49th Annual Regional Anesthesiology and Acute Pain Medicine Meeting

Transversus abdominus plane block as major component for pain management of necrotizing abdominal wall carcinoma.

Introduction:

The transversus abdominus plane (TAP) block is commonly used as a method of supplemental analgesia in abdominal surgeries. While this block has become commonplace for treating incisional pain, this case demonstrates a specific instance in which the TAP block became a major component of the patient’s post-operative analgesia. In this case, we discuss using TAP blocks for surgical disease involving the abdominal wall.

Materials and Methods:

Patient informed consent was obtained for submission of a case report.

Case History:

58 y/o female who had an abdominal wall debridement and debulking for a necrotizing abdominal wall mass

Past medical history: Metastatic squamous cell carcinoma, hypothyroidism, and chronic cancer pain with daily opioid use.

Home medications: Hydrocodone, levothyroxine

Allergies: None

The Challenge

Pre-op Course:

•Patient was admitted to the hospital for a necrotizing abdominal wall mass in the setting of squamous cell carcinoma

•In hospital pain scores of 8-9/10

•Pain regimen of scheduled oral hydrocodone, as needed oral oxycodone, and intravenous morphine for breakthrough pain.

•She was scheduled for an abdominal wall debulking and debridement prior to starting chemotherapy.

Intra-op Course:

•She received 50 mcg of fentanyl on induction, 8 mg of dexamethasone, and 20 mg of methadone.

•Post induction, a lateral TAP block was performed with 30ml per side of 0.25% ropivacaine and epinephrine 1:200,000, under ultrasound guidance (Figure 1).

Post-op Course:

•In PACU the patient reported 0/10 pain for the first 6 hours post procedure, then 2/10 pain

•On revaluation two days post op, she reported good pain relief with an “abrupt increase” in pain about 24 hours after the procedure with associated increase in her opioid intake.

•Pain scores returned to 8-9/10 in severity

Discussion:

Rationale for treatment plan:

TAP block places local anesthetic between transversus abdominis and internal oblique muscle planes; this will target the anterior rami of T7-T12.1,2

Epinephrine was added to increase block duration1

Intravenous methadone was started in the OR for longer duration of action and NMDA receptor benefits

Change in approach:

Continuous infusion catheters3

Preservative free dexamethasone

Incorporation of methadone into pain regimen

49th Annual Regional Anesthesiology and Acute Pain Medicine Meeting

TRANSVERSUS ABDOMINIS PLANE BLOCK AS MAJOR COMPONENT FOR PAIN MANAGEMENT OF NECROTIZING ABDOMINAL WALL CARCINOMA

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