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Accreditation Dings - August 2013 - Outpatient Surgery Magazine

Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.

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OSE_1308_part3_Layout 1 8/8/13 11:10 AM Page 120 ANESTHESIA ALERT cal landmarks to locate the proper needle insertion site on the lateral abdominal wall — then inserting a needle through it and advancing it until 2 pops were felt, indicating the needle had passed through the fascial layers of the external and internal oblique muscles. Ideally, the needle was then within the TAP and could deposit local anesthetic. But the landmark technique was challenging and the results were variable and unpredictable. By using ultrasound, which shows in real time the needle advancing through the muscle layers, we can improve the safety and effectiveness of needle placement. And we can confirm that the needle tip has reached the TAP by injecting l to 2ml of normal saline or local anesthetic. This appears on ultrasound as a hypoechoic or dark area between the fascial layers, as you can see in the ultrasound image. We can also see the remaining local anesthetic as it's administered. 3 common injection sites The distribution of the block depends on the injection site and the volume of local anesthetic. The 3 most common methods for accessing the TAP are the subcostal, mid-axillary and ilioinguinal-iliohypogastric (II/IH) approaches. • Subcostal. The subcostal injection site is inferior to the costal margin near the linea semilunaris. This approach targets nerves T7-12, and is best for upper abdominal surgeries. • Mid-axillary. The mid-axillary injection site is near the mid-axillary line between the costal margin and iliac crest. This approach is ideal for abdominal surgeries below the umbilicus, because it targets nerves T10-L1. • Ilioinguinal-iliohypogastric. The II/IH injection site is medial and superior to the anterior superior iliac spine, which more reliably blocks the 2 branches of L1 (ilioinguinal and iliohypogastric nerves), 1 2 0 O U T PAT I E N T S U R G E R Y M A G A Z I N E O N L I N E | A U G U S T 2013

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