Objectives. What are important outcomes? YOUR patient is having open abdominal surgery for removal of a tumor, which is your analgesic of choice?

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1 Objectives? Jaime Ortiz, MD Associate Professor of Anesthesiology Director of Regional Anesthesia Co Director Acute Pain Management Service Baylor College of Medicine Houston, Describe the data available on whether or not neuraxial anesthesia/analgesia prevents postoperative mortality or morbidity Discuss quality of analgesia provided by alternatives to thoracic epidural analgesia Review data comparing thoracic epidural analgesia to other techniques Discuss whether thoracic epidural analgesia and other peripheral nerve blocks should be a compulsory part of ERAS protocols YOUR patient is having open abdominal surgery for removal of a tumor, which is your analgesic of choice? A) TAP block or other type of infiltration block B) Thoracic epidural catheter C) IV PCA opioid D) Multimodal analgesia YOU are having open abdominal surgery for removal of a tumor, which analgesic technique would YOU choose? A) TAP block or other type of infiltration block B) Thoracic epidural catheter C) IV PCA opioid D) Multimodal analgesia What are important outcomes? Analgesia Decrease side effects Morbidity cardiac, pulmonary, DVTs, other Length of stay Readmission Complications Functional status Quality of life Patient satisfaction Mortality 1

2 MIPS CMS Anesthesiology Specific Measure Set 2018 Pain Pathway MIPS #44: CABG: Preoperative Beta Blocker in Patients with Isolated CABG Surgery MIPS #76: Prevention of CVC Related Bloodstream Infections* MIPS #404: Anesthesiology Smoking Abstinence* MIPS #424: Perioperative Temperature Management* MIPS #426: Post Anesthetic Transfer of Care Measure: Procedure Room to PACU* MIPS #427: Post Anesthetic Transfer of Care Measure: Procedure Room to ICU* MIPS #430: Prevention of PONV Combination Therapy* MIPS #463: Prevention of Post Operative Nausea/Vomiting (PONV) Combination Therapy (Pediatrics)* Thoracic Epidural Analgesia Long history of effectiveness We all learn how to do it during training Standard procedure Can perform quickly in most patients Minimal variation Ultrasound can assist with placement on difficult patients Benefits of Epidural Analgesia Effective, prolonged analgesia Less side effects than systemic analgesia/opioids less sedation, less nausea/vomiting Earlier ambulation, return of bowel function Decreased incidence of pulmonary complications and DVTs Decreased stress response Contraindications of Epidural Patient refusal or inability to cooperate Uncorrected hypovolemia Coagulopathy/ expected postop anticoagulation Increased intracranial pressure secondary to a mass lesion Infection (systemic, local) History of spine surgery? Lack of supporting staff qualified nursing acute pain service Complication of Neuraxial Analgesia/ Anesthesia Back pain Headaches Infection Nerve damage Hypotension Epidural abscess Bleeding Epidural hematoma 2

3 Nerve injury after Neuraxial Blockade Between 1/1,000 and 1/1,000,000 Higher rate for spinal versus epidural 85% of patients with neurological deficits had completed recovery within 3 months (Auroy et al.) Causes Mechanical injury from catheter and/or needle Adverse physiologic responses Drug toxicity Complications of Neuraxial Blockade Post dural puncture headache incidence up to 7% Backache Transient neurological symptoms related to lidocaine used for spinal anesthetics Total spinal anesthesia Cardiac arrest Epidural Hematoma Rare but serious complication 1: 150,000 for epidural blocks 1: 220,000 for spinal anesthetics (Tryba) Risks Female gender Increased age Traumatic placement Abnormalities of spinal cord or vertebral column Underlying coagulopathy Indwelling catheter and LMWH pre, intra or postop Prevention of Epidural Hematoma Optimization of coagulation status Timing of placement and removal of catheter Make decisions on individual patients Frequent neuro checks Vigilance! 3

4 Catheter Timing Prevention of Postoperative Rodgers A, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomized trials. BMJ 2000; 321: trials, 9559 patients Randomized trials with epidural/spinal vs not Did not exclude trials with GA in addition to neuraxial Reduces DVT 44% Reduces PE 55% Reduces transfusion requirements 50% Reduces pneumonia 39% Reduces respiratory depression 59% Reductions in MI and renal failure No difference in mortality Prevention of Postoperative Guay J, et al. Neuraxial anesthesia for the prevention of postoperative mortality and major morbidity: an overview of Cochrane systematic reviews. Anesth Analg 2014; 119: studies with 3006 participants Neuraxial anesthesia compared to GA reduces 0 to 30 day mortality for patients undergoing surgery with an intermediate high cardiac risk level Neuraxial anesthesia decreased risk of pneumonia No difference compared to GA or GA with neuraxial in myocardial infarction 4

