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Eldredge RS, Ochoa B, Carmichael J, Ostlie DJ, Lee J, McMahon L, Notrica DM, Padilla BE. Opioid Prescriptions at Discharge After Minimally Invasive Repair of Pectus Excavatum Are Reduced With Cryoablation. J Pediatr Surg 2024; 59:1291-1296. [PMID: 38584007 DOI: 10.1016/j.jpedsurg.2024.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 03/04/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND The minimally invasive repair of pectus excavatum (MIRPE) is associated with significant postoperative pain and opioid use. The objective of this study was to determine the effect of intercostal nerve cryoablation (Cryo) on inpatient and post-hospital opioid prescription practices following MIPRE. METHODS A retrospective review at a single pediatric center was conducted of patients ≤21 years old who underwent MIRPE. Oral morphine equivalents (OME) of inpatient and discharge opioids were compared between Cryo and no-Cryo cohorts. RESULTS 579 patients were identified (82.8% male, mean age 15.4 ± 2.0 years). Cryo was performed in 73.5% of patients. The total inpatient OME use was less in the Cryo group (0.89 ± 0.68 vs. 1.6 ± 0.5 OME/kg/day; p < 0.001). Patients who underwent Cryo were prescribed significantly less OME at discharge compared to the no-Cryo group (3.9 ± 1.7 vs. 10.0 ± 4.1 OME mg/kg, p < 0.001). There was no statistically significant difference in the proportion of patients who required an opioid prescription refill (Cryo 12.4% vs. no-Cryo 11.5%, p = 0.884) or were readmitted (Cryo 5.3% vs. no-Cryo 4.6%, p = 0.833). CONCLUSION Patients who underwent cryoablation during MIRPE were prescribed significantly less opioid at the time of discharge without increasing the need for opioid refills or hospital readmissions. LEVEL OF EVIDENCE Treatment study; Level III evidence.
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Affiliation(s)
- R Scott Eldredge
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA
| | - Brielle Ochoa
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Jared Carmichael
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Daniel J Ostlie
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA; Department of Child Health and Development, University of Arizona, School of Medicine, Phoenix, AZ, USA
| | - Justin Lee
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Child Health and Development, University of Arizona, School of Medicine, Phoenix, AZ, USA
| | - Lisa McMahon
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA; Department of Child Health and Development, University of Arizona, School of Medicine, Phoenix, AZ, USA
| | - David M Notrica
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA; Department of Child Health and Development, University of Arizona, School of Medicine, Phoenix, AZ, USA
| | - Benjamin E Padilla
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Child Health and Development, University of Arizona, School of Medicine, Phoenix, AZ, USA.
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Franklin AD, Tsao K, Barq R, Kelley-Quon LI, Veneziano G, Aldrink JH. Updates From the Other Side of the Drape: Recent Advances in Multimodal Pain Management and Opioid Reduction Among Pediatric Surgical Patients. J Pediatr Surg 2024; 59:1297-1303. [PMID: 38614947 DOI: 10.1016/j.jpedsurg.2024.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 03/04/2024] [Indexed: 04/15/2024]
Abstract
As the management of acute pain for children undergoing surgical procedures as well as recognition of the short and long term risks of exposure to opioids has evolved, multimodal and multidisciplinary approaches using organized pathways has resulted in improved perioperative outcomes and patient satisfaction. In this 2023 symposium held at the American Academy of Pediatrics on Surgery meeting, a multidisciplinary discussion on current enhanced recovery after surgery pathways, alternate methods of effective pain control and education and advocacy efforts for opioid reduction were discussed, and highlights are included in this article.
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Affiliation(s)
- Andrew D Franklin
- Division of Pediatric Anesthesia, Department of Anesthesia, Vanderbilt University Medical Center, Nashville, TN, USA
| | - KuoJen Tsao
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA
| | - Rabab Barq
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Giorgio Veneziano
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.
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Zacha S, Biernawska J. Cryoanalgesia as the Essential Element of Enhanced Recovery after Surgery (ERAS) in Children Undergoing Thoracic Surgery-Scoping Review. J Pers Med 2024; 14:411. [PMID: 38673038 PMCID: PMC11051180 DOI: 10.3390/jpm14040411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/06/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
This article aims to present cryoanalgesia as an inventive strategy for pain alleviation among pediatric patients. It underlines the tremendous need to align pain management with the principles of the enhanced recovery after surgery (ERAS) approach. The aim of the study was to review the patient outcomes of nerve cryoanalgesia during surgery reported with regard to ERAS in the literature. The literature search was performed using PubMed and Embase to identify articles on the use of cryoanalgesia in children. It excluded editorials, reviews, meta-analyses, and non-English articles. The analysis focused on the study methods, data analysis, patient selection, and patient follow-up. This review includes a total of 25 articles. Three of the articles report the results of cryoanalgesia implemented in ERAS protocol in children. The research outcome indicates shortened hospital stay, potential reduction in opioid dosage, and significant progress in physical rehabilitation. This paper also describes the first intraoperative utilization of intercostal nerve cryoanalgesia during the Nuss procedure in Poland, highlighting its effectiveness in pain management. Adding the cryoanalgesia procedure to multimodal analgesia protocol may facilitate the implementation of the ERAS protocol in pediatric patients.
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Affiliation(s)
- Sławomir Zacha
- Department of Pediatric Orthopedics and Oncology of Musculoskeletal System, Pomeranian Medical University in Szczecin, 70-252 Szczecin, Poland
| | - Jowita Biernawska
- Department of Anesthesiology and Intensive Therapy, Pomeranian Medical University in Szczecin, 70-252 Szczecin, Poland;
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Clark R, Reznik SI. An Order of Ice to Go. Ann Thorac Surg 2024; 117:837-838. [PMID: 37302453 DOI: 10.1016/j.athoracsur.2023.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 05/26/2023] [Indexed: 06/13/2023]
Affiliation(s)
- Rachael Clark
- Department of Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Scott I Reznik
- Division of General Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8879, Dallas, TX 75390.
