Interfascial Plane Blocks: Should We Believe the Hype?

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By the end of this lecture, the learner will be able to: 1. Review the anatomy and techniques for new interfascial plane blocks; 2. Discuss the evidence for these regional analgesic procedures; and 3. Present an approach to evaluate new techniques.

@EMARIANOMD
#WAS2020
Interfascial Plane Blocks
Should We Believe the Hype?
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 #WAS2020
Overview
 How did interfascial plane blocks start?
 Are TAP blocks obsolete?
 What’s new?

@EMARIANOMD #WAS2020
Transversus Abdominis Plane (TAP) Block
 Patient supine
 Identify Triangle of
Petit in mid-axillary line
cephalad to iliac crest
 Needle is inserted
perpendicular to skin
through T of P
 After 2 “pops,” inject
local anesthetic
McDonnell JG. A&A 2007;105:883

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Posterior TAP Dye Spread
McDonnell JG. A&A 2007;105:883
LA Spread

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TAP Block Anatomy
TA
IO

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Ultrasound-Guided TAP
 Patient supine or
lateral
 Scan transverse
(anterior-posterior
plane) between iliac
crest and costal
margin
 Identify 3 muscular
layers (EO, IO, TA)
 Guide needle in-plane
into TAP
Belavy D. BJA 2009;103:726

@EMARIANOMD #WAS2020
Subcostal TAP with Hydrodissection
Hebbard P. A&A 2008;106:674
Barrington MJ, et al. Anaesth 2009;64:745

@EMARIANOMD #WAS2020
Early Debate about Dermatomal Spread
 T10-L1 (1 injection)1,2
– Waiting 30 minutes
 T7-L1 (1 injection)3
– Waiting 2 hours?
– 20 ml per side
 T8-L14,5
– Multiple injections
1. Shibata Y. A&A 2007;105:883
2. Tran TM. BJA 2009;102:123
3. McDonnell JG. A&A 2007;105:883
4. Hebbard P. A&A 2008;106:674
5. Barrington MJ. Anaesth 2009;64:745

@EMARIANOMD #WAS2020
Stoving, et al. RAPM 2015

@EMARIANOMD #WAS2020
TAP Block vs. Placebo
 3 randomized, placebo-controlled trials:
bilateral TAP injections with ropivacaine vs.
saline for hysterectomy1 and C-section2,3
– Lower VAS pain scores in TAP group1,2
– Lower total morphine consumption (mg) in
TAP group1-3
– Less antiemetic therapy and higher satisfaction
with pain relief in TAP group3
1. Carney J. A&A 2008;107:2056
2. McDonnell JG. A&A 2008;106:186
3. Belavy. BJA 2009;103:726

@EMARIANOMD #WAS2020
Colorectal Dis. 2018;20:279

@EMARIANOMD #WAS2020
Can J Anaesth. 2016;63:1184

@EMARIANOMD #WAS2020
• Learn in 4 attempts
• Set-up + bilateral blocks
= 6 min or less!

@EMARIANOMD #WAS2020
Leng & Mariano. RAPM 2020

@EMARIANOMD #WAS2020
Role for Rescue Analgesia?
 3 cases of bilateral TAP blocks used for
rescue analgesia s/p CS under spinal
 Mean decrease in pain score=7; mean
duration=14 hrs
Mirza & Carvalho. CJA 2013;60:299

@EMARIANOMD #WAS2020
Continuous TAP Blocks
Khatibi et al. A&A 2017;124:1298

@EMARIANOMD #WAS2020
Still More Questions
Tran, et al. Anesthesiology 2019

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Newer Truncal Blocks
Chin et al. RAPM 2017;42:133

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Quadratus Lumborum Block
Chin et al. RAPM 2017;42:133

@EMARIANOMD #WAS2020
Anesthesiology. 2019;130:322
Will the real QL please
stand up?

@EMARIANOMD #WAS2020
Erector Spinae Plane Block
Forero, et al. RAPM 2016;41:621

@EMARIANOMD #WAS2020
Erector Spinae Plane Block
Tsui, et al. JCA 2019;53:29

@EMARIANOMD #WAS2020
Ivanusic, Konishi, Barrington. RAPM 2018;43:567

@EMARIANOMD #WAS2020
Anaesthesia 2018;73:1185

@EMARIANOMD #WAS2020
Anaesthesia 1979;34:638

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Mugadza, Mariano, Mazonde. JCA 2019

@EMARIANOMD #WAS2020
Time to Change What We Teach
Turbitt, Mariano, El-Boghdadly. Anaesthesia 2020

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Time to Change What We Teach
Turbitt, Mariano, El-Boghdadly. Anaesthesia 2020
Need to Teach Transferable Skills

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Is There a New Gold Standard?
Insufficient RCT evidence to
support interfascial plane blocks
over epidural for laparotomy

@EMARIANOMD #WAS2020
Summary
 We discussed:
– How did interfascial plane blocks start?
– Are TAP blocks obsolete?
– What’s new?

Upon completion of this presentation, participants will be able to: 1. Discuss the challenge of losing identity and apply strategies to establish a brand; 2. Review missed opportunities in adopting new technology and identify potential applications in future operating room models; 3. Understand barriers to change implementation and develop a team approach that redefines challenges as opportunities.

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Interfascial Plane Blocks: Should We Believe the Hype?

1. @EMARIANOMD #WAS2020 Interfascial Plane Blocks Should We Believe the Hype? 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

2. @EMARIANOMD #WAS2020 Disclosures  None

3. @EMARIANOMD #WAS2020 Overview  How did interfascial plane blocks start?  Are TAP blocks obsolete?  What’s new?