5 Prevention of Postoperative Liu SS, Wu CL. The effect of analgesic technique on postoperative patient reported outcomes including analgesia: a systematic review. Anesth Analg 2007; 105: 789Y808ds 9 meta analysis and 14 RCTs included in review Epidural PCA statistically superior analgesia vs systemic or IV PCA opioids for first 3 postop days Epidural analgesia fails to significantly reduce cardiovascular complications in general surgical population Prevention of Postoperative Liu SS, Wu CL. The effect of analgesic technique on postoperative patient reported outcomes including analgesia: a systematic review. Anesth Analg 2007; 105: 789Y808ds Meta analysis and small RCTs show similar analgesia between continuous perineural techniques and Epidural Not enough evidence comparing epidural to continuous wound catheters or single shot nerve blocks Regional anesthesia techniques overall associated with improved pain scores, but clinical significance not consistently apparent Analgesic related side effects cloud measured outcomes No high quality data on health related quality of life, quality of recovery, or patient satisfaction Prevention of Postoperative Kooij FO, Schlack WS, Preckel B, Hollmann MW. Does regional anesthesia for major surgery improve outcome? Focus on epidural analgesia. Anesth Analg 2014;119:740 4 Influence of epidural analgesia on pulmonary complications is limited to high risk intrathoracic procedures and high risk patients Pain score benefit in the 6 17 mm range on a scale of mm Failure rate of epidural catheters between 13 47% Prevention of Postoperative Liu SS, Wu CL. Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence. Anesth Analg 2007; 104: Insufficient evidence to confirm or deny ability of postoperative analgesic techniques to affect major postoperative mortality or morbidity Current low incidence of postoperative complications due to increased use of minimally invasive surgery, perioperative DVT prophylaxis, multimodal fast track programs for thoracic/abdominal surgery 5

6 Peripheral nerve injury Residual paresthesia Hypoesthesia Permanent paresis Review of 30 studies from by Brull 2007 Neuropathy Spinal/ epidural 0.04% Peripheral nerve block 3% Overall incidence of PERMANENT damage 0.02% to 0.4% Brull et al. Reg Anesth Pain Med 2015; 40: Pathophysiology and Etiology of Nerve Injury Following Peripheral Nerve Blockade. No data confirming superiority of one nerve localization technique over the other Intraneural injection or paresthesia is not entirely predictive of functional nerve injury Injury risk is greater during intrafascicular injection Ultrasound CAN detect intraneural injection Preop neurological deficits puts patients at increased risk Postoperative neurological features more likely related to patient and surgical factors Tourniquet neuropathy can be associated with clinical deficits, duration and pressure both important TRANSVERSUS ABDOMINIS PLANE BLOCK Approaches Midline Incision Borglum J, Jensen K. Abdominal surgery: advances in the use of ultrasound-guided truncal blocks for perioperative pain management. 6

7 Subcostal TAP Rectus Sheath Quadratus lumborum Erector spinae Others Open vs laparoscopic colorectal surgery randomized to TAP (Bilateral with liposomal bupivacaine) vs Epidural (0.0625% bupi with 2 mcg/ ml fentanyl) in the setting of an ENHANCED RECOVERY PROTOCOL Acetaminophen, ketorolac, alvimopan (Entereg), early mobilization, dietary advancement, oral analgesics Epidurals discontinued POD 2 Similar procedures each group More postoperative urinary retention in epidural group (29.7% vs 14.6%) Time to discharge 2.8 (TAP) vs 3.3 (Epi) IS THIS A REAL DIFFERENCE? More PONV in TAP group (31.7% vs 13.5%) Randomized to Bilateral TAP block (liposomal bupivacaine and 0.5% bupivacaine 1:2 ratio) vs T7 epidural with bupivacaine/fentanyl No multimodal regimen but used IV Tylenol, NSAIDS and gabapentin PRN Primary endpoint episodes of hypotension (systolic < 90) TAP (0.6) vs Epi (3) in POD1 POD 2 pain scores the same Total morphine equivalents less for TAP group POD % PATIENT SATISFACTION in pain control for both groups 84% of TAP group needed IV PCAs vs 18% Epi group TAP block with ropivacaine 0.5% VS T9 T10 epidural with ropivacaine 0.2% + morphine Acetaminophen 1 g q 8 h, rescue NSAIDS Same pain intensity TAP group had less PONV, postop ileus No difference in hospital stay, complications, urinary retention RETROSPECTIVE look at esophagectomy patients 32 patients Bilateral TAP block with PCA 29 patients thoracic epidural T5 T8 Similar average pain scores over 72 hours Less hypotension in TAP group 25% vs 76% Faster return of bowel function in TAP block 5 vs 6.7 days Less time in ICU for TAP block 3.2 vs 4.6 days 7