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Janssen N, Daemen JHT, Franssen AJPM, van Polen EJ, van Roozendaal LM, Hulsewé KWE, Vissers Y, de Loos ER. Intercostal nerve cryoablation versus thoracic epidural analgesia for minimal invasive Nuss repair of pectus excavatum: a protocol for a randomised clinical trial (ICE trial). BMJ Open 2024; 14:e081392. [PMID: 38531584 DOI: 10.1136/bmjopen-2023-081392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
INTRODUCTION Epidural analgesia is currently considered the gold standard in postoperative pain management for the minimally invasive Nuss procedure for pectus excavatum. Alternative analgesic strategies (eg, patient-controlled analgesia and paravertebral nerve block) fail in accomplishing adequate prolonged pain management. Furthermore, the continuous use of opioids, often prescribed in addition to all pain management strategies, comes with side effects. Intercostal nerve cryoablation seems a promising novel technique. Hence, the primary objective of this study is to determine the impact of intercostal nerve cryoablation on postoperative length of hospital stay compared with standard pain management of young pectus excavatum patients treated with the minimally invasive Nuss procedure. METHODS AND ANALYSIS This study protocol is designed for a single centre, prospective, unblinded, randomised clinical trial. Intercostal nerve cryoablation will be compared with thoracic epidural analgesia in 50 young pectus excavatum patients (ie, 12-24 years of age) treated with the minimally invasive Nuss procedure. Block randomisation, including stratification based on age (12-16 years and 17-24 years) and sex, with an allocation ratio of 1:1 will be performed.Postoperative length of hospital stay will be recorded as the primary outcome. Secondary outcomes include (1) pain intensity, (2) operative time, (3) opioid usage, (4) complications, including neuropathic pain, (5) creatine kinase activity, (6) intensive care unit admissions, (7) readmissions, (8) postoperative mobility, (9) health-related quality of life, (10) days to return to work/school, (11) number of postoperative outpatient visits and (12) hospital costs. ETHICS AND DISSEMINATION This protocol has been approved by the local Medical Ethics Review Committee, METC Zuyderland and Zuyd University of Applied Sciences. Participation in this study will be voluntary and informed consent will be obtained. Regardless of the outcome, the results will be disseminated through a peer-reviewed international medical journal. TRIAL REGISTRATION NUMBER NCT05731973.
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Affiliation(s)
- Nicky Janssen
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Jean H T Daemen
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Aimée J P M Franssen
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Elise J van Polen
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Lori M van Roozendaal
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Karel W E Hulsewé
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Yvonne Vissers
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Erik R de Loos
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
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Eldredge RS, Ochoa B, Khoury E, Mihalcin K, Ostlie D, Lee J, McMahon L, Notrica D, Padilla BE. Long-Term Sensory Function 3 years after Minimally Invasive Repair of Pectus Excavatum with Cryoablation. J Pediatr Surg 2024; 59:379-384. [PMID: 37973420 DOI: 10.1016/j.jpedsurg.2023.10.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Minimally invasive repair of pectus excavatum (MIRPE) with intercostal nerve cryoablation (Cryo) decreases length of hospitalization and opioid use, but long-term recovery of sensation has been poorly described. The purpose of this study was to quantify long-term hypoesthesia and neuropathic pain after MIRPE with Cryo. METHODS A prospective cohort study was conducted single-institution of patients ≤21 years who presented for bar removal. Consented patients underwent chest wall sensory testing and completed neuropathic pain screening. Chest wall hypoesthesia to cold, soft touch, and pinprick were measured as the percent of the treated anterior chest wall surface area (TACWSA); neuropathic pain was evaluated by questionnaire. RESULTS The study enrolled 47 patients; 87% male; median age 18.4 years. The median bar dwell time was 2.9 years. A median of 2 bars were placed; 80.9% were secured with pericostal sutures. At enrollment, 46.8% of patients had identifiable chest wall hypoesthesia. The mean percentage of TACWSA with hypoesthesia was 4.7 ± 9.3% (cold), 3.9 ± 7.7% (soft touch), and 5.9 ± 11.8% (pinprick). Hypoesthesia to cold was found in 0 dermatomes in 62%, 1 dermatome in 11%, 2 dermatomes in 17% and ≥3 dermatomes in 11%. T5 was the most common dermatome with hypoesthesia. Neuropathic symptoms were identified by 13% of patients; none required treatment. CONCLUSION In long-term follow up after MIRPE with Cryo, 46.8% of patients experienced some chest wall hypoesthesia; the average TACWSA with hypoesthesia was 4-6%. Hypoesthesia was mostly limited to 1-2 dermatomes, most commonly T5. Chronic symptomatic neuropathic pain was rare. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- R Scott Eldredge
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA; Division of General Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Brielle Ochoa
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Emily Khoury
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Kristin Mihalcin
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Daniel Ostlie
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA; University of Arizona School of Medicine, Phoenix, AZ, USA
| | - Justin Lee
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA; University of Arizona School of Medicine, Phoenix, AZ, USA
| | - Lisa McMahon
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA; University of Arizona School of Medicine, Phoenix, AZ, USA
| | - David Notrica
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA; University of Arizona School of Medicine, Phoenix, AZ, USA
| | - Benjamin E Padilla
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA; University of Arizona School of Medicine, Phoenix, AZ, USA.
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van Braak H, de Beer SA, de Jong JR, Stevens MF, Musters G, Zwaveling S, Oomen MWN, der Made WV, Krug E, van Heurn LWE. Intercostal Nerve Cryoablation or Epidural Analgesia for Multimodal Pain Management after the Nuss Procedure: A Cohort Study. Eur J Pediatr Surg 2024. [PMID: 38242172 DOI: 10.1055/a-2249-7588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
BACKGROUND Nuss procedure for pectus excavatum is a minimally invasive, but painful procedure. Recently, intercostal nerve cryoablation has been introduced as a pain management technique. MATERIALS AND METHODS In this cohort study, we compared the efficacy of multimodal pain management strategies in children undergoing a Nuss procedure. The effectiveness of intercostal nerve cryoablation combined with patient-controlled systemic opioid analgesia (PCA) was compared with continuous epidural analgesia (CEA) combined with PCA. The study was conducted between January 2019 and July 2022. Primary outcome was length of stay (LOS), and secondary outcomes were operation room time, postoperative pain, opioid consumption, and gabapentin use. RESULTS Sixty-six consecutive patients were included, 33 patients in each group. The cryoablation group exhibited lower Numeric Rating Scale (NRS) pain scores on postoperative day 1 and 2 (p = 0.002, p = 0.001) and a shorter LOS (3 vs. 6 days (p < 0.001). Cryoablation resulted in less patients requiring opioids at discharge (30.3 vs. 97.0%; p < 0.001) and 1 week after surgery (6.1 vs. 45.4%; p < 0.001)). In the CEA group, gabapentin use was more prevalent (78.8 vs. 18.2%; p < 0.001) and the operation room time was shorter (119.4 vs. 135.0 minutes; p < .010). No neuropathic pain was reported. CONCLUSIONS Intercostal nerve cryoablation is a superior analgesic method compared with CEA, with reduced LOS, opioid use, and NRS pain scores. The prophylactic use of gabapentin is redundant.
