TAP BLOCK

1. Good Afternoon

2. K. Allen, SRNA, L. Allison, SRNA, L. Camp, SRNA, J.
Carlisle, SRNA, M. Cochiaosue, SRNA, A. Hughes,
SRNA, J. Jimenez, SRNA
Middle Tennessee School of Anesthesia

3. Introduction
 How our subject came to fruition
 Purpose
 A brief history
 Anatomy
 How does it work?
 Background
 Results from research
 Possible clinical implications

4. We hope you enjoy the
presentation

5. TAP Blocks: A Brief History
• 1855-Friedrich Gaedcke: First to chemically isolate
cocaine, naming it erythroxyline
• 1884-Karl Koller: Tested anesthetic effectiveness of
2% cocaine solution
• 1885-William Halsted: First brachial plexus blocked
performed
• 1885 - James Leonard Corning: Injected cocaine
between the lumbar spinous processes, first to
publish descriptions of spinal anesthesia
• 1898 - August Bier: Considered the "Father of Spinal
Anesthesia", performed the first surgery under spinal
anesthesia

6. TAP Blocks: A Brief History
 2001-A.N. Rafi: Published "Abdominal field block: a
new approach via the lumbar triangle"
• The article described a single shot abdominal block, using
the lumbar triangle of Petit as an anatomical landmark
• At the time of publication, Rafi had been using this blind
technique for 2 years, on over 200 patients
• Referred to as the RAFI technique, Regional Abdominal
Field Infiltration
 2004-2007-J.G. McDonnell et al., used computerized
tomography and MRI to study the spread and
effectiveness of the single shot abdominal block
• Coined the term transversus abdominal plane (TAP) block

7. Background
 The transversus abdominis plane block is a
regional anesthetic technique first
described in 2001
 It is useful in procedures requiring nerve
block in the anterior abdominal wall region,
from T6 to L1
 It was first used as a blind landmark
technique but more recently it has been
used under ultrasound guidance
 TAP blocks are important because they can
be used as an alternative analgesic
solution in surgery

8. Background
 The ultimate goal of TAP blocks is to
increase analgesia with the use of local
anesthetic
 Absolute contraindications include infection
at the site, allergy to local anesthetic and
patient refusal
 Although complications are rare, TAP
blocks are underutilized
 Beneficial for hysterectomies,
prostatectomies, Caesarean sections,
laparoscopic cholecystectomies and other
abdominal surgeries

9. Background
 The purpose of this research analysis
was to investigate the potential benefits
of the TAP block.
 Seven journal articles were reviewed.
 Some research studies focused on how
effective TAP blocks were in reducing
postoperative opioid use in various
populations.

10. Anatomy
http://www.hindawi.com/journals/arp/2012/731645/fig2/
Transverse section of the abdominal wall demonstrating the relevant
muscular structures and course of nerves (T7 – T12) within the TAP.

11. Anatomy
http://image.slidesharecdn.com/920307ultrasound-
guidedtransversusabdominisplanetapblockrasoul-141227030506-conversion-
gate02/95/ultrasound-guided-transversus-abdominis-plane-tap-block-12-

12. TAP Block Technique
 Ultrasound Anatomy
 https://www.youtube.com/watch?v=9TIHDn7
uBZI&feature=youtu.be&t=92 (at 1:31)
 TAP Block Technique
 https://www.youtube.com/watch?v=ab8Dvja
uk_U&feature=youtu.be&t=14