8 Ten trials, 505 patients Pain scores POD 1 at REST equivalent Epidural higher rate of hypotension Length of stay shorter in TAP group ( 0.6 days) Thoracic Paravertebral Block Paravertebral vs Thoracic Epidural Yeung JH, Gates S, Naidu BV, Wilson MJ, Gao Smith F. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database Syst Rev studies, total of 698 patients low quality evidence PVB less hypotension, PONV, pruritus, urinary retention No difference in 30 day mortality, major complications, hospital stay Equivalent in controlling acute pain Duration of Analgesia after Plane Blocks? Liposomal bupivacaine Can it really provide analgesia for hours? How good is the analgesia? Should it be combined with bupivacaine 0.25%/0.5% Cost/benefit ratio Liposomal bupivacaine 20 ml $314 Bupivacaine 0.25%/0.5% 30 ml $1.41/$1.85 Approved for infiltration blocks Approved for TAP blocks Recent approval for interscalene blocks Catheters Infection risk? Secondary failure rate Liposomal Bupivacaine vs Regular Bupivacaine Hutchins et al. Ultrasound guided subcostal transversus abdominis plane (TAP) infiltration with liposomal bupivacaine for patients undergoing robotic assisted hysterectomy: A prospective randomized controlled study. Gynecol Oncol 2015; 138: Liposomal bupivacaine vs bupivacaine 0.25% Lower max pain scores at all time periods and less PONV in liposomal group Less 72 hour morphine equivalents (24.9 vs 51.7 mg) in liposomal group Satisfaction 93% vs 83% 8

9 Liposomal Bupivacaine vs Regular Bupivacaine Hutchins et al. Ultrasound guided subcostal transversus abdominis plane blocks with liposomal bupivacaine vs. non liposomal bupivacaine for postoperative pain control after laparoscopic handassisted donor nephrectomy: a prospective randomised observerblinded study. Anaesthesia 2016; 71: Liposomal bupivacaine vs 0.25% bupivacaine with adrenaline Decreased maximal pain scores (6 hours, 24 48h, h) in liposomal group Decreased opioid use (48 72 hours) Wound infiltration options Need long acting agents No comparison to epidural Barron et al Lap/robot assisted hysterectomy Liposomal bupivacaine vs 0.25% bupivacaine Decrease in pain scores DAY 3 with liposomal No difference in pain Day 1, Day 14, or while in hospital No difference in opioids, side effects Kalogera et al laparotomy for GYN malignancy Retrospective Liposomal bupivacaine vs 0.25% bupivacaine No difference in pain scores Less use of IV PCA (1.4% vs 8.3%) and less rescue opioids (15.3% vs 28.6%) in liposomal groups ERAS Protocols Colorectal surgery GYN Abdominal Hysterectomy Urology Radical cystectomy and nephrectomy 9

