Show Me the Evidence: Epidurals, PVBs, TAP Blocks Christopher L. Wu, MD Professor of Anesthesiology The Johns Hopkins Hospital Overview Review overall (ERAS and non-eras) data for EA, PVB, TAP Examine ERAS-specific data (if available) Focus on systematic reviews/metaanalysis and RCTs Looking for comparisons of block vs no block 1
Literature Search Not a formal literature search (through an informationalist) December 2015 Pubmed; English language Textwords: [specific block] + metaanalysis /ERAS Epidural: Overall Data Most recent meta 125 trials (9044 patients, 4525 EA) Death with EA (3.1% vs. 4.9%; OR=0.60; 95%CI, 0.39-0.93) EA significantly risk of A Fib, SVT, DVT, respiratory depression, pneumonia, ileus, PONV, GI recovery EA significantly risk of arterial hypotension, pruritus, urinary retention, and motor blockade Technical failures 6.1% of patients Ann Surg 2014;259:1056-67 2
Ann Surg 2014;259:1056-67 Ann Surg 2014;259:1056-67 3
Epidural: ERAS Data Epidural and enhanced recovery / fast track (limit to RCT) = at least 5 RCTs comparing EA vs. no EA (within an ERAS pathway) EA typically imbedded in an ERAS pathway and was not examined separately (ERAS vs. no ERAS) Not a clear benefit for EA in these RCTs 2 meta-analyses on EA in laparoscopic procedures Not technically ERAS per se JAMA Surg 2014;149:1224-3 Surg Endosc 2013;27:2581-91 Epidural: ERAS Data Hip fracture surgery (n=60) 4 days postoperative EA (bupiv+mso 4 ) vs. placebo Well-defined multimodal rehabilitation, 1 gm paracetamol q6h + 25 mg rofecoxib qd during the entire study period EA superior analgesia but no enhanced rehabilitation Elective cardiac surgery (n=654) Fast-track GA+TEA vs. fast-track GA alone All patients received paracetamol 1 gm q6h EA VAS pain up to 48 h (but pain scores low in both groups); no difference in major complications Anesthesiology 2005;102:1197-204 Anesthesiology 2011;114:262-70 4
Epidural ERAS: Event Free Survival Anesthesiology 2011;114:262-70 Epidural: ERAS Data Laparoscopic sigmoidectomy (n=60) GA+EA vs. GA; pts treated according to ERAS principles EA x 48h; ketoprofen 100 mg IV tid; paracetamol 1 gm PO qid EA pain at rest/cough; no difference in return of GI function/los/complication rate Major intestinal resection (n=56) GA+EA vs GA; both groups followed a fast-track pathway EA x 48h;? multimodal analgesia EA no difference in pain, LOS, quality of life, complications Six patients (20.6%) failed epidurals Surg Endosc 2009;23:31-7 Am J Surg 2005;189:268-72 5
Epidural: ERAS Data Elective laparoscopic colorectal resections (n=128) GA+EA vs. GA; enhanced recovery pathway (since 2006) EA x 48 h; paracetamol 1 gm PO qid; metamizole 500 mg qid EA overall complications/vasopressor treatment perioperatively; no difference in LOS, pain scores Epidurals seem to slow down recovery after laparoscopic colorectal resections without adding obvious benefits Ann Surg 2015;261:648-53 Epidural ERAS: Vasopressor Use Ann Surg 2015;261:648-53 6
Epidural: ERAS Data Overall benefits of TEA in laparoscopic procedures uncertain Meta-analysis of 7 RCTs (n=378): epidurals vs. alternative analgesic methods No significant difference in complication rate (OR=1.14 [0.49, 2.64], p=0.76) or LOS; EA faster return of GI fxn, pain scores Meta-analysis (6 RCTs): epidural analgesia on laparoscopic colorectal surgery TEA = first bowel motion (p=0.02) and pain scores (p=0.04) but no difference in LOS hospital, OR time, side effects JAMA Surg 2014;149:1224-3 Surg Endosc 2013;27:2581-91 Epidural: Summary Overall data suggests EA pain, pulmonary and cardiac morbidity, earlier return of GI function Role/benefits of epidural in ERAS less certain EA pain but limited available data indicates no benefit in LOS/complications 7