4. @EMARIANOMD #WAS2020 Overview  How did interfascial plane blocks start?  Are TAP blocks obsolete?  What’s new?

5. @EMARIANOMD #WAS2020 Transversus Abdominis Plane (TAP) Block  Patient supine  Identify Triangle of Petit in mid-axillary line cephalad to iliac crest  Needle is inserted perpendicular to skin through T of P  After 2 “pops,” inject local anesthetic McDonnell JG. A&A 2007;105:883

6. @EMARIANOMD #WAS2020 Posterior TAP Dye Spread McDonnell JG. A&A 2007;105:883 LA Spread

7. @EMARIANOMD #WAS2020 TAP Block Anatomy TA IO

8. @EMARIANOMD #WAS2020 Ultrasound-Guided TAP  Patient supine or lateral  Scan transverse (anterior-posterior plane) between iliac crest and costal margin  Identify 3 muscular layers (EO, IO, TA)  Guide needle in-plane into TAP Belavy D. BJA 2009;103:726

9. @EMARIANOMD #WAS2020 Subcostal TAP with Hydrodissection Hebbard P. A&A 2008;106:674 Barrington MJ, et al. Anaesth 2009;64:745

10. @EMARIANOMD #WAS2020 Early Debate about Dermatomal Spread  T10-L1 (1 injection)1,2 – Waiting 30 minutes  T7-L1 (1 injection)3 – Waiting 2 hours? – 20 ml per side  T8-L14,5 – Multiple injections 1. Shibata Y. A&A 2007;105:883 2. Tran TM. BJA 2009;102:123 3. McDonnell JG. A&A 2007;105:883 4. Hebbard P. A&A 2008;106:674 5. Barrington MJ. Anaesth 2009;64:745

11. @EMARIANOMD #WAS2020 Stoving, et al. RAPM 2015

12. @EMARIANOMD #WAS2020 Overview  How did interfascial plane blocks start?  Are TAP blocks obsolete?  What’s new?

13. @EMARIANOMD #WAS2020 TAP Block vs. Placebo  3 randomized, placebo-controlled trials: bilateral TAP injections with ropivacaine vs. saline for hysterectomy1 and C-section2,3 – Lower VAS pain scores in TAP group1,2 – Lower total morphine consumption (mg) in TAP group1-3 – Less antiemetic therapy and higher satisfaction with pain relief in TAP group3 1. Carney J. A&A 2008;107:2056 2. McDonnell JG. A&A 2008;106:186 3. Belavy. BJA 2009;103:726

14. @EMARIANOMD #WAS2020 Colorectal Dis. 2018;20:279

15. @EMARIANOMD #WAS2020 Can J Anaesth. 2016;63:1184

16. @EMARIANOMD #WAS2020 • Learn in 4 attempts • Set-up + bilateral blocks = 6 min or less!

17. @EMARIANOMD #WAS2020 Leng & Mariano. RAPM 2020

18. @EMARIANOMD #WAS2020 Stoving, et al. RAPM 2015

19. @EMARIANOMD #WAS2020 Role for Rescue Analgesia?  3 cases of bilateral TAP blocks used for rescue analgesia s/p CS under spinal  Mean decrease in pain score=7; mean duration=14 hrs Mirza & Carvalho. CJA 2013;60:299

20. @EMARIANOMD #WAS2020 Continuous TAP Blocks Khatibi et al. A&A 2017;124:1298

21. @EMARIANOMD #WAS2020 Still More Questions Tran, et al. Anesthesiology 2019

22. @EMARIANOMD #WAS2020 Overview  How did interfascial plane blocks start?  Are TAP blocks obsolete?  What’s new?

23. @EMARIANOMD #WAS2020 Newer Truncal Blocks Chin et al. RAPM 2017;42:133

24. @EMARIANOMD #WAS2020 Quadratus Lumborum Block Chin et al. RAPM 2017;42:133

25. @EMARIANOMD #WAS2020 Anesthesiology. 2019;130:322 Will the real QL please stand up?

26. @EMARIANOMD #WAS2020 Erector Spinae Plane Block Forero, et al. RAPM 2016;41:621

27. @EMARIANOMD #WAS2020 Erector Spinae Plane Block Tsui, et al. JCA 2019;53:29

28. @EMARIANOMD #WAS2020

29. @EMARIANOMD #WAS2020 Ivanusic, Konishi, Barrington. RAPM 2018;43:567

30. @EMARIANOMD #WAS2020 Anaesthesia 2018;73:1185

31. @EMARIANOMD #WAS2020 Anaesthesia 1979;34:638

32. @EMARIANOMD #WAS2020

33. @EMARIANOMD #WAS2020 RAPM 2020

34. @EMARIANOMD #WAS2020 Mugadza, Mariano, Mazonde. JCA 2019

35. @EMARIANOMD #WAS2020 Time to Change What We Teach Turbitt, Mariano, El-Boghdadly. Anaesthesia 2020

36. @EMARIANOMD #WAS2020 Time to Change What We Teach Turbitt, Mariano, El-Boghdadly. Anaesthesia 2020 Need to Teach Transferable Skills

37. @EMARIANOMD #WAS2020 Is There a New Gold Standard? Insufficient RCT evidence to support interfascial plane blocks over epidural for laparotomy

38. @EMARIANOMD #WAS2020 Summary  We discussed: – How did interfascial plane blocks start? – Are TAP blocks obsolete? – What’s new?

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Interfascial Plane Blocks: Should We Believe the Hype?