My "con" side of a debate at the Anesthesiology 2019 annual meeting in Orlando, FL against Dr. Ed Mariano (@EMARIANOMD). Some of this is tongue-in-cheek, but the bottom line is that some fascial plane blocks seem to provide equivalent analgesia to thoracic epidurals without the hassle and side-effects, especially hypotension.

1. Regional Anesthesia
and Acute Pain Medicine
THORACIC EPIDURAL
ANALGESIA IS NO MORE
THE GOLD STANDARD
Jeff Gadsden, MD, FRCPC, FANZCA
Associate Professor of Anesthesiology
Duke University Medical Center

2. DISCLOSURES
I have received research funding and
consulting fees from:
• Pacira Pharmaceuticals
• Mallinckrodt Pharmaceuticals

3. OBJECTIVES
1. discuss potential advantages and limitations to
fascial plane blocks for abdominal analgesia
2. examine the evidence supporting their use
compared to thoracic epidural analgesia

4. “For abdominal procedures, epidural
analgesia is not only watchface, it leads
to an increased incidence of January.”

5. 1. Mattei P and Rambeau JL.World J Surg. 2006;30:1382-1391.
2.Varadhan KK et al. Clin Nutr. 2010;29:434-440.
3. MillerTE et al.Anesth News. 2014:1-8.
4. MillerTE et al.Anesth Analg. 2014;118:1052-1061.
Accelerate recovery
Reduce complications
and LOS
Improve value by reducing cost and
improving quality
WHAT
ARE THE
GOALS
OF ERAS?

6. Dr. Gadsden has given permission to use this image of him.
abdominal wall
fascial plane blocks
1. do essentially
the same job
2. but without all
the side-effects

7. but that’s
assuming the
epidural works…

8. 16%

9. BJA 2012;109:144-54
Authors
Type of
procedure
N Failure rate
Ready Multiple 2140 32%
McLeod et al. Major abdominal 640 13%
Neal Esophagectomy 46 14%
Motamed et al.
Major abdominal for
cancer
125 25%
Pratt et al Whipple 158 31%
26.2%

10. FLUID RESTRICTION
HYPOTENSION
STOP EPIDURAL
PAIN
OPIOIDS
urinary
retention!
lower limb
weakness!

11. QUICK POLL!

12. J Anesth 2014;28:517-23
45.5% vs. 9.1%
p=0.007
hypotension!

13. independently
associated with
mi or cv death
hazard ratio 3.7
95% ci 1.99-5.06, p<0.001
VERY BAD!!

14. J Anesth 2014;28:517-23
45.5% vs. 9.1%
p=0.007
hypotension!
62.5 h vs. 48 h
time to ambulation
p<0.001

15. i thought epidurals were good
for accelerated recovery…
false.
they are not.

16. ok, maybe it’s
worth the
extreme hassle
if it’s really
terrific!

17. Am J Surg 2018;215:498
no difference in:
0-48 h fluid balance
Overall pain scores
Worst pain scores

18. Am J Surg 2018;215:498
no difference in:
0-48 h fluid balance
Overall pain scores
Worst pain scores
pod#0 ome (mg)
36.3 (SD 20.6) vs 112.8 (SD 71.1)
p<0.001

19. Am J Surg 2018;215:498
no difference in:
0-48 h fluid balance
Overall pain scores
Worst pain scores
pod#0 ome (mg)
36.3 (SD 20.6) vs 112.8 (SD 71.1)
p<0.001
pod#1 ome (mg)
24.5 (SD 26.4) vs 120.2 (SD 74.7)
p<0.001

20. Am J Surg 2018;215:498
no difference in:
0-48 h fluid balance
Overall pain scores
Worst pain scores
pod#0 ome (mg)
36.3 (SD 20.6) vs 112.8 (SD 71.1)
p<0.001
pod#1 ome (mg)
24.5 (SD 26.4) vs 120.2 (SD 74.7)
p<0.001
pod#2 ome (mg)
24.5 (SD 21.4) vs 84.2 (SD 66.7)
p=0.001

