Analgesia for Ex Lap

     What do you do for analgesia for your Ex Lap cases? Typical responses that I get are ‘nothing’ or ‘sometimes an epidural.’ Have you ever followed their post-op experience? If you don’t put in an epidural, I’m sure you probably don’t end up doing that. In the past, those have been MY responses. Today, it is different…very different.

     There is a bit of coordination and infrastructure to this, but I have found the results to have been well worth the investment. I have been putting in subcostal TAP catheters for the last few months in for many “Ex Lap-type” cases after the surgeon closes the incision. I have absolutely kept some of these patients from remaining intubated and have kept several more out of the ICU. In fact, I have had some patients take zero opioids of any kind post-operatively. Do you know how much quicker recovery occurs with little or no pain and no opioid side-effects and no epidural side-effects? Want to feel like you’ve made a difference in somebody’s hospitalization? This is the kind of thing that makes you excited to come to work every day!

     Here are a few tips that may help if you are considering this course. [nonmember]…

 

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First, pick thinner patients for your first attempts. Going down through a fair amount of adipose makes the angle more steep. As you continue to advance your needle, you are forced to go downward as you try to follow the angle of the ribs caudally. I use a six inch 18 gauge epidural needle, and I try my best to ‘hub’ the needle. For larger patients, I have found that bending the needle allows me to direct it distally in a more flat plane once I get to the space I am trying to traverse. It does, however, add another dimension to ultrasound guidance to have a needle advancing in-plane that is curved.

     I ask for a ten or fifteen minute ‘heads up’ warning and I try to get my supplies, already bundled together, out onto the field while they are closing. I ask also for them not to apply any bandages until I am finished since they always obstruct my path. You really feel the clock ticking when everyone is waiting on you to wake up the patient and get to the next case (or worse, go to lunch!), so every minute you can save is worth it. When starting out, flush your extension tubing with normal saline instead of local anesthetic since figuring out how to ‘bolus and advance’ successfully can have you run through a great deal of local on one side, and you may run into toxic doses before you know it. Track back will allow your bolus at the end to return the full length of your catheter to get complete coverage if needed in this circumstance.

     Finally, I have my anesthetists use fentanyl as needed during the case so that as my block is setting up, we don’t get a ‘relative overdose’ from long-acting opioids after I take away all the painful stimulation. Again, this block stuff is not a ‘one man band’. You need teamwork, education and communication to make something like this fly. It is the significant degree of support that I have around me that allows me to take care of my patients to this extent.

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