Perioperative Pain Management Using Local and Regional Analgesia for Cardiothoracic Surgeries, Mastectomy, and Abdominal Surgeries in Adults and Children

This Guideline deals with the recommendations of perioperative pain management using local and regional anesthesia for Cardiothoracic surgeries, mastectomy, and abdominal surgeries in adults and children.

The Guidelines Development Group (GDG) of the Egyptian Board of Anesthetics, Surgical Intensive Care, and Pain Management has adopted with modification:

The 2026 American Society of Anesthesiologists Practice Guideline on Perioperative Pain Management Using Local and Regional Analgesia for Cardiothoracic Surgeries, Mastectomy, and Abdominal Surgeries. Joshi, GP, Mariano; Elkassabany, et al. Anesthesiology 144(1):p 19-43, January 2026.  (Reference No. 1)

Open Truncal Surgeries in Adults

1.     For adults undergoing open cardiothoracic surgeries including lobectomy, aortic valve replacement, coronary artery bypass grafts, mitral valve repair, or septal repair, we recommend fascial plane blocks to reduce pain and/or opioid requirements in the first 24 h postoperatively. (Strong, Moderate evidence)

2.     For adults undergoing open abdominal, retroperitoneal, and pelvic surgeries, we recommend fascial plane blocks to reduce pain and/or opioid requirements in the first 24 h postoperatively. Fascial blocks also improve patient satisfaction. (Strong, Moderate evidence)

*The Pooled results of the 2026 ASA Practice Guideline [1] summary of evidence for critical and important outcomes for open cardiothoracic surgeries derived from five randomized clinical trials assessing pain intensity showed that fascial plane blocks led to a reduction in pain at 24 h postoperatively that exceeded the Minimal Clinically Important Difference (MCID) of 1 point [6-10]. A variety of block techniques described in the included studies cover different regions of the chest. Fascial plane blocks included erector spinae plane, pectointercostal, serratus anterior plane, and superficial parasternal intercostal plane. Similarly, pooled analysis of eight trials showed that fascial plane blocks reduced the use of opioids compared to controls with a mean difference of 60 oral morphine equivalents (OME) [7,8,10-15]. The overall strength of evidence for both pain intensity and opioid use was rated moderate due to risk of bias limitations primarily related to lack of blinding of patients and/or outcome assessors [https://links.lww.com/ALN/E271]. The 2026 ASA panel recommends incorporating fascial plane blocks into the multimodal analgesic regimen for patients undergoing open cardiothoracic surgeries based on decreased pain at rest and decreased opioid use within 24 h.

** The summary of evidence of the 2026 ASA Practice Guideline [1] that included pooled analysis of 22 randomized clinical trials suggests that fascial plane blocks reduced pain at rest (10 trials suggest reduction of dynamic pain and 11 trials showed a reduction in opioid use at 24 h postoperatively compared with controls) . While the reduction in pain intensity was modest, the reduction in opioid use for fascial plane blocks was 35 OME. A pooled analysis of five trials indicated that fascial plane blocks were also associated with an increase in patient satisfaction [16-20]. The overall strength of evidence for pain intensity and/or opioid use was moderate due to either risk of bias limitations related to lack of blinding or to imprecision (i.e., the 95% CI for dynamic pain overlaps with the MCID threshold); [https://links.lww.com/ALN/E271]. The 2026 ASA panel recommends fascial plane blocks to reduce pain and/or opioid requirements and improve patient satisfaction for adults undergoing open abdominal, retroperitoneal, and pelvic surgeries. It is noteworthy that analgesic benefits were observed, although there was significant variability in the randomized clinical trials reviewed. Similarly, a reduction in opioid use with fascial plane blocks was found despite variability in the postoperative analgesic regimen in the control cohort, ranging from opioids alone to nonopioids analgesics, acetaminophen, NSAIDs, and COX-2–specific inhibitors.

Mastectomy

3.     For adults undergoing mastectomy, we recommend fascial plane or paravertebral blocks to reduce pain and/or opioid requirements in the first 24 h postoperatively. Fascial plane blocks also improve patient satisfaction and quality of recovery. (Strong, Moderate evidence)

* The 2026 ASA panel [1] pooled analysis of 20 randomized clinical trials showed that fascial plane blocks reduced pain at rest and 11 trials showed that they also reduced dynamic pain at 24 h. However, the reduction in pain met the MCID of 1 point for dynamic pain but not for pain at rest. Nine randomized clinical trials showed a reduction in pain at rest with paravertebral block, and four trials achieved a MCID of 1-point in dynamic pain. The 2026 ASA panel pooled analysis of 18 trials for fascial plane blocks which included erector spinae plane, interpectoral plane, pectoserratus plane, and serratus anterior plane and 5 trials for paravertebral blocks showed that both were associated with a reduction in opioid use in the first 24 h after surgery, with a decrease of 25 OME.

