Regional anesthesia has become more popular in recent years due to several factors. An increasing prevalence of enhanced recovery after surgery (ERAS) protocols, increased access to improved ultrasound technology, and a greater appreciation for their opioid-sparing effects have made regional anesthesia a mainstay for a variety of practices.
One of the most ubiquitous blocks in an anesthesiologists’ armamentarium is the Transversus Abdominal Plane (TAP) block. The TAP block is easy to perform, has a low-risk profile, and provides reliable analgesia for abdominal procedures. This procedure is so “safe”, that some anesthesiologists wonder if it is appropriate to perform TAP blocks on anesthetized patients without obtaining consent.
A typical informed consent for a general anesthetic details common associated risks, including damage to the lips, teeth or gums, sore throat, hoarseness, pain, nausea, loss of airway. Uncommon, yet grave complications including heart attack, death or stroke should be mentioned as well and discussed as appropriate given a patient’s comorbidities. If a regional technique or other invasive procedure is anticipated, they should be discussed. Clinicians know all-too-well that surgeries do not always go as planned. Surgical and anesthetic consent forms typically contain a clause explaining that the operative team will perform appropriate life-saving interventions as indicated.
TAP blocks are an adjunct to a multi-modal approach to analgesia. It is difficult to imagine a scenario when a TAP block would be regarded a life-saving intervention; however, if this scenario were to present, it would be appropriate to proceed based on one’s clinical judgement. There are many scenarios when a patient would greatly benefit from a fascial plane block, especially in the setting of multiple co-morbidities when analgesia and opioid-reducing would greatly enhance recovery and possibly reduce morbidity. In these situations, it would be appropriate to consent the patient after emergence once capacity has been regained.
Some clinicians may consider soliciting consent from the patient’s medical decision-maker or healthcare power of attorney. However, since a TAP block is rarely (if ever) an emergent, life-saving intervention, this would be an inappropriate course of action. Obtaining consent from a surrogate decision maker should be reserved for situations in which a delay in care would lead to loss of life, limb, or increased morbidity.
Additionally, if it is likely that a patient will not regain capacity within a reasonable amount of time, then it would be appropriate to discuss goals of care with a surrogate decision maker and provide care that is conducive to the patient’s prior-expressed goals. Soliciting consent from a surrogate decision-maker should be reserved for the gravest of circumstances.
Some clinicians argue that TAP blocks have incredibly low rates of complications. Although this is true, clinicians should still refrain from performing a procedure for which a patient did not consent. The ethical principle of autonomy is not dictated by the associated procedural risks. Autonomy is a patient’s fundamental right to self-govern, and clinicians should attempt to respect this standard whenever possible.
A comparison has been made to establishing intravenous access. Anesthesiologists do not typically solicit consent prior to placing an IV in the preoperative holding area. However, a patient has consented to surgery and anesthesia merely by presenting to the hospital the day of surgery (likely following a work-up in the surgeon’s clinic). Furthermore, a patient assents to an IV placement since they could at any point during the procedure, refuse all further attempts.
Performance of a TAP block should be preceded by an informed consent that discusses the possible complications that are common to all regional anesthetics: local anesthetic systemic toxicity, failed block, infection, hematoma, and/or damage to other structures. Respect for patient autonomy requires informed consent be obtained prior to performing an invasive procedure.
Some clinicians may argue that a TAP block is indicated for their patient based upon beneficence. Under the reasonable-patient standard, most patients would want the best option for pain management. Altruism makes it difficult to “doom” a patient to unmanageable post-operative pain. However, there are multiple options for post-operative pain control. Studies show that TAP blocks are not superior to a multi-modal analgesic approach to pain management that does not incorporate regional anesthesia. Alternative methods should be employed to provide adequate post-operative analgesia. Once a patient regains capacity, the clinician can discuss the risks, benefits and alternatives of a TAP block and solicit an informed decision.
Finally, some clinicians may argue that surgeons commonly perform TAP blocks without explicit informed consent. A surgeon’s consent generally covers other indicated procedures. It is also not uncommon for surgeons to infiltrate local anesthetic into their surgical field.
A TAP block performed by a surgeon requires no significant deviation from their standard practice. However, as anesthesiologists, our standard practice is to obtain informed consent prior to performing an elective, peripheral nerve block. Diverging from standard practice places clinicians into an area that may be difficult to navigate resulting in moral-distress, “doctor-shopping” or an internal ethical dilemma. The standard of care mandates an anesthesiologist solicits informed consent prior to performing an invasive procedure.
Although transversus abdominal plane blocks are a safe component of a multi-modal approach to analgesia, clinicians should always obtain informed consent prior to their performance. A simple solution would be encouraging clinicians to consent each patient undergoing intra-abdominal surgery for a potential TAP block. This approach allows for patient autonomy by providing a brief discussion of the associated risks and benefits of the procedure. Departments should work to develop policies and protocols, ensuring they provide standardized and consistent care.
Anesthesiologists must work to ensure ethical care is provided to all patients and for all services rendered.
References
- Taylor R Jr, Pergolizzi JV, Sinclair A, Raffa RB, Aldington D, Plavin S, Apfel CC. Transversus abdominis block: clinical uses, side effects, and future perspectives. Pain Pract. 2013 Apr;13(4):332-44. doi: 10.1111/j.1533-2500.2012.00595.x. Epub 2013 Feb 13. PMID: 22967210.
- De Q. Tran, Daniela Bravo, Prangmalee Leurcharusmee, Joseph M. Neal; Transversus Abdominis Plane Block: A Narrative Review. Anesthesiology 2019; 131:1166–1190 doi: https://doi.org/10.1097/ALN.0000000000002842