WHERE are you hurting???
It is critically important that you evaluate closely the location (and quality) of your patient’s pain before recommending changes in therapy or deciding whether your TAP or Subcostal TAP block is functioning properly. Without proper evaluation (and elucidating in the chart or face to face), your block may be considered a failure, seen as a waste of money or could even lead to worse outcomes. Beyond these, if you can’t figure out what is going on, you will certainly not be able to optimize your patient care goals. It is critical to your ability to expand your nerve block program, especially early on, that you be able to understand the subtleties of pain evaluation and what your blocks cover (& what they do not cover). In addition, this will help you to select the most appropriate location of your TAP block placement from the start!
Let’s talk about this in reference to the TAP block. I have done hundreds of TAP blocks for abdominal surgery and found the visceral pain element to be minimal or non-existent. This is especially true in colon resections as the bowels are not stretching at all due to the initial surgically-induced ileus. Many patients go without opioids at all throughout their hospitalization, ambulate early and get return of bowel function quickly. Therefore, this is not a debate of whether this is an adequate or optimal decision or not; this is a discussion of how to optimize this therapy.
First, do not accept vague descriptions from your patient about where they are hurting. The turned away head and waving hand somewhere over the abdomen are completely useless. Tell them to use one finger to point to the area that hurts. You want to find out if that is at baseline or only with P.T. and/or coughing. Determining the quality of their sensation without leading them into one thing or another is another important skill. We’ll discuss more about obtaining a good pain history in future posts.
I break down the regions that you should evaluate in the above drawing. You should use an objective tool to determine surface sensation and/or temperature discrimination as well as the patient’s report of location of pain.
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I hope this was helpful and will be on your mind the next time you consider doing a TAP block or are following-up on your patients the following days! Consider your plan for TAP blocks for the following incisions: