dr. pry - tap block: clinical application for pain management_isapm manado 2015
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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
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 )
T E K N I K L A N D M A R K ( B L I N D )
• Triangular of Petit (TOP)
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”
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”
• McDonnel (2004) :cephalad dari krista iliakadi TOP, “double pop”
T E K N I K L A N D M A R K ( B L I N D )
T E K N I K L A N D M A R K ( B L I N D )
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%
T E K N I K L A N D M A R K ( B L I N D )
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
T E K N I K L A N D M A R K ( B L I N D )
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
T E K N I K L A N D M A R K ( B L I N D )
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
• Landmark alternatif ygdisarankan : posterior darigaris mid-aksilar pada areacephalad dari krista iliakaatau di LIP (latissimo-iliacpoint)
T E K N I K L A N D M A R K ( B L I N D )
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
• Landmark alternatif ygdisarankan : posterior darigaris mid-aksilar pada areacephalad dari krista iliakaatau di LIP (latissimo-iliacpoint)
T E K N I K L A N D M A R K ( B L I N D )
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
• Landmark alternatif ygdisarankan : posterior darigaris mid-aksilar pada areacephalad dari krista iliakaatau di LIP (latissimo-iliacpoint)
T E K N I K L A N D M A R K ( B L I N D )
Jankovic Z. Transversus abdominis plane block: The Holy Grail of anaesthesia for (lower) abdominal surgery. Period Biol, Vol 111, No 2, 2009; 203-8.
T E K N I K D I PA N D U U S G
• Pendekatan Posterior
• studi cadaver : penyebaran obat T10 - L1
T E K N I K D I PA N D U U S G
• Pendekatan Posterior
• studi cadaver : penyebaran obat T10 - L1
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
EOM
IOM
TAM
RAM
TAM
IOM
EOM
EOM
IOM
TAM
RAM
EOM
IOM
TAM
EOM
IOM
TAM
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
TAM
PC
RAM
TAM
PC
RAM
RAM
TAM
OEMLS
PC
TAM
PC
RAM
RAM
TAM
OEMLS
PC
TAM
PC
RAM
RAM
TAM
OEMLS
PC
TAM
PC
RAM
RAM
TAM
OEMLS
PC
TAM
IOM
EOM
TAM
PC
RAM
RAM
TAM
OEMLS
PC
TAM
IOM
EOM
TAM
PC
RAM
RAM
TAM
OEMLS
PC
TAM
IOM
EOM
TAM
PC
RAM
RAM
TAM
OEMLS
PC
TAM
IOM
EOM
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