TAP Block: Overall Data TAP and surgery (limit RCT) 140 citations At least 10 meta-analyses examining TAP blocks TAP vs. no TAP: overall TAP pain/opioid use,?ponv Preoperative better than postoperative TAP Analgesic efficacy of TAP minimized by IT opioids TAP vs. LA wound infiltration Comparable short-term analgesia; TAP block superior long-lasting analgesia Anesth Analg 2014;118:454-63 Anesth Analg 2015;121:1640-54 Colorectal Dis 2102;14,e635-42 Int J Clin Exp Med 2014;7:2966-75 BMC Anesthesiology 2014;14:121 Can J Anaesth 2012;59:766-78 J Clin Anesth 2011;23:7-14 Dis Colon Rectum 2014;57:237-50 Cochrane Database Syst Rev 2010;12:CD007705 Eur J Obstet Gynecol Reprod Biol 2013;166:1-9 TAP Block: Overall Data De Oliveira Jr et al (2014): 10 RCTs (n=633) TAP Pain rest @ 4/24 hrs; opioid use Preoperative (vs postoperative) TAP early pain Association between LA dose and late pain/opioids use Baeriswyl et al (2015): 31 RCTs (n=1611) US guided TAP only TAP Pain rest/movt @ 6h and opioid use @ 6/24 hrs; no difference in PONV or prutirus No additional analgesia for SA with long-acting opioid Anesth Analg 2014;118:454-63 Anesth Analg 2015;121:1640-54 8
De Oliveira Jr et al: Early Pain at Rest Anesth Analg 2014;118:454-63 De Oliveira Jr et al: Late Pain at Rest Anesth Analg 2014;118:454-63 9
Baeriswyl et al: Opioid Consumption Anesth Analg 2015;121:1640-54 TAP Block: ERAS Data TAP and surgery (limit to RCT) = approximately 35 RCTs comparing TAP vs. no TAP No obvious evidence that these RCT were ERAS Review of Methods section gave no indication for an ERAS pathway Several RCTs which included TAP as part of multimodal analgesic regimen (4 CD, 2 GYN, Lap chole) Minority of TAP RCTs incorporated multimodal analgesia Results equivocal 10
TAP Block: ERAS Data Elective CD under SA w/ IT MSO 4 0.1mg (n=100) 40 ml of 0.375% ropivacaine or saline; 50 mg PO diclofenac q8hrs + 1 gm PO acetaminophen q6hrs x 48 hrs postoperatively TAP block, when used as part of a multimodal regimen inclusive of intrathecal morphine, does not improve post-cd analgesia Elective CD under SA w/ IT fentanyl 15µg (n=50) 40 ml of 0.5% ropivacaine or saline; rectal diclofenac 100 mg and rectal acetaminophen 1 gm at the end of surgery Acetaminophen 1 gm PO qid + ibuprofen 400 mg PO tid No difference in VAS pain scores; TAP = opioid usage; improved satisfaction with pain relief Reg Anesth Pain Med 2009;34:586-9 Br J Anaesth 2009;103:726-30 TAP Block: ERAS Data Elective CD under SA w/ IT fentanyl 15µg (n=50) 1.5 mg/kg ropivacaine 0.75% (max = 150 mg) per side; rectal diclofenac 1 mg/kg (max = 100 mg), rectal acetaminophen 1 gm at the end of surgery Acetaminophen 1 gm PO qid + rectal diclofenac 100 mg q18h TAP VAS pain scores/opioid usage/incidence of sedation CD under SA w/ IT fent 10µg and MSO 4 0.150mg (n=60) TAP: high- (3 mg/kg), low-dose ropivacaine (1.5 mg/kg), saline IV ketorolac 30 mg at skin closure; IV ketorolac 30 mg and acetaminophen 650 mg PO q6h x 24h TAP: no difference in pain except pain w/ high-dose at 6 hrs Anesth Analg 2008;106:186-91 Int J Obstet Anesth 2013;22:188-93 11