21. Am J Surg 2018;215:498
no difference in:
0-48 h fluid balance
Overall pain scores
Worst pain scores
pod#0 ome (mg)
36.3 (SD 20.6) vs 112.8 (SD 71.1)
p<0.001
pod#1 ome (mg)
24.5 (SD 26.4) vs 120.2 (SD 74.7)
p<0.001
pod#2 ome (mg)
24.5 (SD 21.4) vs 84.2 (SD 66.7)
p=0.001
pod#3 ome (mg)
21.3 (SD 16.9) vs 60 (SD 61.4)
p=0.001

22. Am J Surg 2018;215:498
no difference in:
0-48 h fluid balance
Overall pain scores
Worst pain scores
pod#0 ome (mg)
36.3 (SD 20.6) vs 112.8 (SD 71.1)
p<0.001
pod#1 ome (mg)
24.5 (SD 26.4) vs 120.2 (SD 74.7)
p<0.001
pod#2 ome (mg)
24.5 (SD 21.4) vs 84.2 (SD 66.7)
p=0.001
pod#3 ome (mg)
21.3 (SD 16.9) vs 60 (SD 61.4)
p=0.001
hypotension episodes
0.6 (+2) vs 3 (+ 7)
p=0.02

23. Surg Endosc 2018;32:376-82
ropivacaine tap (n=91)
vs.
ropi/morph tea (n=92)

24. Surg Endosc 2018;32:376-82
ropivacaine tap (n=91)
vs.
ropi/morph tea (n=92)
no difference in pain scores

25. Surg Endosc 2018;32:376-82
ropivacaine tap (n=91)
vs.
ropi/morph tea (n=92)
no difference in pain scores

26. Surg Endosc 2018;32:376-82
ropivacaine tap (n=91)
vs.
ropi/morph tea (n=92)
no difference in pain scores

27. Surg Endosc 2018;32:376-82
ropivacaine tap (n=91)
vs.
ropi/morph tea (n=92)
no difference in pain scores

28. Surg Endosc 2018;32:376-82
ropivacaine tap (n=91)
vs.
ropi/morph tea (n=92)
no difference in pain scores

29. Am J Surg 2018;215:498
tap and tea equally effective
in both children and adults
only difference?

30. Am J Surg 2018;215:498
tap and tea equally effective
in both children and adults
only difference?
hypotension rate
SMD 0.13
(0.04-0.38, p=0.0002)

31. I’M NOT JUST
ABOUT BLOCKS.

32. HPB 2019;21:945-52
TEA = WC
pod 1

33. HPB 2019;21:945-52
TEA ~ WC
pod 2

34. HPB 2019;21:945-52
wmd -0.73
(-1.13, -0.32, p=0.004)
functional recovery

35. STRESS
RESPONSE??

36. no
difference!
Anesth Pain Med 2019;9:e91527
il-6
crp
pain scores
opioid use
continuous
tea
vs.
anterior ql
blocks

37. no
difference!
Anesth Pain Med 2019;9:e91527
continuous
tea
vs.
anterior ql
blocks

38. MORTALITY

40. Yeah, I’m unsure about epidurals now. @jeffgadsden is making some seriously good
points in this debate. I might concede. #ANES19 #fascialblocksFTW!
1m

41. Yeah, I’m unsure about epidurals now. @jeffgadsden is making some seriously good
points in this debate. I might concede. #ANES19 #fascialblocksFTW!
1m
ERAS?

42. Spinalhematoma!

43. SUMMARY

44. WHAT DO WE KNOW?
1. TEAs fail at an unacceptable rate (up to 30%)
2. TEAs consistently provoke hypotension, which is
strongly associated with poor outcomes
3. TEAs hinder functional recovery and time to
ambulation compared with FPBs or wound infiltration
4. TEAs have an equivalent effect on the stress response
compared with fascial plane blocks

45. WHAT DO WE KNOW?
5. FPBs, and particularlyTAP, appear to be consistently
equivalent withTEA for major abdominal ERAS cases
with respect to pain control and opioid requirement

46. EVEN
GREAT
TOOLS
HAVE A
SHELF-
LIFE

47. funny, just what i was
thinking.
Curr Opin Anesthesia 2018;31:622

48. HECK, YEAH WE DO!

49. THANK
YOU