Thoracic Epidural Analgesia is the Gold Standard for Major Abdominal Surgery

At Anesthesiology 2019, the annual meeting of the American Society of Anesthesiologists (#ANES19), I debated Dr. Jeff Gadsden from Duke on the topic of whether or not thoracic epidural analgesia is the gold standard for major abdominal surgery. Dr. Vijay Gottumukkala organized and moderated the debate and assigned sides: pro (me) and con (Jeff).

1. Thoracic Epidural Analgesia is the Gold Standard for Major Abdominal Surgery 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 #ANES19

2. Disclosures None This is a friendly debate. Jeff and I are real life friends. I have published no articles on epidurals; therefore no COI.

3. Is This Even a Fair Debate? Epidural Interfascial Plane Blocks

4. Interfascial Plane Blocks Are Cool “We need more studies” - Every interfascial plane block article author

5. Objectives Define major surgery and gold standard Prove to you that thoracic epidural analgesia is the gold standard for major abdominal surgery

6. Definition of Major Surgery

7. Manion & Brennan. Anesth 2011;115:181

8. Clinical Scenario What type of regional analgesic technique would you want if you or a loved one had to have MAJOR open abdominal surgery ( e.g., Whipple, gastrectomy)? Assume healthy, not anticoagulated. Thoracic epidural Fancy fascial plane block

9. Twitter Poll

10. Definition of Gold Standard https://www.lexico.com/en/definition/gold_standard

11. Manion & Brennan. Anesth 2011;115:181

12. Hong & Jung. Pain Phys 2016;19:E1013-E1018

13. Carmichael et al. Dis Colon Rectum 2017;60:761

14. Is thoracic epidural analgesia (TEA) the gold standard for major abdominal surgery? TEA is the point of reference so the answer is YES .

15. Is TEA Ever Contraindicated? Horlocker et al. RAPM 2018;43:263

16. Is the Role of TEA Changing? RAPM 2012;37:310

17. What Other Options Exist? Chin et al. RAPM 2017;42:133

18. Elsharkawy , Pawa , Mariano. RAPM 2018;43:341

19. Interfascial Plane Blocks: Evidence Review Thoracic Epidural Transversus abdominis plane block Lateral Subcostal Posterior Surgical Rectus sheath block Transversalis fascia plane block Chin et al. RAPM 2017;42:133

20. Interfascial Plane Blocks: Evidence Review Thoracic Epidural Transversus abdominis plane block Lateral Subcostal Posterior Surgical Rectus sheath block Transversalis fascia plane block Chin et al. RAPM 2017;42:133 Wu et al. A&A 2013;117:507 Wahba & Kamal. J Anesth 2014;28:517 Ganapathy et al. EJA 2015;32:797 Shaker et al. Am J Surg 2018;215:498 Tomita et al. Masui 2015;64:208 Evidence from RCTs ( laparotomy): 2 favor TEA 1 no difference 1 favors TAP 1 favors rectus sheath

21. Interfascial Plane Blocks: Evidence Review Thoracic Epidural Quadratus lumborum block 1: Lateral 2: Posterior 3: Anterior or Transmuscular (TQL) and Transverse Oblique Paramedian TQL Chin et al. RAPM 2017;42:133 Dam et al. A&A 2017;125: 303

22. Interfascial Plane Blocks: Evidence Review Thoracic Epidural Quadratus lumborum block 1: Lateral 2: Posterior 3: Anterior or Transmuscular (TQL) and Transverse Oblique Paramedian TQL Chin et al. RAPM 2017;42:133 Dam et al. A&A 2017;125: 303 Evidence from RCTs ( laparotomy): No RCTs

23. Interfascial Plane Blocks: Evidence Review Thoracic Epidural Erector spinae plane block Rhomboid interscostal and subserratus plane block Kadam & Wahba . JACP 2018;34:564 Elsharkawy et al. RAPM 2018;43:745

24. Interfascial Plane Blocks: Evidence Review Thoracic Epidural Erector spinae plane block Rhomboid interscostal and subserratus plane block Kadam & Wahba . JACP 2018;34:564 Elsharkawy et al. RAPM 2018;43:745 Nagaraja et al. Ann Card Anaesth 2018;21:323 Evidence from RCTs ( laparotomy): No RCTs 1 favors ESP in cardiac surgery

25. Interfascial Plane Blocks Are Cool “We need more studies ”

26. What about IV Lidocaine?

27. What about IV Lidocaine?

28. Can TEA Be More Reliable? Parra et al. RAPM 2017;42:17 Auyong et al. RAPM 2017;42:204 YES

29. Can We Train Anesthesiologists Better? https://www.acgme.org/Specialties/Program-Requirements-and-FAQs-and-Applications/pfcatid/6/Anesthesiology YES

30. Summary We reviewed the definitions of major surgery and gold standard. We established that for major abdominal surgery, a thoracic epidural is the gold standard for regional analgesia.