While no trials involving paravertebral blocks assessed quality of recovery, pooled analysis indicated that fascial plane blocks were associated with improved quality of recovery [21-23] and higher patient satisfaction [23-26]. The evidence for fascial plane blocks was rated moderate due primarily to risk of bias limitations related to inadequate randomization (e.g., lack of allocation concealment). The evidence for paravertebral blocks was rated low due to limitations in risk of bias, inconsistency (e.g., variation in the magnitude or direction of effect of individual studies in the pooled analysis), and/or imprecision (95% CI crossing the null or MCID threshold; [https://links.lww.com/ALN/E271].

**Evidence of the 2026 ASA panel [1] suggests that fascial plane and paravertebral blocks provide effective analgesia after mastectomy. Although there were no differences between paravertebral block and fascial plane blocks, fascial plane blocks were associated with improved quality of recovery and patient satisfaction. These findings are consistent with previous systematic reviews and meta-analyses reporting that paravertebral block and fascial plane blocks were superior to control or surgical site local anesthetic infiltration for reducing postoperative pain and opioid use [27].

Minimally Invasive Truncal Surgeries in Adults

4.     For adults undergoing minimally invasive cardiothoracic surgeries including lobectomy, valve repair/replacement, and esophageal procedures, we suggest regional techniques including neuraxial and fascial plane blocks to reduce pain in the first 24 h postoperatively. (Conditional, Low evidence)

5.     For adults undergoing minimally invasive abdominal surgeries including cholecystectomy, appendectomy, bariatric, gastrectomy, and liver resection surgeries, we recommend fascial plane blocks to reduce pain and/or opioid requirements in the first 24 h postoperatively. (Strong, Moderate evidence)

6.     For adults undergoing minimally invasive hernia repair, we suggest fascial plane blocks to reduce pain in the first 24 h postoperatively. (Conditional, Low evidence)

*The 2026 ASA summary of evidence [1] for Minimally Invasive Cardiothoracic Surgeries included pooled analyses of 20 trials for single-injection fascial plane blocks and 6 trials for continuous fascial plane blocks showed a reduction in pain at 24 h, but the reduction did not meet the MCID of 1 point [28]. Fascial plane blocks included erector spinae plane, intercostal plane, and serratus anterior plane. However, single-injection fascial plane blocks were associated with a reduction in opioid use by 37 OME [29-31]. Pooled analyses of six trials showed that continuous epidural analgesia reduced both pain at rest and dynamic pain at 24 h exceeding the MCID of 1 point. While six trials showed that single-injection paravertebral blocks were associated with only a modest reduction in pain, further analyses of these trials indicated a 33 OME reduction in opioid use. Pooled analyses showed a reduction in pain at rest that met the MCID of 1 point [32,33] but not for dynamic pain [32, 34] with continuous paravertebral block. The overall strength of evidence was rated low for most outcomes due to risk of bias and imprecision (95% CI crossed the MCID threshold [28]. The ASA 2026 panel suggested the inclusion of neuraxial or fascial plane blocks within a multimodal analgesic regimen to decrease pain after surgery. However, studies of single-injection paravertebral and fascial plane blocks show clinically relevant reductions in opioid use for the first 24 h after surgery. The opioid-sparing effect may be important to consider for cardiothoracic surgery patients as they are at higher risk for postoperative respiratory compromise. While continuous epidural demonstrated clinically relevant reductions in pain at rest and dynamic pain that exceeded the MCID, this technique is not recommended for minimally invasive thoracic surgery by the Procedure Specific Postoperative Pain Management group and others [35,36].  As an alternative, for patients who may benefit from extending the duration of local anesthetic effect, continuous paravertebral block may offer clinically relevant analgesia at rest.

