This was part of a debate held at #ANES20 (recording available from ASA) between me and Dr. Jeff Gadsden from Duke University School of Medicine. Dr. Gadsden and I clashed on the same topic last year at #ANES19 during which I promoted thoracic epidural analgesia, and Dr. Gadsden made the case for interfascial plane blocks. This year we switched sides! Link to my slides from #ANES19: https://www.slideshare.net/EdwardRMariano/thoracic-epidural-analgesia-is-the-gold-standard-for-major-abdominal-surgery The objectives of this session were as follows: 1. Discuss multimodal pain management strategies in the context of enhanced recovery programs; 2. Discuss advantages and disadvantages of thoracic epidural analgesia for major abdominal surgery in the context of enhanced recovery programs; 3. Discuss advantages and disadvantages of truncal somatic blocks in the context of enhanced recovery programs; and 4. Discuss developing safe and effective procedure specific pain management strategies for major abdominal surgery.

1. @EMARIANOMD
In Case You Missed Gadsden vs. Mariano I

2. Gadsden vs. Mariano II
Thoracic Epidural vs. Interfascial Plane Blocks
THIS TIME IT’S VIRTUAL
#ANES20

3. @EMARIANOMD
Switched Sides: Now I’m the Underdog

4. Interfascial Plane Blocks Offer a Safer, More
Efficacious and Cost-Effective Alternative to
Thoracic Epidural Analgesia
Edward R. Mariano, M.D., M.A.S.
Professor of Anesthesiology, Perioperative & Pain Medicine
Stanford University School of Medicine
Chief, Anesthesiology and Perioperative Care
Veterans Affairs Palo Alto Health Care System
@EMARIANOMD
#ANES20

5. Interfascial Plane Blocks Offer a Safer, More
Efficacious and Cost-Effective Alternative to
Thoracic Epidural Analgesia
Edward R. Mariano, M.D., M.A.S.
Professor of Anesthesiology, Perioperative & Pain Medicine
Stanford University School of Medicine
Chief, Anesthesiology and Perioperative Care
Veterans Affairs Palo Alto Health Care System
@EMARIANOMD
#ANES20

6. Interfascial Plane Blocks Offer a Safer, More
Efficacious and Cost-Effective Alternative to
Thoracic Epidural Analgesia
Edward R. Mariano, M.D., M.A.S.
Professor of Anesthesiology, Perioperative & Pain Medicine
Stanford University School of Medicine
Chief, Anesthesiology and Perioperative Care
Veterans Affairs Palo Alto Health Care System
@EMARIANOMD
#ANES20

7. @EMARIANOMD
Disclosures
 None

8. @EMARIANOMD
Let’s Pretend that Jeff Likes Epidurals

9. @EMARIANOMD
Let’s Pretend that Jeff Likes Epidurals

10. @EMARIANOMD
I Will Not Try to Prove Superiority
Epidural
Interfascial
Plane Blocks

11. @EMARIANOMD
My Objectives
 Redefine major abdominal surgery
 Discuss the future of thoracic epidural analgesia
 Prove to you that interfascial plane blocks are an
acceptable alternative to thoracic epidural

12. @EMARIANOMD
My Objectives
 Redefine major abdominal surgery
 Discuss the future of thoracic epidural analgesia
 Prove to you that interfascial plane blocks are an
acceptable alternative to thoracic epidural

13. @EMARIANOMD
What Is Major Abdominal Surgery?

14. @EMARIANOMD
What Is Major Abdominal Surgery?

15. @EMARIANOMD
What Is Major Abdominal Surgery?
Still Need Epidural?

16. @EMARIANOMD
My Objectives
 Redefine major abdominal surgery
 Discuss the future of thoracic epidural analgesia
 Prove to you that interfascial plane blocks are an
acceptable alternative to thoracic epidural

17. @EMARIANOMD
Major abdominal
surgery patients who
get an epidural
Major abdominal
surgery patients who
DON’T get an epidural
Elsharydah, et al. Proc (Bayl Univ Med Cent) 2017
Kim, et al. Pancreas 2020
• 15% colectomy
• 19% distal pancreatectomy
• 23% pancreaticoduodenectomy

18. @EMARIANOMD
Kim, et al. Pancreas 2020

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RAPM 2012;37:310

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Residency Training in Thoracic Epidurals
https://www.acgme.org/Specialties/Program-Requirements-and-FAQs-and-
Applications/pfcatid/6/Anesthesiology

22. @EMARIANOMD

23. @EMARIANOMD
Growing Role for Subspecialists?
Parra et al. RAPM 2017;42:17
Auyong et al. RAPM 2017;42:204
How many
residency
graduates can
routinely do this?

24. @EMARIANOMD
My Objectives
 Redefine major abdominal surgery
 Discuss the future of thoracic epidural analgesia
 Prove to you that interfascial plane blocks are an
acceptable alternative to thoracic epidural

25. @EMARIANOMD
Mariano & Schatman. J Pain Res 2019

26. @EMARIANOMD
We Have Plenty of Alternatives to Epidural
Chin et al. RAPM 2017;42:133

27. @EMARIANOMD
If Epidurals Were Perfect…
Tsui, et al. JCA 2019;53:29
Why so much interest in new
interfascial plane blocks?

28. @EMARIANOMD
Pragmatic Criteria Support Alternatives
Mudumbai, Auyong, Memtsoudis, Mariano. Pain Manag 2018

29. @EMARIANOMD
Major abdominal
surgery patients who
get an epidural
Major abdominal
surgery patients who
DON’T get an epidural
Elsharydah, et al. Proc (Bayl Univ Med Cent) 2017
Kim, et al. Pancreas 2020
• 15% colectomy
• 19% distal pancreatectomy
• 23% pancreaticoduodenectomy

30. @EMARIANOMD
Major abdominal
surgery patients who
get an epidural
Major abdominal surgery
patients who get
INTERFASCIAL PLANE BLOCKS
Elsharydah, et al. Proc (Bayl Univ Med Cent) 2017
Kim, et al. Pancreas 2020

31. @EMARIANOMD
Time to Focus on Basic Blocks
Turbitt, Mariano, El-Boghdadly. Anaesthesia 2020

32. @EMARIANOMD
Time to Focus on Basic Blocks
Turbitt, Mariano, El-Boghdadly. Anaesthesia 2020
Need to Teach Transferable Skills
TAP

33. @EMARIANOMD
• Learn in 4 attempts
• Set-up + bilateral blocks
= 6 min or less!

34. @EMARIANOMD
Qin, et al. BMC Anesthesiol 2020

35. @EMARIANOMD
Leng & Mariano. RAPM 2020

36. @EMARIANOMD
Still Much to Learn
Elsharkawy, Pawa, Mariano. RAPM 2018;43:341

37. @EMARIANOMD
Research Takes Time

38. @EMARIANOMD
Summary
 We redefined major abdominal surgery
 We discussed the future of thoracic epidural analgesia
 Hopefully I proved to you that interfascial plane blocks
are an acceptable alternative to thoracic epidural