Role of long-acting local anaesthetics in extended postoperative analgesia across defined surgical pathways
05 May 2026
The latest 2026 American Society of Anesthesiologists (ASA) Practice Guideline provides evidence based recommendations on perioperative pain management, with a focus on using local and regional anaesthesia (RA) for mastectomy and open as well as minimally invasive surgeries. This article highlights the role of long-acting local anaesthetics, such as bupivacaine and ropivacaine, delivered via fascial plane blocks (FPBs) in extending postoperative analgesia following mastectomy and cardiothoracic and abdominal surgery in adults and children.
ASA 2026 Practice Guideline
Optimal perioperative pain management facilitates postoperative functional recovery by hastening ambulation and rehabilitation, while inadequate postoperative pain management is associated with chronic postsurgical pain, which can affect long-term quality of life. [Anesthesiology 2026;144:19-43]
Aims and methodology
The ASA Task Force, consisting of anaesthesiologists with expertise in RA, a general surgeon, a patient representative, and epidemiology-trained methodologists, conducted a systematic review of procedure-specific regional and local analgesia techniques to provide evidence-based recommendations regarding appropriate management of perioperative pain, which are outlined in the latest 2026 ASA Practice Guideline.
The Task Force conducted a comprehensive search of medical literature published between January 2013 and June 2023 with the view of answering two key questions:
- In patients undergoing elective or urgent surgeries, what are the effectiveness and harms of regional analgesia techniques vs controls (eg, no intervention, placebo, or sham)?
- In patients undergoing elective or urgent surgeries, what are the comparative effectiveness and harms of regional analgesia technique(s) vs another regional analgesia technique(s)?
The interventions included in the systematic review were neuraxial analgesia, paravertebral blocks, peripheral nerve blocks, chest and abdominal wall FPBs, local infiltration of the surgical site, and intraperitoneal instillation. Critical outcome measures were pain scores at rest or with cough or movement (dynamic pain) using various assessment tools (eg, Visual Analogue Scale, Numeric Rating Scale, Children’s Hospital of Eastern Ontario Pain Scale) and total opioid use in the first 24 hours postsurgery. The minimal clinically important difference (MCID) in pain scores was defined as a reduction of ≥1 point on a scale of 0–10 mm or ≥10 points on a scale of 0–100 mm.
Recommendations
Open cardiothoracic surgeries in adults
Pooled results from five randomized clinical trials (RCTs) assessing pain intensity showed that FPBs led to a reduction in pain at 24 hours postoperatively that exceeded MCID. Similarly, pooled analysis of eight RCTs showed that FPBs reduced the use of opioids vs controls, with a mean difference of 60 oral morphine equivalents (OME).
The Task Force strongly recommended incorporating FPBs into the multimodal analgesic regimen for patients undergoing open cardiothoracic surgeries, noting that the studies included in the analysis used a variety of block techniques covering different regions of the chest and that the choice of block should be influenced by surgical approach and site of anticipated pain.
Open abdominal surgeries in adults
Pooled analysis of 22 RCTs suggested that FPBs reduced pain at rest, while 10 trials suggested reduction of dynamic pain, and 11 trials showed reduced opioid use. While the reduction in pain intensity was modest, the reduction in opioid use for FPBs was 35 OME. A pooled analysis of five trials indicated that FPBs were also associated with an increase in patient satisfaction.
The Task Force strongly recommended using FPBs to reduce pain and/or opioid requirements and improve patient satisfaction for adults undergoing open abdominal, retroperitoneal, and pelvic surgeries.
Mastectomy
Pooled analysis of 20 RCTs showed that FPBs reduced pain at rest, and 11 trials showed a reduction in dynamic pain at 24 hours postsurgery, with only the latter meeting the MCID. Nine RCTs showed a reduction in pain at rest with paravertebral block, and four trials achieved the MCID in dynamic pain. Pooled analysis of 18 trials for FPBs and five trials for paravertebral blocks showed that both were associated with reduced opioid use in the first 24 hours after surgery, with a decrease of 25 OME.
While no trials involving paravertebral blocks assessed quality of recovery, pooled analysis indicated that FPBs were associated with improved quality of recovery and higher patient satisfaction.
FPBs or paravertebral blocks were strongly recommended for adults undergoing mastectomy to reduce pain and/or opioid requirements in the first 24 hours postoperatively. FPBs were also recommended for improving patient satisfaction and quality of recovery.
Minimally invasive cardiothoracic surgeries in adults
Pooled analyses of 20 trials for single-injection and six trials for continuous FPBs showed a reduction in pain at 24 hours, which, however, did not meet the MCID. At the same time, single-injection FPBs were associated with reduced opioid use by 37 OME. Pooled analyses of six trials showed that continuous epidural analgesia reduced both pain at rest and dynamic pain at 24 hours exceeding the MCID.
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, but not for dynamic pain, with continuous paravertebral block.
As the overall strength of evidence was low, the Task Forced suggested including neuraxial blocks or FPBs within a multimodal analgesic regimen to decrease pain after minimally invasive cardiothoracic surgeries.
Minimally invasive abdominal surgeries in adults
Pooled analysis of 62 RCTs showed a reduction in pain intensity and opioid use in all surgical groups, but pain reduction did not meet the MCID. Pooled analysis of three trials indicated higher quality of recovery with FPBs that met the MCID for nephrectomy. Similarly, five trials showed higher quality of recovery for appendectomy surgical subgroups, but the difference did not meet MCID.
It was recommended that FPBs be used for cholecystectomy, appendectomy, bariatric surgery, gastrectomy, and liver resection to reduce pain and/or opioid requirements in the first 24 hours postoperatively. It was also suggested that FPBs be used for adults undergoing minimally invasive hernia repair to reduce pain in the first 24 hours postoperatively.
Open cardiothoracic and abdominal surgeries in paediatric patients
Pooled analysis of seven trials investigating open cardiac surgery found that FPBs reduced opioid use within the first 24 hours, and six trials reported minimal pain reduction within the first 12–24 hours. Pooled analysis of two RCTs evaluating open hernia repair suggested that FPBs reduced pain within the first 12–24 hours post-surgery.
The Task Force strongly recommended that for patients <18 years of age undergoing open cardiothoracic surgeries, FPBs be used to reduce pain and/or opioid requirements in the first 24 hours postoperatively. Use of FPBs was also suggested for patients <18 years of age undergoing open hernia repair to reduce pain in the first 24 hours postoperatively.
