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Bird of New Zealand - photo by Tom Yanagi, M.D.
At times one would prefer to avoid general anesthesia for laparoscopic dialysis catheter placement. Bilateral subcostal TAP blocks with IV sedation offer another option for dealing with these chronically ill patients.
The patient was a 120 kg 30 year old male with ESRD, hypertention, and diabetes who presented for CAPD catheter revision. The surgical plan was to use low pressure insufflation and exteriorize the catheter, clear the obstructed ports, and replace it.
The patient received fentanyl 100ug and midazolam 2mg IV. Bilateral subcostal TAP blocks using 30 cc of 1.5% lidocaine on each side were placed under ultrasound guidance. Lidocaine was chosen for its rapidity of onset, but mepivacaine 2% may be a suitable choice for its longer post operative analgesia.
A propofol infusion was begun. The surgeon injected lidocaine at the port sites. The patient tolerated the pneumoperitoneum without requiring additional narcotics or changing the propofol infusion rate. There was a slight reaction when the trochars were placed, but otherwise the procedure proceeded uneventfully. In all the patient received only the preblock medication and 158 mg of propofol for the entire case.
An excellent video presented by Dr. Brandon Winchester describes both the posterior and subcostal TAP blocks. The video is 45 minutes long, but the description of the TAP blocks are found in minutes 15-35.
Cairns, Australia - photo by Tom Yanagi, M.D.
