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Interfascial Plane Blocks: Should We Believe the Hype?

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.

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.

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Interfascial Plane Blocks: Should We Believe the Hype?

  1. 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. 2. @EMARIANOMD #WAS2020 Disclosures  None
  3. 3. @EMARIANOMD #WAS2020 Overview  How did interfascial plane blocks start?  Are TAP blocks obsolete?  What’s new?
  4. 4. @EMARIANOMD #WAS2020 Overview  How did interfascial plane blocks start?  Are TAP blocks obsolete?  What’s new?
  5. 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. 6. @EMARIANOMD #WAS2020 Posterior TAP Dye Spread McDonnell JG. A&A 2007;105:883 LA Spread
  7. 7. @EMARIANOMD #WAS2020 TAP Block Anatomy TA IO
  8. 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. 9. @EMARIANOMD #WAS2020 Subcostal TAP with Hydrodissection Hebbard P. A&A 2008;106:674 Barrington MJ, et al. Anaesth 2009;64:745
  10. 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. 11. @EMARIANOMD #WAS2020 Stoving, et al. RAPM 2015
  12. 12. @EMARIANOMD #WAS2020 Overview  How did interfascial plane blocks start?  Are TAP blocks obsolete?  What’s new?
  13. 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. 14. @EMARIANOMD #WAS2020 Colorectal Dis. 2018;20:279
  15. 15. @EMARIANOMD #WAS2020 Can J Anaesth. 2016;63:1184
  16. 16. @EMARIANOMD #WAS2020 • Learn in 4 attempts • Set-up + bilateral blocks = 6 min or less!
  17. 17. @EMARIANOMD #WAS2020 Leng & Mariano. RAPM 2020
  18. 18. @EMARIANOMD #WAS2020 Stoving, et al. RAPM 2015
  19. 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. 20. @EMARIANOMD #WAS2020 Continuous TAP Blocks Khatibi et al. A&A 2017;124:1298
  21. 21. @EMARIANOMD #WAS2020 Still More Questions Tran, et al. Anesthesiology 2019
  22. 22. @EMARIANOMD #WAS2020 Overview  How did interfascial plane blocks start?  Are TAP blocks obsolete?  What’s new?
  23. 23. @EMARIANOMD #WAS2020 Newer Truncal Blocks Chin et al. RAPM 2017;42:133
  24. 24. @EMARIANOMD #WAS2020 Quadratus Lumborum Block Chin et al. RAPM 2017;42:133
  25. 25. @EMARIANOMD #WAS2020 Anesthesiology. 2019;130:322 Will the real QL please stand up?
  26. 26. @EMARIANOMD #WAS2020 Erector Spinae Plane Block Forero, et al. RAPM 2016;41:621
  27. 27. @EMARIANOMD #WAS2020 Erector Spinae Plane Block Tsui, et al. JCA 2019;53:29
  28. 28. @EMARIANOMD #WAS2020
  29. 29. @EMARIANOMD #WAS2020 Ivanusic, Konishi, Barrington. RAPM 2018;43:567
  30. 30. @EMARIANOMD #WAS2020 Anaesthesia 2018;73:1185
  31. 31. @EMARIANOMD #WAS2020 Anaesthesia 1979;34:638
  32. 32. @EMARIANOMD #WAS2020
  33. 33. @EMARIANOMD #WAS2020 RAPM 2020
  34. 34. @EMARIANOMD #WAS2020 Mugadza, Mariano, Mazonde. JCA 2019
  35. 35. @EMARIANOMD #WAS2020 Time to Change What We Teach Turbitt, Mariano, El-Boghdadly. Anaesthesia 2020
  36. 36. @EMARIANOMD #WAS2020 Time to Change What We Teach Turbitt, Mariano, El-Boghdadly. Anaesthesia 2020 Need to Teach Transferable Skills
  37. 37. @EMARIANOMD #WAS2020 Is There a New Gold Standard? Insufficient RCT evidence to support interfascial plane blocks over epidural for laparotomy
  38. 38. @EMARIANOMD #WAS2020 Summary  We discussed: – How did interfascial plane blocks start? – Are TAP blocks obsolete? – What’s new?

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