ASA 2026 Guideline: Regional Blocks in Abdominal, Cardiothoracic, and Mastectomy Surgeries

Key Takeaways for Faster Decision-Making#

Where the Recommendation Is Strong (Adults)

• Open cardiothoracic, open abdominal, and mastectomy surgery (adults): fascial plane blocks are a strong recommendation, with moderate evidence for pain/opioid reduction (and satisfaction/QoR in specific scenarios).

Minimally Invasive: Where It Is Strong vs Conditional

• Minimally invasive abdominal (adults): strong/moderate recommendation for several surgeries; minimally invasive hernia repair remains conditional/low.

How to Choose the Block in Practice

• Block selection should consider the incision site + expected pain location.

Where AnestCopilot Fits In

• If you need to review anatomical landmarks, doses, and local anesthetic volumes for each block, Anestcopilot is the tool always at hand for quick consultations.

Context and Scope of the ASA 2026 Guideline#

The American Society of Anesthesiologists published a guideline (2026) focused on perioperative analgesia with local and regional techniques for cardiothoracic surgeries, mastectomies, and abdominal surgeries (adults and pediatrics).

Outcomes analyzed were centered on pain scales and/or opioid consumption within the first 24 hours.

Recommendations were derived from randomized clinical trials (2013-Jun/2023; updated Dec/2024), and the document itself highlights recurring methodological limitations (quality, inconsistency, and small sample sizes).

A Critical Point for Practice: What the Guideline Was Not Designed to Answer#

A critical point for practice: the guideline groups fascial plane blocks as a category and excludes comparative evaluation between different blocks.

In other words, it was not designed to say "which fascial block is best," but rather whether it is worth incorporating these techniques by type of surgery.

All Recommendations: Strength of Recommendation and Level of Evidence#

Below are the recommendations organized exactly by surgical scenario, with strength and evidence.

What the Guideline Shows as Advantages (Clinical Effect) by Surgical Scenario#

In this guideline, "advantages" are described primarily as outcomes within the first 24 hours, using pain scales and/or opioid consumption.

A) Open Cardiothoracic (Adults): Strong Recommendation, Moderate Evidence

Advantages (24h outcomes):

• Pain reduction at rest with magnitude > MCID (minimum clinically important difference defined as 1 point on a 0-10 scale).
• Opioid consumption reduction, mean difference ~60 OME (oral morphine equivalents).

Which blocks were represented in the studies:

• Erector spinae plane block (ESP), pecto-intercostal, serratus anterior plane block, parasternal superficial intercostal plane block.

Practical guidance (as the guideline itself recommends choosing): Since blocks cover different regions of the chest wall, block selection should be guided by the surgical approach and the expected pain site. The guideline gives the example: parasternal superficial intercostal plane block for sternotomy pain.

Relevant note: The guideline acknowledges controversies and technical variability of the ESP block (including inconsistent performance across different studies), which may impact anesthetic distribution and clinical effects.

B) Minimally Invasive Cardiothoracic (Adults): Conditional Recommendation, Low Evidence

Advantages: There is statistical pain reduction and, especially, clinically relevant opioid reduction at 24h in some studies. This is highlighted as potentially important given the higher risk of postoperative respiratory compromise in these patients.

Which techniques/blocks appear in the evidence base:

• Fascial plane blocks (examples: ESP, intercostal block, serratus anterior), paravertebral (single injection and continuous) and continuous epidural.

Practical guidance (how the guideline frames it): The recommendation is to include regional techniques (neuraxial and/or fascial plane blocks) in a multimodal regimen. The recommendation is conditional due to overall low evidence.

The text also contextualizes that continuous epidural, although with clinically relevant pain reduction in some outcomes, is not recommended for minimally invasive thoracic surgery by specific postoperative pain management groups (the guideline cites the Procedure Specific Postoperative Pain Management group) and suggests considering alternatives such as continuous paravertebral when prolonging local anesthetic effect is needed.

C) Open Abdominal/Retroperitoneal/Pelvic (Adults): Strong Recommendation, Moderate Evidence

Advantages (24h): Reduction in pain at rest and with movement, and opioid reduction. Pain reduction is described as modest, but with opioid reduction (~35 OME) and increased patient satisfaction.

Examples of blocks included in the evidence (fascial plane blocks):

• ESP, transversus abdominis plane block (TAP), quadratus lumborum (QL) and intercostal.

Practical guidance (limits and applicability): The guideline emphasizes high variability between studies (procedure, technique, dose/site, timing, and who performs it), but still observes overall analgesic benefit.

Important: There is no specific recommendation for open inguinal hernia, because these surgeries are frequently already performed under local/regional anesthesia, making it difficult to infer the incremental gain of a fascial block.

D) Minimally Invasive Abdominal (Adults): Strong Recommendation, Moderate Evidence (Except Hernia: Conditional/Low)

Advantages: The guideline groups minimally invasive surgeries by incision pattern and somatic pain intensity. It highlights that fascial plane blocks primarily reduce somatic pain and have less influence on visceral pain, but still show consistent opioid reduction across surgical categories.

Examples of blocks included in the evidence (fascial plane blocks):

• ESP, quadratus lumborum, rectus sheath, serratus anterior plane, TAP.

Practical guidance: Recommended (strong/moderate) for cholecystectomy, appendectomy, bariatric, gastrectomy, and hepatic resections. Suggested (conditional/low) for minimally invasive hernia.

E) Mastectomy (Adults): Strong Recommendation, Moderate Evidence

Advantages (24h): Fascial plane blocks reduce pain (at rest and with movement), reduce opioids, and improve quality of recovery and satisfaction.

Paravertebral also reduces opioids and pain in some outcomes, but with often lower evidence strength. There are no trials (in the analyzed database) evaluating quality of recovery with paravertebral.

Which blocks were represented in the studies:

• Fascial plane blocks: ESP, interpectoral, pectoserratus, serratus anterior.
• Additionally, paravertebral (single injection) also comprises the evidence compared to controls.

Practical guidance: The guideline concludes that both (paravertebral and fascial plane blocks) provide effective analgesia. In available comparative analyses, there were no relevant differences between them, but fascial plane blocks were associated with improved quality of recovery and satisfaction.

Take-Home#

• Open cardiothoracic, open abdominal, and mastectomy surgery (adults): fascial plane blocks are a strong recommendation, with moderate evidence for pain/opioid reduction (and satisfaction/QoR in specific scenarios).
• Minimally invasive abdominal (adults): strong/moderate recommendation for several surgeries; minimally invasive hernia repair remains conditional/low.
• Block selection should consider the incision site + expected pain location.
• If you need to review anatomical landmarks, doses, and local anesthetic volumes for each block, Anestcopilot is the tool always at hand for quick consultations.