TAP Block: ERAS Data Abdominal hysterectomy (n=50) 1.5 mg/kg ropivacaine 0.75% (max=150 mg); rectal diclofenac 100 mg, rectal acetaminophen 1 gm before incision Rectal acetaminophen 1 gm q6h; rectal diclofenac 100 mg q16h TAP VAS pain scores/opioid usage/incidence of sedation Laparoscopic hysterectomy (n=197) 40 ml of 0.25% bupivacaine Acetaminophen 1 gm PO qid, ibuprofen 400 mg PO tid x 5d TAP: VAS pain at discharge; no differences pain scores between groups at 24/48/72 h or opioid use Anesth Analg 2008;107:2056-60 Acta Obstet Gynecol Scand 2014;93:345-50 TAP Block: ERAS Data Laparoscopic cholecystectomy (n=80) 50 ml of 0.25% bupivacaine; 1 gm paracetamol q6h and 75 mg diclofenac at 12 hrs post operation TAP: VAS pain at 6 hrs; no difference in opioid use Laparoscopic cholecystectomy (n=80) 20 ml of 0.5% ropivacaine; acetaminophen 1 gm PO q6h, ibuprofen 400 mg PO q6h TAP: opioid use/vas pain with cough; no difference in pain at rest/ponv/sedation J Am Coll Surg 2015;221:335-44 Anesth Analg 2012;115:527-33 12
TAP Block: ERAS Data Large bowel resection (n=32) 40 ml of 0.375% levobupivacaine; rectal diclofenac 1 mg/kg (max=100 mg), rectal acetaminophen 1 gm before incision Acetaminophen 1 gm PO q6h, and rectal diclofenac 100 mg q18h TAP VAS pain and opioid use Anesth Analg 2007;104:193-7 TAP Block: Summary Overall TAP block data Some overall analgesic efficacy Preoperative better than postoperative TAP Analgesic efficacy of TAP minimized by IT opioids No TAP block data with ERAS pathway per se When examining TAP in context of multimodal analgesic regimen, data is uncertain 13
Paravertebral Block: Overall Data PVB vs. no PVB Inguinal hern. PONV Breast Pain (up to 72 h)/opioid use, QoR/satisfaction Thoracotomy pulmonary complications PVB vs. other neuraxial blocks Inguinal hern. Nausea/urinary retention Thoracotomy comparable pain relief vs. EA, PONV, urinary retention, hypotension PVB vs. other blocks Inguinal hern. Pain vs. ilioinguinal/tap block Anesth Analg 2015;121:556-69 Br J Anaesth 2010;105:842-52 Pain Physician 2015;18:E757-80 J Plast Reconstr Aesthet Surg 2011;64:1261-9 PLoS One 2014;9:e96233 Br J Anaesth 2006;96:418-26 Anesth Analg 2008;107:1026-40 PVB (vs. no block): Pain at 24 hours 14
PVB (vs. no block): PONV J Plast Reconstr Aesthet Surg 2011;64:1261-9 PVB vs. EA: Pain at 24 hours PLoS One 2014;9:e96233 15
PVB vs. EA: Hypotension PLoS One 2014;9:e96233 Paravertebral Block: ERAS Data Paravertebral and surgery (limit to RCT) = approximately 26 RCTs comparing PVB vs. no PVB No obvious evidence that these RCT were ERAS Review of Methods section gave no indication for an ERAS pathway Few studies incorporated multimodal analgesia 16
Paravertebral Block: ERAS Data Video-assisted thoracoscopic surgery (n=80) 6 PVB (5 ml of 0.5% bupivacaine with 0.0005% epi) or saline 15 mg IV ketorolac q6h x 24 h PVB Intraoperative fentanyl/iv PCA morphine use; max pain scores at 6 hrs Breast cancer surgery (n=60) Single-injection PVB with bupivacaine 5 mg/ml (1.5 mg/kg) or saline before general anesthesia. Acetaminophen 1 gm PO tid; ibuprofen 10 mg/kg PO tid PVB opioid use/pain at 24 hrs/ponv in PACU/sedation Anesthesiology 2006;104:1047-53 Anesth Analg 2004;99:1837-43 PVB Block: Summary Overall PVB block data PVB pain/ponv/pulmonary complications Comparable analgesia to epidural PONV, urinary retention, hypotension Little PVB block data with ERAS pathway per se Few studies incorporating PVB with multimodal Pain/PONV/opoid use 17
Final Thoughts Overall analgesic benefits for EA, TAP, PVB Typically pain, opioid consumption and occasionally complications Little available data examining these blocks in context of an ERAS pathway Blocks are considered part of multimodal analgesia Benefits may not be as obvious in the presence of an ERAS pathway 18