13. STUDY SAMPL
E SIZE
STUDY
DESIGN
VARIABLES OF
INTEREST
FINDINGS RECOMMENDATION
Baeriswyl,
M., et al.
1611 Meta analysis
of 31
randomized
controlled
studies
Cumulative IV morphine
consumption
postoperatively.
Pain scores at rest and on
movement at 6 and 24 hours
postoperatively.
Cumulative IV morphine consumption was
reduced by an average of 6 mg in favor of the
ultrasound-guided TAP block group at 6
hours postoperatively.
The use of TAP blocks provides increased
postoperative pain relief and reduces morphine
requirements.
Belavy,
D., et al.
50 Randomized,
double-blind,
placebo-
controlled
Patients receiving an active
TAP block and morphine
PCA compared to patients
receiving a placebo block
and morphine PCA.
In the 24 hours following caesarean delivery
the median morphine dose was 43% lower in
the active block group compared to the
placebo group.
The use of TAP blocks provides higher pain
relief and reduces morphine requirements.
Fields,
A.C., et al.
100 Randomized,
double-blind,
placebo-
controlled
TAP block vs. placebo
injection for laparoscopic
ventral hernia repair (LVHR)
Patients who received TAP blocks had
decreased cumulative opioid use and pain
scores compared with patients who received
a placebo.
The study supports using TAP blocks in LVHR.
It significantly decreases both short-term
postoperative opioid use and pain experienced
by patients.
Mrunalini,
P., et al.
60 Double-blind,
randomized,
controlled trial
TAP block vs. placebo on
post op pain score and
tramadol PCA pump use.
Mean total pain scores were significantly
lower in the TAP block group when compared
to the control group.
TAP block is effective for reducing post-op pain
and opioid usage after laparotomy.
Peterson,
P. L., et al.
80 Randomized,
double-blind,
placebo-
controlled
Patients were assessed at 0,
2, 4, 6, 8, and 24 hours for
post-op pain levels (when
coughing and at rest), opioid
consumption, and side
effects.
Pain levels were reduced in the TAP versus
the placebo group while coughing but not at
rest. Median morphine consumption was 7.5
mg in the placebo group versus 5 mg in the
TAP group.
TAP block after laparoscopic cholecystectomy
may have some beneficial effect in reducing
pain while coughing and on opioid
requirements.
Siddiqui,
M.R., et
al.
174 Meta-analysis
of 4
randomized
control studies
Mean 24 hour opioid use,
time elapsed before first
request for post-op
analgesia, pain scores at
three post-op intervals.
Reduction in post-operative opioid use,
increased time between first request for
analgesia, and reduction of pain scores in
PACU in TAP block group.
TAP block is comparable to morphine for post-
operative analgesia. Growing evidence points
towards a role in routine abdominal surgery.
Wu, Y., et
al.
90 Randomized,
double blind,
intention to
treat basis
TAP block vs. placebo on
morphine consumption at 24
hours and pain scores.
TAP block with general anesthesia effectively
reduces morphine consumption and lowers
pain scores in the first 24 hours compared
with general anesthesia alone.
TAP block along with general anesthesia may
reduce postoperative pain.

14. • Average opioid amount given was lower in TAP block groups
• Average lower postoperative pain scores in TAP block groups
• Increase time to first request for further analgesia in TAP block groups

15. Recommendations
 By utilizing the TAP block patients may
be able to consume less opioids and
experience less pain postoperatively
than if the case was strictly a general
anesthesia case with opioids as the sole
pain relief adjunct