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Affiliation(s)
- Hendrik van Braak
- Department of Pediatric Surgery, Amsterdam UMC Locatie AMC, AZ, Amsterdam, Noord-Holland, The Netherlands
| | - Sjoerd A de Beer
- Department of Pediatric Surgery, Amsterdam UMC Locatie AMC, AZ, Amsterdam, Noord-Holland, The Netherlands
| | - Justin R de Jong
- Department of Pediatric Surgery, Amsterdam UMC Locatie AMC, AZ, Amsterdam, Noord-Holland, The Netherlands
| | - Markus F Stevens
- Department of Anesthesiology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Gijsbert Musters
- Department of Gastrointestinal Surgery and Surgical Oncology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Sander Zwaveling
- Department of Pediatric Surgery, Amsterdam UMC Locatie AMC, AZ, Amsterdam, Noord-Holland, The Netherlands
| | - Matthijs W N Oomen
- Department of Pediatric Surgery, Amsterdam UMC Locatie AMC, AZ, Amsterdam, Noord-Holland, The Netherlands
| | - Wendeline Van der Made
- Department of Surgery, Leiden Universitair Medisch Centrum, Leiden, Zuid-Holland, The Netherlands
| | - Egbert Krug
- Department of Surgery, Leiden Universitair Medisch Centrum, Leiden, Zuid-Holland, The Netherlands
| | - L W Ernest van Heurn
- Department of Pediatric Surgery, Amsterdam UMC Locatie AMC, AZ, Amsterdam, Noord-Holland, The Netherlands
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Walker SM, Peters J, Verriotis M, Farag F, Jay MA, Howard RF. Sensitivity and Specificity of a Neuropathic Screening Tool (Self-Report Leeds Assessment of Neuropathic Symptoms and Signs, S-LANSS) in Adolescents With Moderate-Severe Chronic Pain. THE JOURNAL OF PAIN 2024; 25:451-465. [PMID: 37741521 DOI: 10.1016/j.jpain.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 08/27/2023] [Accepted: 09/07/2023] [Indexed: 09/25/2023]
Abstract
Neuropathic screening tools improve recognition of neuropathic pain in adults. Although utilized in pediatric populations, the sensitivity, specificity and methodology of screening tool delivery have not been compared in children. We evaluated the Self-Report Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) in adolescents (10-18 years) referred to a tertiary pediatric pain clinic. History and examination by specialist clinicians and multidisciplinary assessment informed classification of the primary pain type. In a prospective cohort, scores were obtained at interview (S-LANSS interview; n = 161, 70% female), and following substitution of self-reported signs with examination findings in the primary pain region (Leeds Assessment of Neuropathic Symptoms and Signs, LANSS examination). Secondly, we retrospectively retrieved questionnaires self-completed by adolescents at their initial clinic appointment (S-LANSS self-completed; n = 456, 73% female). Thirdly, we explored relationships between patient-reported outcomes and S-LANSS scores. S-LANSS interview scores varied with pain classification, and S-LANSS self-completed scores were similarly highest with neuropathic pain (median [interquartile range]: 18 [11, 21]) and complex regional pain syndrome (21 [14, 24]), variable with musculoskeletal pain (13 [7, 19]) and lowest with visceral pain (6.5 [2, 11.5]) and headache (8.5 [4, 14]). As in adults, the cutpoint score of 12/24 was optimal. Sensitivity was highest with inclusion of examination findings and lowest with self-completion (LANSS examination vs S-LANSS interview vs S-LANSS self-completed: 86.3% vs 80.8% vs 74.7%), but specificity was relatively low (37.8% vs 36.7% vs 48%). High S-LANSS scores in non-neuropathic groups were associated with female sex and high pain catastrophizing. The S-LANSS is a sensitive screening tool for pain with neuropathic features in adolescents, but needs to be interpreted in the context of clinical evaluation (clinicaltrials.gov NCT03312881). PERSPECTIVE: This article reports high sensitivity of the S-LANSS screening tool for identifying pain with neuropathic features in adolescents with moderate-severe chronic pain. However, as sensitivity is lower than in adult populations, further interdisciplinary evaluation is necessary to inform diagnosis and management.
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Affiliation(s)
- Suellen M Walker
- Paediatric Pain Research Group, Developmental Neurosciences Program, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Judy Peters
- Paediatric Pain Research Group, Developmental Neurosciences Program, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Madeleine Verriotis
- Paediatric Pain Research Group, Developmental Neurosciences Program, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Fadila Farag
- Paediatric Pain Research Group, Developmental Neurosciences Program, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Matthew A Jay
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Richard F Howard
- Paediatric Pain Research Group, Developmental Neurosciences Program, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
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Perez MN, Ferrantella A, Johnson KN, Goldstein SD. Intercostal spinal nerve cryoablation for analgesia following pectus excavatum repair. Semin Pediatr Surg 2024; 33:151382. [PMID: 38190771 DOI: 10.1016/j.sempedsurg.2024.151382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
Pectus excavatum is a common chest wall deformity, most often treated during adolescence, that presents a significant postoperative pain control challenge for pediatric surgeons following surgical correction. The purpose of this article is to review the technique and outcomes of intercostal spinal nerve cryoablation for postoperative analgesia following surgical correction of pectus excavatum. Contemporary and historic literature were reviewed. Findings are summarized to provide a concise synopsis of the benefits of intercostal spinal nerve cryoablation relative to alternative analgesic modalities, as well as advocate for more widespread inclusion of this technique into multimodal pain regimens.
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Affiliation(s)
- Mallory N Perez
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Anthony Ferrantella
- Department of Surgery, Phoenix Children's Hospital, Mayo Clinic College of Medicine and Science, Phoenix, AZ, USA
| | - Kevin N Johnson
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Seth D Goldstein
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Eldredge RS, Lai K, Ochoa B, Khoury E, Mihalcin K, Ostlie D, Lee J, McMahon L, Egan C, Molitor M, Bae JO, Notrica D, Padilla BE. A Prospective Study of Sensory Changes in Pediatric Patients After Minimally Invasive Repair of Pectus Excavatum With Cryoablation. J Pediatr Surg 2024; 59:138-145. [PMID: 37914592 DOI: 10.1016/j.jpedsurg.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 09/06/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Cryoablation during minimally invasive repair for pectus excavatum (MIRPE) reduces opioid use and hospital length of stay. Skin hypoesthesia of the chest wall also occurs. This study sought to determine the frequency, onset, duration, and location of sensory changes and neuropathic pain after cryoablation. METHODS A prospective study was conducted on patients aged ≤21 years undergoing MIRPE with cryoablation of T3 to T7 dermatomes bilaterally for 120 s at a single institution between March 2021 to December 2022. Patients underwent sensory testing of the chest wall and neuropathic pain surveys (S-LANSS) preoperatively and then postoperatively for 6 months. Incidence and duration of hypoesthesia and neuropathic pain were evaluated. RESULTS Of 61 patients enrolled in the study, 45 completed evaluations at six months postoperatively. All patients had skin hypoesthesia on postoperative day (POD)1. The mean percentage of the treated anterior chest wall surface area (TACWSA) with hypoesthesia to cold stimulus was 52% (±29.3) on POD 0 and 55% (±19.7) on POD 1. Sensation returned over time, with hypoesthesia affecting 11.1% (±15.5) TACWSA at 6 months. At study completion 58% of patients (26/45) had complete return of sensation; hypoesthesia was found at: 1 dermatome 13% (2/45), 2 dermatomes 22% (11/45), and 3 dermatomes 4% (2/45). Neuropathic pain (S-LANSS ≥12) was documented in 16% (9/55) of patients at hospital discharge but decreased to 6.7% of patients at 6 months. CONCLUSION Onset of skin hypoesthesia after cryoablation occurred on POD0 and affected 52% of the TACWSA. All patients experienced return of sensation to varying degrees, with 58% experiencing normal sensation in all dermatomes by 6 months. The etiology of persistent hypoesthesia to select dermatomes is unknown but may be related to operative technique or cryoablation. Chronic neuropathic pain is uncommon. LEVEL OF EVIDENCE II. TYPE OF STUDY Prognosis Study.
