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Thoracic Epidural Analgesia is the Gold Standard for Major Abdominal Surgery

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Thoracic Epidural Analgesia is the Gold Standard for Major Abdominal Surgery

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Descripción

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).

Transcripción

  1. 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. 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. 3. @EMARIANOMD Is This Even a Fair Debate? Epidural Interfascial Plane Blocks
  4. 4. @EMARIANOMD Interfascial Plane Blocks Are Cool “We need more studies” - Every interfascial plane block article author
  5. 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. 6. @EMARIANOMD Definition of Major Surgery
  7. 7. @EMARIANOMD Manion & Brennan. Anesth 2011;115:181
  8. 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. 9. @EMARIANOMD Twitter Poll
  10. 10. @EMARIANOMD Definition of Gold Standard https://www.lexico.com/en/definition/gold_standard
  11. 11. @EMARIANOMD Manion & Brennan. Anesth 2011;115:181
  12. 12. @EMARIANOMD Hong & Jung. Pain Phys 2016;19:E1013-E1018
  13. 13. @EMARIANOMD
  14. 14. @EMARIANOMD Carmichael et al. Dis Colon Rectum 2017;60:761
  15. 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. 16. @EMARIANOMD Is TEA Ever Contraindicated? Horlocker et al. RAPM 2018;43:263
  17. 17. @EMARIANOMD Is the Role of TEA Changing? RAPM 2012;37:310
  18. 18. @EMARIANOMD What Other Options Exist? Chin et al. RAPM 2017;42:133
  19. 19. @EMARIANOMD Elsharkawy, Pawa, Mariano. RAPM 2018;43:341
  20. 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. 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. 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. 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. 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. 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. 26. @EMARIANOMD Interfascial Plane Blocks Are Cool “We need more studies”
  27. 27. @EMARIANOMD
  28. 28. @EMARIANOMD What about IV Lidocaine?
  29. 29. @EMARIANOMD What about IV Lidocaine?
  30. 30. @EMARIANOMD Can TEA Be More Reliable? Parra et al. RAPM 2017;42:17 Auyong et al. RAPM 2017;42:204
  31. 31. @EMARIANOMD Can We Train Anesthesiologists Better? https://www.acgme.org/Specialties/Program-Requirements-and-FAQs-and- Applications/pfcatid/6/Anesthesiology
  32. 32. @EMARIANOMD
  33. 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.

Descripción

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).

Transcripción

  1. 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. 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. 3. @EMARIANOMD Is This Even a Fair Debate? Epidural Interfascial Plane Blocks
  4. 4. @EMARIANOMD Interfascial Plane Blocks Are Cool “We need more studies” - Every interfascial plane block article author
  5. 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. 6. @EMARIANOMD Definition of Major Surgery
  7. 7. @EMARIANOMD Manion & Brennan. Anesth 2011;115:181
  8. 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. 9. @EMARIANOMD Twitter Poll
  10. 10. @EMARIANOMD Definition of Gold Standard https://www.lexico.com/en/definition/gold_standard
  11. 11. @EMARIANOMD Manion & Brennan. Anesth 2011;115:181
  12. 12. @EMARIANOMD Hong & Jung. Pain Phys 2016;19:E1013-E1018
  13. 13. @EMARIANOMD
  14. 14. @EMARIANOMD Carmichael et al. Dis Colon Rectum 2017;60:761
  15. 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. 16. @EMARIANOMD Is TEA Ever Contraindicated? Horlocker et al. RAPM 2018;43:263
  17. 17. @EMARIANOMD Is the Role of TEA Changing? RAPM 2012;37:310
  18. 18. @EMARIANOMD What Other Options Exist? Chin et al. RAPM 2017;42:133
  19. 19. @EMARIANOMD Elsharkawy, Pawa, Mariano. RAPM 2018;43:341
  20. 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. 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. 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. 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. 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. 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. 26. @EMARIANOMD Interfascial Plane Blocks Are Cool “We need more studies”
  27. 27. @EMARIANOMD
  28. 28. @EMARIANOMD What about IV Lidocaine?
  29. 29. @EMARIANOMD What about IV Lidocaine?
  30. 30. @EMARIANOMD Can TEA Be More Reliable? Parra et al. RAPM 2017;42:17 Auyong et al. RAPM 2017;42:204
  31. 31. @EMARIANOMD Can We Train Anesthesiologists Better? https://www.acgme.org/Specialties/Program-Requirements-and-FAQs-and- Applications/pfcatid/6/Anesthesiology
  32. 32. @EMARIANOMD
  33. 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.

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