10 Total hip replacement (N=512,393) Total knee replacement(n=1,028,069) Modalities opioids, nerve blocks, acetaminophen, steroids, gabapentin/pregabalin, NSAIDS, COX 2 inhibitors, ketamine 85.6% received multimodal More than 2 modalities (other than opioids) 19% fewer respiratory complications 26% fewer GI complications 18.5% decrease in opioid prescription 12.1% decrease in length of stay Nonsteroidal anti inflammatory drugs and cyclooxygenase 2 inhibitors seemed to be the most effective modalities used Pick what is best for each patient!!!! Make clinical judgements Different approaches for different patients Discuss options with patient and surgeon Open vs Laparoscopic procedures Use multimodal analgesia Learn new techniques! Conclusions Epidurals have a long history of effectiveness, but come with risks Abdominal wall blocks require less maintenance, less risks to consider, can use on sicker patients In the setting of multimodal analgesia and ERAS protocols, should be able to get at least similar analgesia in most patients Consider failure rate of both techniques in your hands What would you choose for yourself? References Rawal N. Epidural technique for postoperative pain: gold standard no more? Reg Anesth Pain Med May Jun;37(3): doi: /AAP.0b013e c6. Liu SS, Wu CL. The effect of analgesic technique on postoperative patient reported outcomes including analgesia: a systematic review. Anesth Analg. 2007;105:789Y808ds Memtsoudis SG1, Liu SS. Do neuraxial techniques affect perioperative outcomes? The story of vantage points and number games. Anesth Analg Sep;119(3): doi: /ANE Liu SS, Wu CL. Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence. Anesth Analg Mar;104(3): Kooij FO, Schlack WS, Preckel B, Hollmann MW. Does regional anesthesia for major surgery improve outcome? Focus on epidural analgesia. Anesth Analg 2014;119:740 4 Guay J, Choi PT, Suresh S, Albert N, Kopp S, Pace NL. Neuraxial anesthesia for the prevention of postoperative mortality and major morbidity: an overview of Cochrane systematic reviews. Anesth Analg 2014; 119: Memtsoudis SG, Sun X, Chiu XL, Stundner O, Liu SS, Banerjee S, Mazumdar M, Sharrock NE. Perioperative comparative effectiveness of anesthetic technique of orthopedic patients. Anesthesiology May;118(5): doi: /ALN.0b013e d. Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van ZA, Sage D, Futter M, Saville G, Clark T, MacMahon S. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomized trials. BMJ 2000; 321: Auroy Y, Narchi P, Messiah et al. Serious complications related to regional anesthesia: results of a prospective survey in France. Anethesiology 1997; 87: Memtsoudis SG, Poeran J, Zubizarreta N, Cozowicz C, Mörwald EE, Mariano ER, Mazumdar M. Association of Multimodal Pain Management Strategies with Perioperative Outcomes and Resource Utilization: A Population based Study. Anesthesiology May;128(5): References Iyer SS, Bavishi H, Mohan CV, Kaur N. Comparison of Epidural Analgesia with Transversus Abdominis Plane Analgesia for Postoperative Pain Relief in Patients Undergoing Lower Abdominal Surgery: A Prospective Randomized Study. Anesth Essays Res Jul Sep;11(3): doi: / Pirrera B, Alagna V, Lucchi A, Berti P, Gabbianelli C, Martorelli G, Mozzoni L, Ruggeri F, Ingardia A, Nardi G, Garulli G. Transversus abdominis plane (TAP) block versus thoracic epidural analgesia (TEA) in laparoscopic colon surgery in the ERAS program. Surg Endosc Jan;32(1): doi: /s Epub 2017 Jul 1. Brogi E, Kazan R, Cyr S, Giunta F, Hemmerling TM. Transversus abdominal plane block for postoperative analgesia: a systematic review and meta analysis of randomized controlled trials. Can J Anaesth Oct;63(10): doi: /s x. Epub 2016 Jun 15. Review. PMID: Ganapathy S, Sondekoppam RV, Terlecki M, Brookes J, Das Adhikary S, Subramanian L. Comparison of efficacy and safety of lateral to medial continuous transversus abdominis plane block with thoracic epidural analgesia in patients undergoing abdominal surgery: A randomised, open label feasibility study. Eur J Anaesthesiol Nov;32(11): doi: /EJA Yeung JH, Gates S, Naidu BV, Wilson MJ, Gao Smith F. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database Syst Rev Feb 21;2:CD doi: / CD pub2. Review. Levy G, Cordes MA, Farivar AS, Aye RW, Louie BE. Transversus Abdominis Plane Block Improves Perioperative Outcome After Esophagectomy Versus Epidural. Ann Thorac Surg Feb;105(2): doi: /j.athoracsur Epub 2017 Dec 2. Brull R, Hadzic A, Reina MA, Barrington MJ. Pathophysiology and Etiology of Nerve Injury Following Peripheral Nerve Blockade. Reg Anesth Pain Med 2015; 40: Baeriswyl M, Zeiter F, Piubellini D, Kirkham KR, Albrecht E. The analgesic efficacy of transverse abdominis plane block versus epidural analgesia: A systematic review with meta analysis. Medicine (Baltimore) Jun;97(26):e