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Affiliation(s)
- R Scott Eldredge
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA
| | - Krista Lai
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Brielle Ochoa
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Emily Khoury
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Kristin Mihalcin
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Daniel Ostlie
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Justin Lee
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Child Health and Development, University of Arizona, School of Medicine, Phoenix, AZ, USA
| | - Lisa McMahon
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Craig Egan
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Mark Molitor
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Jae-O Bae
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - David Notrica
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA
| | - Benjamin E Padilla
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Child Health and Development, University of Arizona, School of Medicine, Phoenix, AZ, USA.
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Handlogten K. Pediatric regional anesthesiology: a narrative review and update on outcome-based advances. Int Anesthesiol Clin 2024; 62:69-78. [PMID: 38063039 DOI: 10.1097/aia.0000000000000421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Kathryn Handlogten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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Zacha S, Jarosz K, Kokot K, Biłas J, Skonieczna-Żydecka K, Gerus S, Kojder K, Biernawska J. Benefits of the Erector Spinae Plane Block before Cryoanalgesia in Children Undergoing Surgery for Funnel Chest Deformity. J Pers Med 2023; 13:1696. [PMID: 38138923 PMCID: PMC10744559 DOI: 10.3390/jpm13121696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 11/30/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
Thoracic surgery causes significant pain despite standard multimodal analgesia. Intraoperative cryoanalgesia may be a solution. The onset of the clinical effect of cryoanalgesia can take 12-36 h. The addition of a regional anaesthesia before the cryoanalgesia procedure can enable analgesic protection for the patient during this period. The main aim of the study was to evaluate the benefits of the erector spinae plane (ESP) block prior to Nuss surgery. The 'control' group consisted of 10 teenagers who underwent cryoablation together with intravenous multimodal analgesia according to the standard protocol. The 'intervention' group included 26 teenage patients who additionally received an erector spinae plane block before operation. Pain relief (p = 0.015), opioid use (p = 0.009), independent physical activity and rehabilitation (p = 0.020) were faster in the intervention group. No features of local anaesthetic drug toxicity or complications of the ESP block were observed. The bilateral ESP block together with intraoperative intercostal nerve cryoablation performed prior to Nuss correction of funnel chest were more effective in terms of pain control.
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Affiliation(s)
- Sławomir Zacha
- Department of Paediatric Orthopaedics and Musculoskeletal Oncology, Pomeranian Medical University, 71-252 Szczecin, Poland; (S.Z.); (J.B.)
| | - Konrad Jarosz
- Department of Clinical Nursing, Pomeranian Medical University, 70-204 Szczecin, Poland
| | - Karolina Kokot
- Department of Anaesthesiology and Intensive Therapy, Pomeranian Medical University, 71-252 Szczecin, Poland; (K.K.); (K.K.); (J.B.)
| | - Jarosław Biłas
- Department of Paediatric Orthopaedics and Musculoskeletal Oncology, Pomeranian Medical University, 71-252 Szczecin, Poland; (S.Z.); (J.B.)
| | - Karolina Skonieczna-Żydecka
- Department of Biochemical Science, Faculty of Health Sciences, Pomeranian Medical University, 70-204 Szczecin, Poland;
| | - Sylwester Gerus
- Department of Paediatric Surgery and Urology, Wroclaw Medical University, 50-367 Wrocław, Poland;
| | - Klaudyna Kojder
- Department of Anaesthesiology and Intensive Therapy, Pomeranian Medical University, 71-252 Szczecin, Poland; (K.K.); (K.K.); (J.B.)
| | - Jowita Biernawska
- Department of Anaesthesiology and Intensive Therapy, Pomeranian Medical University, 71-252 Szczecin, Poland; (K.K.); (K.K.); (J.B.)
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Breglio AM, Fitzgerald TN, Moore CB, Einhorn LM. Evaluation of Analgesic Practice Changes Following the Nuss Procedure in Pediatric Patients. J Surg Res 2023; 291:289-295. [PMID: 37481964 PMCID: PMC10528185 DOI: 10.1016/j.jss.2023.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 05/26/2023] [Accepted: 06/19/2023] [Indexed: 07/25/2023]
Abstract
INTRODUCTION Pectus excavatum repair by the Nuss procedure results in severe postoperative pain. Regional blocks and intercostal nerve cryoablation (INC) have emerged as potential strategies to manage analgesia. This study compares pain-related outcomes following these perioperative interventions. METHODS We reviewed charts of patients <18 y who underwent the Nuss procedure at Duke Children's Hospital from July 2018 to June 2022. Patients were divided into three groups by analgesic strategy: no block, regional catheters, or INC, representing the chronologic change in our practice. The primary outcome was total and daily in-hospital opioid utilization measured by oral morphine equivalents (OMEs). Secondary outcomes included average daily pain scores, length of stay, opioid refills after discharge, and complications. RESULTS Twenty-one patients were included and analyzed: no block (n = 6), regional catheters (n = 7), and INC (n = 8). INC-treated patients required significantly lower total postoperative, in-hospital OMEs (64 ± 47 [mean ± standard deviation]) than those with no block (270 ± 217, P = 0.04) or those with regional catheters (273 ± 176, P = 0.03). INC was associated with longer average operative times (161 ± 36 min) than no block (105 ± 21 min, P = 0.005) or regional catheters (90 ± 11 min, P < 0.001). INC-treated patients had shorter hospital length of stays (median 68 h) than those with regional catheters (median 74 h, P = 0.006). CONCLUSIONS INC was associated with longer operative times but decreased in-hospital OMEs when compared to bilateral regional block catheters and multimodal analgesia alone.
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Affiliation(s)
- Andrew M Breglio
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Tamara N Fitzgerald
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Carrie B Moore
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Lisa M Einhorn
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.
