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

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

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

6. @EMARIANOMD
Definition of Major Surgery

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

8. @EMARIANOMD
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.
A. Thoracic epidural
B. Fancy fascial plane block

9. @EMARIANOMD
Twitter Poll

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

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

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

13. @EMARIANOMD

14. @EMARIANOMD
Carmichael et al. Dis Colon Rectum 2017;60:761

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

16. @EMARIANOMD
Is TEA Ever Contraindicated?
Horlocker et al. RAPM 2018;43:263

17. @EMARIANOMD
Is the Role of TEA Changing?
RAPM 2012;37:310

18. @EMARIANOMD
What Other Options Exist?
Chin et al. RAPM 2017;42:133

19. @EMARIANOMD
Elsharkawy, Pawa, Mariano. RAPM 2018;43:341

20. @EMARIANOMD
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

21. @EMARIANOMD
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

22. @EMARIANOMD
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

23. @EMARIANOMD
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

24. @EMARIANOMD
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

25. @EMARIANOMD
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

26. @EMARIANOMD
Interfascial Plane Blocks Are Cool
“We need more studies”

27. @EMARIANOMD

28. @EMARIANOMD
What about IV Lidocaine?

29. @EMARIANOMD
What about IV Lidocaine?

30. @EMARIANOMD
Can TEA Be More Reliable?
Parra et al. RAPM 2017;42:17
Auyong et al. RAPM 2017;42:204

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

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33. @EMARIANOMD
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.