11 References Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: A Novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41: [PubMed: ] Adhikary SD, Pruett A, Forero M, and Thiruvenkatarajan V. Erector spinae plane block as an alternative to epidural analgesia for post operative analgesia following video assisted thoracoscopic surgery: A case study and a literature review on the spread of local anaesthetic in the erector spinae plane. Indian J Anaesth Jan; 62(1): doi: /ija.IJA_693_17 Steinthorsdottir KJ, Wildgaard L, Hansen HJ, Petersen RH, Wildgaard K. Regional analgesia for video assisted thoracic surgery: A systematic review. Eur J Cardiothorac Surg. 2014;45: [PubMed: ] Chin KJ, Adhikary S, Sarwani N, Forero M. The analgesic efficacy of pre operative bilateral erector spinae plane (ESP) blocks in patients having ventral hernia repair. Anaesthesia. 2017;72: [PubMed: ] Hamilton DL, Manickam B. Erector spinae plane block for pain relief in rib fractures. Br J Anaesth. 2017;118: [PubMed: ] Torgeson M1, Kileny J1, Pfeifer C1, Narkiewicz L1, Obi S2. Conventional Epidural vs Transversus Abdominis Plane Block with Liposomal Bupivacaine: A Randomized Trial in Colorectal Surgery. J Am Coll Surg Apr 30. pii: S (18)30320 X. doi: /j.jamcollsurg Shaker TM1, Carroll JT2, Chung MH3, Koehler TJ4, Lane BR5, Wolf AM3, Wright GP. Efficacy and safety of transversus abdominis plane blocks versus thoracic epidural anesthesia in patients undergoing major abdominal oncologic resections: A prospective, randomized controlled trial. Am J Surg Mar;215(3): doi: /j.amjsurg Epub 2017 Nov 16. Pirrera B1, Alagna V1, Lucchi A1, Berti P1, Gabbianelli C1, Martorelli G1, Mozzoni L2, Ruggeri F1, Ingardia A2, Nardi G2, Garulli G3. Transversus abdominis plane (TAP) block versus thoracic epidural analgesia (TEA) in laparoscopic colon surgery in the ERAS program. Surg Endosc Jan;32(1): doi: /s Epub 2017 Jul 1. Kalogera E1, Bakkum Gamez JN, Weaver AL, Moriarty JP, Borah BJ, Langstraat CL, Jankowski CJ, Lovely JK, Cliby WA, Dowdy SC.Abdominal Incision Injection of Liposomal Bupivacaine and Opioid Use After Laparotomy for Gynecologic Malignancies. Obstet Gynecol Nov;128(5): Barron KI1, Lamvu GM2, Schmidt RC3, Fisk M3, Blanton E3, Patanwala I3.Wound Infiltration With Extended Release Versus Short Acting Bupivacaine Before Laparoscopic Hysterectomy: A Randomized Controlled Trial. J Minim Invasive Gynecol Feb;24(2): doi: /j.jmig Epub 2016 Nov 14 References Horlocker TT. Regional anaesthesia in the patient receiving antithrombotic and antiplatelet therapy. Br J Anaesth 2011; 107: i Horlocker T, et al. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence Based Guidelines (Third Edition). Reg Anesth Pain Med 2010; 35: Horlocker T, et al. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence Based Guidelines (Fourth Edition). Reg Anesth Pain Med 2018; 43: Chin KJ, McDonnell JG, Carvalho B, Sharkey A, Pawa A, Gadsden J. Essentials of Our Current Understanding: Abdominal Wall Blocks. Reg Anesth Pain Med 2017; 42: Borglum J, Jensen K. Abdominal surgery: advances in the use of ultrasound guided truncal blocks for perioperative pain management. surgery Børglum J1, Gögenür I, Bendtsen TF. Abdominal wall blocks in adults. Curr Opin Anaesthesiol Oct;29(5): doi: /ACO Brull R, McCartney CJL, Chan VWS, El Beheiry H. Neurological complications after regional anesthesia: contemporary estimates of risk. Anesth Analg 2007; 104: Hutchins J1, Delaney D1, Vogel RI2, Ghebre RG3, Downs LS Jr3, Carson L3, Mullany S3, Teoh D3, Geller MA4. Ultrasound guided subcostal transversus abdominis plane (TAP) infiltration with liposomal bupivacaine for patients undergoing robotic assisted hysterectomy: A prospective randomized controlled study. Gynecol Oncol Sep;138(3): doi: /j.ygyno Epub 2015 Jun 6. Hutchins JL1, Kesha R1, Blanco F2, Dunn T2, Hochhalter R1. Ultrasound guided subcostal transversus abdominis plane blocks with liposomal bupivacaine vs. non liposomal bupivacaine for postoperative pain control after laparoscopic hand assisted donor nephrectomy: a prospective randomised observerblinded study. Anaesthesia Aug;71(8): doi: /anae Epub 2016 May