment and drugs that I’ll have access to…. will they be the same one I’m familiar with or will they be some kind of rigged contraption with an O2 flow tubing hooked up to volatile agent? I’ll try to post daily and include some pics as well. I’m supposed to arrive in Guatemala tonight….

Teeny tiny hearts

Diagram of a heart with tricuspid atresia, and...
Image via Wikipedia

Pediatric cardiac anesthesiologists are pretty much the Gods of anesthesia.  What do I mean by this?  Well, putting kids to sleep and finding IVs and managing their little airways can be tricky.  Now, let’s take that and make it more complex by giving them funky heart anatomy and connections and we’ve got some real tricky anesthesia!

Picture tiny babies, 1-2kg (for the U.S.: 2-4lbs), with teeny tiny hearts…who only have a fightin’ chance in this world with corrective heart surgery.  These tiny hearts are beating away…with some type of pathology that will kill them oftentimes before they reach adulthood.

Sick kids + general anesthesia = possible scary scenario.  Throw in a really good pediatric cardiac anesthesiologist (and pedi heart surgeon)… and that could mean many more years of happy memories!  I’m not sure how these amazing physicians sleep at night (high stress!), but they’re outstanding and certainly have earned my respect!

Some of the cases that I’ve come across:  division of vascular ring; bidirectional Glenn; Fontan; Tetralogy of Fallot repair (extracardiac); hypoplastic aortic arch repair; PDA ligations; modified Blalock-Taussig shunts; AV canal repair; Aortic valve replacement; tricuspid valve repair;  mitral valve repair; Repair of Coarctation.

Some of the pathology I’ve seen: Tetralogy of Fallot, hypoplastic left heart syndrome, coarctation, bicuspid aortic valve, mitral valve prolapse, tricuspid valve prolapse, heterotaxy, unbalanced AV canal, complete vascular ring, patients who were s/p Norwood-Sano, double outlet RV

All I can say is that rotating through pedi hearts for a month was an outstanding experience… one that all adult cardiac anesthesiologists should do.

Teeny Tiny Hearts

Diagram of a heart with tricuspid atresia, and...
Image via Wikipedia

Nov 21, 2010

Pediatric cardiac anesthesiologists are pretty much the Gods of anesthesia.  What do I mean by this?  Well, putting kids to sleep and finding IVs and managing their little airways can be tricky.  Now, let’s take that and make it more complex by giving them funky heart anatomy and connections and we’ve got some real tricky anesthesia!

Picture tiny babies, 1-2kg (for the U.S.: 2-4lbs), with teeny tiny hearts…who only have a fightin’ chance in this world with corrective heart surgery.  These tiny hearts are beating away…with some type of pathology that will kill them oftentimes before they reach adulthood.

Sick kids + general anesthesia = possible scary scenario.  Throw in a really good pediatric cardiac anesthesiologist (and pedi heart surgeon)… and that could mean many more years of happy memories!  I’m not sure how these amazing physicians sleep at night (high stress!), but they’re outstanding and certainly have earned my respect!

Some of the cases that I’ve come across:  division of vascular ring; bidirectional Glenn; Fontan; Tetralogy of Fallot repair (extracardiac); hypoplastic aortic arch repair; PDA ligations; modified Blalock-Taussig shunts; AV canal repair; Aortic valve replacement; tricuspid valve repair;  mitral valve repair; Repair of Coarctation.

Some of the pathology I’ve seen: Tetralogy of Fallot, hypoplastic left heart syndrome, coarctation, bicuspid aortic valve, mitral valve prolapse, tricuspid valve prolapse, heterotaxy, unbalanced AV canal, complete vascular ring, patients who were s/p Norwood-Sano, double outlet RV

All I can say is that rotating through pedi hearts for a month was an outstanding experience… one that all adult cardiac anesthesiologists should do.