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Mehl SC, Sun RC, Anbarasu CR, Portuondo JI, Espinoza AF, Whitlock RS, Shah SR, Nuchtern JG, Minifee PK, Rodriguez JR, Le LD, Stafford SJ, Mazziotti MV. Association of Intercostal Nerve Cryoablation During Nuss Procedure With Complications and Costs. Ann Thorac Surg 2023; 116:803-809. [PMID: 35489402 DOI: 10.1016/j.athoracsur.2022.04.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/01/2022] [Accepted: 04/06/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Intercostal nerve cryoablation with the Nuss procedure has been shown to decrease opioid requirements and hospital length of stay; however, few studies have evaluated the impact on complications and hospital costs. METHODS A retrospective cohort study was performed for all Nuss procedures at our institution from 2016 through 2020. Outcomes were compared across 4 pain modalities: cryoablation with standardized pain regimen (n = 98), patient-controlled analgesia (PCA; n = 96), epidural (n = 36), and PCA with peripheral nerve block (PNB; n = 35). Outcomes collected included length of stay, opioid use, variable direct costs, and postoperative complications. Univariate and multivariate hierarchical regression analysis was used to compare outcomes between the pain modalities. RESULTS Cryoablation was associated with increased total hospital cost compared with PCA (cryoablation, $11 145; PCA, $8975; P < .01), but not when compared with epidural ($9678) or PCA with PNB ($10 303). The primary driver for increased costs was operating room supplies (PCA, $2741; epidural, $2767; PCA with PNB, $3157; and cryoablation, $5938; P < .01). With multivariate analysis, cryoablation was associated with decreased length of stay (-1.94; 95% CI, -2.30 to -1.57), opioid use during hospitalization (-3.54; 95% CI, -4.81 to -2.28), and urinary retention (0.13; 95% CI, 0.05-0.35). CONCLUSIONS Cryoablation significantly reduces opioid requirements and length of stay relative to alternative modalities, but it was associated with an increase in total hospital costs relative to PCA, but not epidural or PCA with PNB. Cryoablation was not associated with allodynia or slipped bars requiring reoperation.
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Affiliation(s)
- Steven C Mehl
- Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas.
| | - Raphael C Sun
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas
| | | | | | - Andres F Espinoza
- Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas
| | | | - Sohail R Shah
- Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas
| | - Jed G Nuchtern
- Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas
| | - Paul K Minifee
- Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas
| | - J Ruben Rodriguez
- Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas
| | - Louis D Le
- Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas
| | - Shawn J Stafford
- Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas
| | - Mark V Mazziotti
- Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas
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Lai K, Eldredge RS, Zobel M, Hargis-Villanueva A, Ostlie A, Padilla BE. Intercostal Nerve Cryoablation for Postoperative Pain Control in Pediatric Thoracic Surgery: A Scoping Review. J Laparoendosc Adv Surg Tech A 2023; 33:994-1004. [PMID: 37462727 DOI: 10.1089/lap.2023.0070] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
Background: Cryoanalgesia uses the application of cold temperatures to temporarily disrupt peripheral sensory nerve function for pain control. This review outlines the principles of cryoablation, clinical applications, and clinical data for its use in pediatric thoracic surgery. Methods: A comprehensive PubMed search was performed using the principal terms and combinations of cryoablation, cryoanalgesia, Nuss, Nuss repair, pectus, pectus excavatum, thoracic surgery, thoracotomy, and chest wall. Pediatric articles were reviewed and included if relevant. Adult articles were reviewed for supporting information as needed. Reference lists of included articles were reviewed for possible additional sources. Discussion: The scientific and clinical principles of cryoablation are outlined, followed by a focused review of current clinical application and outcome data. Conclusion: Postoperative pain is a major challenge following thoracic surgery. Cryoanalgesia is emerging as an adjunct in pediatric thoracic surgery, particularly for the Nuss procedure or minimally invasive repair of pectus excavatum. It effectively controls pain, decreasing postoperative opioid use and hospital length of stay with few short-term complications. Although more long-term studies are needed, early evidence suggests there is reliable return of sensation to the chest wall and long-term neuropathic pain is rare.
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Affiliation(s)
- Krista Lai
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - R Scott Eldredge
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Michael Zobel
- Division of Pediatric Surgery, University of California San Francisco, San Francisco, USA
| | | | - Andrew Ostlie
- Department of Child Health, University of Arizona School of Medicine, Tucson, Arizona, USA
| | - Benjamin E Padilla
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
- Department of Child Health, University of Arizona School of Medicine, Tucson, Arizona, USA
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16
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Eldredge RS, McMahon L. Intercostal nerve cryoablation therapy for the repair of pectus excavatum: a systematic review. Front Surg 2023; 10:1235120. [PMID: 37693640 PMCID: PMC10484532 DOI: 10.3389/fsurg.2023.1235120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
Introduction The minimally invasive repair of pectus excavatum (PE) is a painful procedure that can result in long-term hospitalization and opioid use. To mitigate the length of stay and opioid consumption, many different analgesia strategies have been implemented. The aim of this study is to review the use and patient outcomes of intercostal nerve cryoablation (INC) during PE repair reported in the literature. Methods An unfunded literature search using PubMed identifying articles discussing INC during PE repair from 1946 to 1 July 2023 was performed. Articles were included if they discussed patient outcomes with INC use during PE repair. Articles were excluded if they were reviews/meta-analyses, editorials, or not available in English. Each article was reviewed for bias by analyzing the study methods, data analysis, patient selection, and patient follow-up. Articles comparing outcomes of INC were considered significant if p-value was <0.05. Results A total of 34 articles were included in this review that described INC use during pectus repair. Most supported a decreased hospital length of stay and opioid use with INC. Overall, INC was associated with fewer short-term and long-term complications. However, the researchers reported varied results of total hospital costs with the use of INC. Conclusion The review was limited by a paucity of prospective studies and low number of patients who received INC. Despite this, the present data support INC as a safe and effective analgesic strategy during the repair of PE.
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Affiliation(s)
| | - Lisa McMahon
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children’s Hospital, Phoenix, AZ, United States
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Akinboro S, John R, Reyna T, Davis R, Ayoub C, Sangster R, Kim J, Nguyen H, Moreno C, Guner Y, Goodman L, Yu PT, Morphew T, Kabeer M. A pilot study of multi-modal pain management for same-day discharge after minimally invasive repair of pectus excavatum (Nuss procedure) in children. Pediatr Surg Int 2023; 39:159. [PMID: 36967421 PMCID: PMC10040230 DOI: 10.1007/s00383-023-05429-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2023] [Indexed: 03/28/2023]
Abstract
BACKGROUND Despite advancements in minimally invasive repair of pectus excavatum (MIRPE), Nuss procedure, postoperative pain control remains challenging. This report covers a multimodal regimen using bilateral single-shot paravertebral block (PVB) and bilateral thoracoscopic intercostal nerve (T3-T7) cryoablation, leading to significant reduction in length of stay (LOS) and high rate of same-day discharge. METHODS This is a comparative study of pain management protocols for patients undergoing the Nuss procedure at a single center from 2016 through 2020. All patients underwent the the same surgical technique for the treatment of pectus excavatum at a single center. Patients received bilateral PVB with continuous infusion (Group 1, n = 12), bilateral PVB with infusion and right-side cryoablation (Group 2, n = 9), or bilateral single-shot PVB and bilateral cryoablation (Group 3, n = 17). The primary outcome was LOS with focus on same-day discharge, and the secondary outcome was decreased opioid usage. RESULTS Eleven of 17 patients in Group 3 (65%) (bilateral single-shot PVB and bilateral cryoablation) were discharged the same day as surgery. The remaining Group 3 patients were discharged the following day with no complications or interventions. Compared to Group 1 (no cryoablation), Group 3 had shorter LOS (median 4.4 days vs. 0.7 days, respectively, p < 0.001) and significantly decreased median opioid use on the day of surgery (0.92 mg/kg vs. 0.47 mg/kg, p = 0.006). CONCLUSION Findings demonstrate the feasibility of multimodal pain management for same-day discharge after the Nuss procedure. Future multisite studies are needed to investigate the superiority of this approach to established methods. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | - Rebecca John
- Children's Hospital of Orange County, Orange, USA.
