Subcostal Transverse Abdominal Plane (TAP) Catheters: A Novel Approach To Aid ExtubationAfter Clamshell Thoracotomy

Nicholas Wegener MD, Neil Borad MD, Shona Lee MD, Shelby Badani MD

Introduction:

Incisional pain post-thoracotomy can be challenging.

Predisposes to ventilation-perfusion mismatch, hypoxemia, infection, increased opioid use, increased length of stay, increased respiratory support (1-3).

50% develop post-thoracotomy pain syndrome (1).

Gold standard is thoracic epidural infusion.

Side effects include hypotension, urinary retention, epidural hematoma.

Contraindicated with pharmacologic anticoagulation and coagulation disorders.

Alternatives include paravertebral, intercostal nerve, and fascial plane blocks (1-3).

Subcostal TAP blocks anesthetize the T6-T9 intercostal nerves (4-5).

Commonly used after upper abdominal surgeries.

Goal of early pain control is to improve respiratory mechanics and prevent conversion of acute to chronic pain.

Discussion:

Planned preoperative thoracic epidural placement deferred by surgical team morning of surgery.

Surgical team opting for intraoperative cryoablation (ultimately not performed).

Thoracic epidural contraindicated post-operatively in setting of initiation therapeutic anticoagulation.

Erector spinae, paravertebral, and serratus catheters deferred POD 1 given hemodynamic status, body habitus, positioning, and numerous lines and drains.

Subcostal TAPs have been used successfully post-liver transplant to aid in extubating (4,5).

Based on incision location and patient confirmation of pain location, decided on potential benefit of subcostal TAP catheters.

Subsequently weaned from ventilator with satisfactory pain control. 

This case report identifies a novel approach to treating post-operative clamshell pain in scenarios where conventional regional techniques are contraindicated.