**Minimally invasive abdominal surgeries have become increasingly common across a broad range of surgical specialties due to established benefits of smaller incisions, reduced surgical stress response, and faster recovery, while appreciating lower risks of complications compared to open procedures [37,38]. Compared with an open surgical approach, a minimally invasive approach is associated with lower postoperative pain and opioid requirements [39,40]. The 2026 ASA panel [1] grouped different types of minimally invasive surgical procedures because these procedures have almost similar surgical incisions, resulting in similar intensity of somatic pain, although visceral pain may vary. The 2026 ASA body of evidence [1] included 62 randomized clinical trials. Pooled analysis showed a reduction in pain intensity and opioid use in all surgical groups, but the reduction in pain did not meet the MCID threshold. Fascial plane blocks included erector spinae plane, quadratus lumborum, rectus sheath, serratus anterior plane, and transversus abdominis plane. Pooled analysis of three trials indicated higher quality of recovery with fascial plane blocks that met the MCID threshold for nephrectomy [4-43]. Similarly, five trials showed higher quality of recovery for appendectomy surgical subgroups, but the difference did not meet the MCID threshold [44-48]. The strength of evidence was moderate due to risk of bias (allocation concealment and blinding) and inconsistency due to variation in the magnitude of effect. It is generally accepted that fascial plane blocks reduce somatic pain but minimally influence visceral pain [49]. Notably, despite not yet fully understanding their mechanisms of action [50], fascial plane blocks resulted in a reduction in opioid usage consistently across all surgical categories.

Open Truncal Surgeries in Children (Younger than 18 yr)

7.     For children (younger than 18 yr) undergoing open cardiothoracic surgeries, we recommend fascial plane blocks to reduce pain and/or opioid use in the first 24 h postoperatively. (Strong, Moderate evidence)

8.     For children (younger than 18 yr) undergoing open hernia repair, we suggest a fascial plane block to reduce pain in the first 24 h postoperatively. (Conditional, Low evidence)

*The 2026 ASA panel summary of evidence [1] for Open Cardiothoracic Surgeries in Children (Younger than 18 yr) from the pooled analyses of seven trials found that fascial plane blocks reduced opioid use within the first 24 h [51-57] and in six trials reported minimal pain reduction within the first 12 to 24 h [51-53, 57-59]. The strength of evidence rating for reduced opioid use was moderate due to study risk of bias (lack of patient or observer blinding) and low for pain due to limitations in risk of bias and imprecision for study and patient characteristics, GRADE assessments, and meta-analysis results.The 2026 ASA panel [1] recommends the incorporation of fascial plane blocks into the multimodal analgesic regimen to reduce pain and/or opioid use and improve recovery in infants and children undergoing cardiothoracic surgery. However, the following limitations to the evidence should be noted. The pain assessments coalesced in this meta-analysis reflect a variety of acceptable, but not necessarily interchangeable scoring systems including the Modified Objective Pain Scale; Face, Legs, Activity, Cry and Consolability scale; and the Numeric Rating Scale. Confounding factors, like postoperative delirium or agitation and operator or parenteral interpretation, can bias the score reporting and further skew cohort results. Another noteworthy consideration is the lack of standardized sensory testing for block efficacy, which is not uniformly assessed in the postoperative period for the pediatric population. As a result, block efficacy is often presumed and not definitively investigated, further hindering the formulation of robust recommendations for widespread practice.

**The ASA 2026 body of evidence [1] for Open Abdominal Surgeries for Children (Younger than 18 yr) included two randomized clinical trials comparing single-injection fascial plane blocks (erector spinae plane and quadratus lumborum) to controls [60-61]. Both trials utilized opioids, with NSAIDs and acetaminophen adjuncts for postoperative pain management. Pooled analysis suggests that fascial plane blocks reduced pain within the first 12 to 24 h postoperative. The overall strength of evidence for pain intensity was low due to risk of bias limitations and imprecision due to the small number of studies included in the evidence base. The 2026 ASA panel [1] suggests the incorporation of fascial plane or peripheral nerve blocks to reduce pain and opioid use in children undergoing open inguinal hernia repair surgery. The studies analyzed herein lacked sensory assessments (efficacy), utilized different pain assessment scales (Numeric Rating Scale vs. Face, Legs, Activity, Cry and Consolability scale), and compared caudal analgesia for children aged 2 to 5 yr old, for which a shorter duration of action/spread with local anesthetic and hence postoperative rescue opioid use would be predictable. Caudal block is the most widely utilized regional technique for children undergoing lower abdominal surgery. Current trends suggest more interest in adjunct fascial plane blocks for lower abdominal pediatric surgery, as these offer prolonged localized coverage without the inherent systemic risks associated with caudal anesthesia [62].