| | - Troy Reyna
- Children's Hospital of Orange County, Orange, USA
| | - Rachel Davis
- Children's Hospital of Orange County, Orange, USA
| | | | | | - Joseph Kim
- Children's Hospital of Orange County, Orange, USA
| | - Hai Nguyen
- Children's Hospital of Orange County, Orange, USA
| | | | - Yigit Guner
- Children's Hospital of Orange County, Orange, USA
| | | | - Peter T Yu
- Children's Hospital of Orange County, Orange, USA
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Chen SY, Mack SJ, Stein JE, Kelley-Quon LI, Kim ES. Intercostal Nerve Cryoablation is Associated with Reduced Opioid Use in Pediatric Oncology Patients. J Surg Res 2023; 283:377-384. [PMID: 36427448 PMCID: PMC10756229 DOI: 10.1016/j.jss.2022.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/24/2022] [Accepted: 11/02/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Intercostal nerve cryoablation reduces postoperative pain in adults undergoing thoracotomy and children undergoing pectus excavatum repair. We hypothesize that cryoablation is associated with decreased post-thoracotomy pain and opioid use in pediatric oncology patients. METHODS A single-center retrospective cohort study was performed for oncology patients who underwent thoracotomy from January 1, 2017 to May 31, 2021. Outcomes included postoperative opioid use measured in morphine milligram equivalents per kilogram (MME/kg), pain scores (scale 0-10), and opioid prescription at discharge. Univariable analysis compared patients who received cryoablation to patients who did not receive cryoablation. Multivariable regression analysis controlling for age and prior thoracotomy evaluated associations between cryoablation and postoperative pain. RESULTS Overall, 32 patients (19 males:13 females) underwent thoracotomy with 16 who underwent >1 thoracotomy resulting in 53 thoracotomies included for analysis. Cryoablation was used in 14 of 53 (26.4%) thoracotomies. Throughout the postoperative hospitalization, patients receiving cryoablation during thoracotomy consumed less opioids compared to patients who did not receive cryoablation (median 0.38 MME/kg, interquartile range [IQR] 0.20-1.15 versus median 1.47 MME/kg, IQR 0.71-4.02, P < 0.01). Maximum pain scores were lower in cryoablation patients (median 6, IQR 5-8) than noncryoablation patients (median 8, IQR 6-10), with a significant difference observed on postoperative day 4 (P = 0.01). Cryoablation patients were also less frequently prescribed opioids at discharge (21.4% versus 58.97%, P = 0.02). Multivariable regression demonstrated that cryoablation was associated with 2.59 MME/kg less opioid use (95% confidence interval -4.56 to -0.63) and decreased likelihood of opioid prescription at discharge (adjusted odds ratio 0.14, 95% confidence interval 0.03-0.67). CONCLUSIONS Cryoablation is significantly associated with decreased post-thoracotomy pain and opioid use in pediatric cancer patients and should be considered in postoperative pain regimens.
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Affiliation(s)
- Stephanie Y Chen
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Shale J Mack
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - James E Stein
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Eugene S Kim
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.
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Velayos M, Alonso M, Estefanía K, Jesus Muñoz A, Torres R, Hernández F, Reinoso F, Torre CDL. Ultrasound-Guided Percutaneous Cryoanalgesia for Pectus Excavatum: When Should It be Applied? Eur J Pediatr Surg 2023; 33:61-67. [PMID: 36257335 DOI: 10.1055/s-0042-1757361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION The addition of ultrasound-guided percutaneous cryoanalgesia (PCr) for pain management after pectus excavatum (PE) surgery offers a new and advantageous approach. Our aim is to describe our experience with PCr applied on the same day, 24 hours, and 48 hours prior to PE surgery. MATERIAL AND METHODS Prospective pilot study in patients undergoing ultrasound-guided PCr (2019-2022) was divided into three groups: PCr on the same day of surgery (PCrSD), PCr 24 hours before (PCr24), and PCr 48 hours before (PCr48). We describe the application of technique and data obtained by comparing the three groups. RESULTS We present 42 patients (25 PCrSD, 11 PCr24, 6 PCr48). PCr24 had a shorter procedure duration than PCrSD (65.8 vs. 91.2 minute; p = 0.048). Related to analgesia, PCr24 and PCr48 showed lower opioid consumption than PCrSD in PCA volume (48.5 and 49.6 vs. 75.1 mL; p = 0.015) and PCA time (23.3 and 23.8 vs. 34.3 hours; p = 0.01). Degree of pain (VAS scale) on the day of surgery and on the second postoperative day was lower in PCr24 and PCr48 than in PCrSD (4 and 2 vs. 5; p = 0.012; 0 and 1 vs. 2; p = 0.01, respectively) as well as shorter hospital stay (3 and 3.5 vs. 5 days; p = 0.021). In addition, PCr24 showed lower opioid consumption and hospital stay than PCr48 (p > 0.05). The greatest savings in hospital costs were obtained in the PCr24 group. CONCLUSION PCr48 and PCr24 prior to PE surgery offers lower opioid consumption, less pain and shorter hospital stay than PCrSD. PCr24 is comparable to PCr48, but seems to show advantages and simpler logistics for the patient and the hospital.