16. Article
Author
Strengths Weaknesses Grade
Baeriswyl,
M., et al.
This meta-analysis examined 31 controlled trials including
1611 adult participants. This study included all types of
abdominal surgeries in adult patients. The large and varied
sample size allows results to be generalized to a large
population.
Evidence of publication bias in favor of TAP blocks.
Large amount of heterogeneity between stuides.
1A
Belavy, D., et
al.
There was no evidence of researcher bias throughout the
study. The study only had one independent variable so the
internal validity was high.
Study had small sample size, & only compared pt’s
undergoing cesareans.
1B
Fields, A.C.,
et al.
Internal validity high, independent variable consistent
throughout the study. External validity-because of this study
generalizations can be made about pt’s undergoing LVHR
will benefit from receiving TAP block , by reducing post-op
pain & opioid use.
Surgeons had knowledge of group assignments,
some pt’s excluded from study, & data not collected
on clinical differences.
1A
Mrunalini, P.,
et al.
Internal validity high. Confounding information not included
like morbidly obese, drug dependence on opioids, and
psychiatric disorders. Researcher bias not present.
Findings limited to 24hr post op. Ultrasound guided
not used. External validity. Not easily generalized to
all patients undergoing laparoscopic procedures.
1A
Peterson,
P.L., et al.
Internal validity high, external validity also high for any
patients having laparoscopic abdominal surgery. Sampling
technique: randomized, double-blind. Data collected at
regular intervals and consistent. No evidence of researcher
bias throughout the study.
No assessment data b/ 8-24hrs, no sensory
assessment done after blocks were performed to
compare their effectiveness.
1A
Siddiqui,
M.R., et al.
Inclusion was completed by three separate researchers,
eliminating personal bias. Despite small sample size, meta-
analysis provides opportunity to for comparison of results
among separate studies.
Small sample size for meta-analysis. Heterogeneity
of studies associated with different surgeries &
timing/length of block administration.
1A
Wu, Y., et al.
Internal validity high, external validity also high. Independent
variables were consistent throughout the study. Sampling
technique was randomized and single-blind. No evidence of
research bias was notable.
Pt’s w/ ASA>III & BMI>30 were excluded, which
limits the external generalizability. Only single-
injection subcostal TAP block was studied vs.
continuous-infusion TAP block, even though a
continuous epidural was used for comparison.
1A

17. Clinical Implications
Opioid Amount?
VAS Pain Scores?
Time to Request (More Analgesia)

18. • In our studies the use of TAP
blocks provided higher pain relief
and reduced opioid consumption
when compared to placebo
groups
• TAP blocks were found especially
beneficial during times of activity
or coughing postoperative lay

19. While all the studies suggest a decrease in pain scores and
opioid administration there is a wide variation on the degree of
benefit across the literature review.
Additionally, none of the studies in the review show a significant
decrease in opioid related side effects such as nausea,
vomiting, or decrease GI motility.

20. References
Belavy, D., Colishaw, P., Howes, M. & Phillips, F. (2009). Ultrasound-guided transversus abdominis
plane block for analgesia after Caesarean Delivery. British Journal of Anesthesia, 103(5), 726-730.
doi:10.1093
Baeriswyl, M., Kirkham, K. R., Kern, C., & Albrecht, E. (2015). The Analgesic Efficacy of Ultrasound-
Guided Transversus Abdominis Plane Block in Adult Patients. Anesthesia & Analgesia, 121(6), 1640-
1654. Retrieved December 21, 2015.
Fields, A.C., Gonzalez, D.O., Chin, E.H., Nguyen, S.Q., Zhang, L.P., Divino, C.M. (2015).
Laparoscopic-assisted transversus abdominis plane block for postoperative pain control in
laparoscopic ventral hernia repair: a randomized controlled trial. American College of Surgeons,
221(2), 462-469. doi: 10.1016/j.jamcollsurg
Mrunalini, P., Raju, N.V.R., Nath, V.N., Saheb, S.M. (2014). Efficacy of transversus abdominis plane
block in patients undergoing emergency laparotomies. Anesthesia: Essays and Researches, 8(3),
377-382. doi: 10.4103/0259-1162.143153
Peterson, P. L., Stjernholm, P., Kristiansen, V. B., Torup, H., Hansen, E. G., Mitchell, A. U., . . .
Mathiesen, O. (2012). The beneficial effect of transversus abdominis plane block after laparoscopic
cholecystectomy in day-case surgery: a randomized clinical trial. Anesthesia & Analgesia, 115(3),
527-533. doi: 10.1213/ANE.0b013e318261f16e
Siddiqui, M.R., 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(1), 7–14.
[PubMed: 21296242]
Wu, Y., Liu, F., Tang, H., Wang, Q., Chen, L., Wu, H., . . . Xu, X. (2013). The Analgesic Efficacy of
Subcostal Transversus Abdominis Plane Block Compared with Thoracic Epidural Analgesia and
Intravenous Opioid Analgesia After Radical Gastrectomy. Regional Anesthesia, 117(2), 507-513.
doi:10.1213/ANE.0b013e318297fcee