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Affiliation(s)
- María Velayos
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Mercedes Alonso
- Departament of Anesthesia, La Paz University Hospital, Madrid, Spain
| | - Karla Estefanía
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Antonio Jesus Muñoz
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Raquel Torres
- Pain Unit Nursery, La Paz University Hospital, Madrid, Spain
| | - Francisco Hernández
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Francisco Reinoso
- Departament of Anesthesia, La Paz University Hospital, Madrid, Spain
| | - Carlos De la Torre
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
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Lai K, Eldredge RS, Nguyen M, Padilla BE, McMahon LE. Initial outcomes using cryoablation in surgical management of slipping rib syndrome. J Pediatr Surg 2023:S0022-3468(22)00835-1. [PMID: 36737261 DOI: 10.1016/j.jpedsurg.2022.12.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 12/16/2022] [Accepted: 12/29/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Minimally invasive repair of pectus excavatum (MIRPE) and cartilaginous rib excision (CRE) for slipping rib syndrome (SRS) are painful procedures. Intercostal nerve cryoablation (Cryo) controls pain and decreases opioid use in MIRPE. Herein, we describe our experience with cryoablation in CRE. METHODS A retrospective chart review was performed of all patients undergoing CRE between 2018 and 2022. Data on demographics, clinical characteristics, operative details, and hospital course were collected. RESULTS A total of 98 patients underwent CRE: 68 CRE without cryo, 22 CRE + Cryo, and 8 combined MIRPE + CRE + Cryo. Ninety percent of patients underwent bioabsorbable rib plating. Patients were predominantly female (79%, 73%, 50% respectively) with median ages 17.6, 16.9, and 14.2 years respectively. CRE + Cryo patients used significantly less opioids in hospital (0.6 OME/kg [0.1,1.2]) compared to CRE without cryo (1.0 OME/kg [0.6,2.1]), p < 0.05. The median length of stay (LOS) in CRE + Cryo was 1 day [1,2] compared to 2 days in CRE without cryo [1,2], p = 0.09. MIRPE + CRE + Cryo patients used 0.6 OME/kg [0.2,8.0] with a 2 day [1,5.5] LOS. Ninety-one percent of Cryo patients had cryoablation of T9 and/or T10 intercostal nerves, with no documented abdominal wall laxity at median follow-up of 16 days. Cryo was applied extra-thoracically in CRE + cryo without thoracoscopy or lung isolation, while MIRPE + CRE + Cryo used a combination extra-/intra-thoracic cryoablation in with thoracoscopy. CONCLUSION Intercostal nerve cryoablation reduces opioid use and LOS in patients undergoing cartilaginous rib excision for slipping rib syndrome. Cryotherapy to as low as T10 did not result in abdominal wall laxity and can be applied extra-thoracically without the need for thoracoscopy. Ongoing prospective studies are required to assess the long-term outcomes. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Krista Lai
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA.
| | - R Scott Eldredge
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Melissa Nguyen
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Benjamin E Padilla
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Lisa E McMahon
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA.
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Zeineddin S, Goldstein SD, Linton S, DeBoer C, Alayleh A, Ortiz I, Sands L, Kujawa S, Suresh S, Ghomrawi H, Abdullah F. Effectiveness of one minute per level intercostal nerve cryoablation for postoperative analgesia after surgical correction of pectus excavatum. J Pediatr Surg 2023; 58:34-40. [PMID: 36283847 DOI: 10.1016/j.jpedsurg.2022.09.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/16/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Intraoperative intercostal nerve cryoablation has emerged as a promising modality for postoperative analgesia following Surgical Correction of Pectus Excavatum (SCOPE). Most centers use two-minute cryoablation per level, although data from histologic and adult studies suggest the effectiveness of one-minute freezes. We aimed to describe our center's experience with one minute per level cryoablation. METHODS A retrospective single institution review of patients undergoing SCOPE was performed to compare patients pre- and post-intercostal nerve cryoablation implementation. Cryoablation was performed as one minute for each of the thoracic intercostal nerves T3-T7. Multivariable regression analyses were conducted to compare the outcomes and cost between pre- and post-implementation groups. RESULTS During the study period, 198 patients underwent SCOPE with one Nuss bar, receiving either intraoperative intercostal nerve cryoablation (Cryo, n = 100) or preoperative thoracic paravertebral catheters (NoCryo, n = 98). Surgical time was on average 9 min longer for the Cryo group (p<0.01). Median length of stay for the Cryo group was 3 days shorter compared to the NoCryo group (p<0.01). The Cryo group had a 19-fold and 5.6-fold reduction in average inpatient and total postoperative opioid usage, respectively (p<0.01). Total hospital costs were significantly lower in the Cryo group (p<0.01). Overall complication rate was not statistically significant different between the two groups. CONCLUSIONS Intraoperative one minute per level cryoablation is a potent approach to postoperative analgesia for SCOPE patients that led to a shorter hospital length of stay, lower hospital costs, and decreased opioid use compared to conventional analgesia at our institution. Pediatric surgeons performing correction of chest wall deformities should consider offering this technique.
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Affiliation(s)
- Suhail Zeineddin
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA; Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Seth D Goldstein
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA; Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Samuel Linton
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA; Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Christopher DeBoer
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA; Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Amin Alayleh
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA
| | - Irma Ortiz
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA
| | - Laurie Sands
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA
| | - Suzanne Kujawa
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA
| | - Santhanam Suresh
- Department of Pediatric Anesthesia, Children's Hospital of Chicago, Chicago, IL, USA
| | - Hassan Ghomrawi
- Department of Surgery, Northwestern University, Chicago, IL, USA; Department of Pediatrics, Northwestern University, Chicago, IL, USA
| | - Fizan Abdullah
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA; Department of Surgery, Northwestern University, Chicago, IL, USA.
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Manworren RCB, Di Franco MV, Mishra T, Kaduwela N. Pain Quality After Pediatric Pectus Excavatum Repair. Pain Manag Nurs 2022; 23:811-818. [PMID: 35927201 DOI: 10.1016/j.pmn.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 06/08/2022] [Accepted: 06/11/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Neuropathic pain medications are included in multimodal postoperative analgesic strategies, but quality of perioperative pain is rarely assessed. AIMS The purpose of this study was to describe adolescents' pain experiences after thoracoscopic pectus excavatum repair (Nuss procedure) using the Adolescent Pediatric Pain Tool. DESIGN This prospective descriptive longitudinal study was designed to test the hypothesis that pain quality descriptors reported are consistent with neuropathic pain. METHODS A convenience sample of 23 adolescents aged 12 to 17 years from a single urban, university affiliated, nonprofit children's hospital consented to self-report pain using the Adolescent Pediatric Pain Tool before and during hospitalization, and up to 14 months after Nuss procedure. Visual analytic techniques were used to analyze reported pain intensity, location, and affective, evaluative, sensory, and temporal qualities. RESULTS Postoperative pain quality, intensity, number of sites, and surface area decreased over time. Word clouds illustrated that neuropathic sensory and temporal pain quality descriptors increased in frequency 2 to 6 weeks after surgery and were the predominant descriptors 2 to 4 months after surgery. Dot matrix charts illustrated an inconsistent relationship of pain quality and intensity with pain surface area. CONCLUSIONS Pain quality should be assessed with valid, reliable, and developmentally appropriate tools. Visual analytics help illustrate pain quality at single points in time and longitudinally and may be helpful in guiding postoperative pain treatment.
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Affiliation(s)
- Renee C B Manworren
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Maria Victoria Di Franco
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; University of Illinois, Champaign-Urbana, Illinois
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Lai K, Notrica DM, McMahon LE, Kang P, Molitor MS, Egan JC, Bae JO, Hunteman ZM, Ostlie DJ, Lee JH, Padilla BE. Cryoablation in 350 Nuss procedures: Evolution of hospital length of stay and opioid use. J Pediatr Surg 2022:S0022-3468(22)00717-5. [PMID: 36494205 DOI: 10.1016/j.jpedsurg.2022.10.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 10/10/2022] [Accepted: 10/30/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Current studies show cryoablation decreases opioid requirements and lengths of stay (LOS) in patients undergoing the Nuss procedure for pectus excavatum. This study evaluated the relationship between cryoablation and clinical outcomes for the Nuss procedure. METHODS A retrospective single-center chart review was performed on patients undergoing the Nuss procedure with intercostal cryoablation from December 2017-August 2021. Demographics, hospital course, and postoperative complications were abstracted. To evaluate the evolution of outcomes over time, the earliest quarter (Q1) of cryoablation patients was compared to the last quarter (Q4). RESULTS Over 45 months, 350 Nuss procedures with cryoablation were performed. The mean age at operation was 15.7 ± 2.3 years with an average Haller Index of 5.4 ± 4.2. The mean operative time was 136 ± 40.5 minutes. On average, patients used 2.8 ± 2.5 OME/kg of opioid in hospital with a LOS of 2.7 ± 1.1 days. The Q4 patients were discharged 1.3 days earlier (p<0.05) than Q1 patients, with 80% of Q4 discharged by postoperative day #2 vs. 23% in Q1 (p<0.05). Q4 patients received 74% (p<0.05) less opioid in hospital and 21% (p<0.05) less on discharge. Within 90 days postoperatively, complication rates (chest tube placement, wound infection, readmission, neuropathic pain) were similar. Only two patients (0.6%) required reoperation for bar migration/slippage. CONCLUSION With increased experience, cryoablation for the Nuss procedure decreased opioid use by 74% and was associated with 80% of patients achieving early discharge. Major complication rates were not increased. Cryoablation can be successfully implemented as an effective method of postoperative analgesia. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Krista Lai
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - David M Notrica
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Lisa E McMahon
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Paul Kang
- Mel and Enid Zuckerman College of Public Heath, University of Arizona, Tucson, AZ, United States
| | - Mark S Molitor
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - J Craig Egan
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Jae-O Bae
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Zebediah M Hunteman
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Daniel J Ostlie
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Justin H Lee
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Benjamin E Padilla
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States.
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Neurolysis for analgesia following pectus repair in a national cohort. J Pediatr Surg 2022; 57:315-318. [PMID: 35339278 DOI: 10.1016/j.jpedsurg.2022.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Pectus excavatum and pectus carinatum are the most common chest wall deformities of childhood. Surgical repair can be complicated by post-operative analgesic challenges. Thoracic epidural analgesia, patient-controlled analgesia, and multimodal pain control are among the most common strategies. We sought to define the current utilization of intraoperative thoracic neurolysis, hypothesizing that this would minimize length of stay (LOS) and post-operative narcotic use with relatively higher proportion of non-narcotic post-operative analgesia. METHODS We performed a retrospective review of the Pediatric Health Information System (PHIS) database between 2017 and 2020. We first identified patients who underwent a pectus repair via ICD-10-PCS codes. We used ICD-10-PCS codes 01580ZZ and 01584ZZ to identify those patients who underwent concomitant thoracic neurolysis. Statistical analyses were performed using R; p value less than 0.05 was considered significant. RESULTS We identified 2979 patients who underwent a pectus repair. 184 underwent a concomitant thoracic nerve destruction procedure (6.7%); 13 were performed in 2017 (2.01%), 76 in 2018 (10.7%), and 84 in 2019 (9.6%). LOS was shorter in those patients who underwent neurolysis (mean=2.55 vs 3.73 days, SD=1.33 vs 1.78 days, p<0.001). There were fewer post-operative ICU admissions in neurolysis patients (3/184 vs. 193/2795, p = 0.003). The cost of procedures that included a neurolysis were higher, though not significantly so (mean=$24,885.64 vs $22,200.59). CONCLUSION Thoracic neurolysis may be a useful analgesic strategy, expediating post-operative discharge and potentially obviating the need for intensive care. Further larger-scale prospective trials should be considered to further elucidate the role of this analgesia method. LEVEL OF EVIDENCE Level III.
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Rettig RL, Rudikoff AG, Lo HYA, Lee CW, Vazquez WD, Rodriguez K, Shaul DB, Conte AH, Banzali FM, Sydorak RM. Same day discharge for pectus excavatum-is it possible? J Pediatr Surg 2022; 57:34-38. [PMID: 33678403 DOI: 10.1016/j.jpedsurg.2021.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/04/2021] [Accepted: 02/03/2021] [Indexed: 01/12/2023]
Abstract
PURPOSE The use of intercostal nerve cryoablation (INC) has been an effective modality for treating pain in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate if PE patients undergoing Nuss procedures with INC and intercostal nerve block (INB) could safely be discharged the same day of surgery. METHODS A prospective study with IRB approval of 15 consecutive patients undergoing PE Nuss repair with INC, INB, and an enhanced recovery after surgery (ERAS) protocol was conducted. The primary outcome measure was hospital length of stay (LOS) in hours. Secondary variables included same day discharge, postoperative complications, emergency department (ED) visits, urgent care (UC) visits, opioid use, and return to the operating room (OR). RESULTS LOS averaged 11.9 h amongst 15 patients. Ten patients (66.7%) went home on postoperative day (POD) 0, and the rest went home on POD 1. No patients stayed in the hospital due to pain. Reasons for failure to discharge included urinary retention, drowsiness, vomiting, and anxiety, but not pain. No patients were readmitted to the ED. One patient visited UC for constipation. One patient had bar migration requiring return to the OR for revision. Ten (66.7%) patients did not use opioids after discharge. CONCLUSIONS Same day discharge is feasible and safe in PE patients undergoing Nuss procedure with INC and INB. INC with INB can adequately control pain without significant complications. Same day discharge can be safely considered for PE patients undergoing Nuss procedure with INC with INB. TYPE OF STUDY Prognosis study LEVEL-OF-EVIDENCE RATING: Level II.
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Affiliation(s)
- R Luke Rettig
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Andrew G Rudikoff
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Hoi Yee Annie Lo
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Constance W Lee
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Walter D Vazquez
- Department of Pediatric Surgery, Kaiser Permanente San Diego Medical Center, 9455 Clairemont Mesa Blvd, San Diego 92123, CA, United States
| | - Karen Rodriguez
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Donald B Shaul
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Antonio Hernandez Conte
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Franklin M Banzali
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Roman M Sydorak
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States.
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Song SH, Moon DH, Shim YH, Jung H, Lee S. Limited cryoablation reduces hospital stay and opioid consumption compared to thoracic epidural analgesia after minimally invasive repair of pectus excavatum. Medicine (Baltimore) 2022; 101:e29773. [PMID: 35945758 PMCID: PMC9351910 DOI: 10.1097/md.0000000000029773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
pain following minimally invasive repair of pectus excavatum (MIRPE) is a critical concern that leads to a prolonged hospital stay and high doses of opiates administered to the patients. This study aimed to evaluate the efficacy of intraoperative cryoanalgesia (cryoablation of the intercostal nerves) during MIRPE. We retrospectively analyzed the data of 64 patients who underwent MIRPE and received cryoanalgesia or epidural analgesia between January 2019 and January 2021. The oral morphine milligram equivalent (MME) was used to calculate the dosage of opioid agents. The median age was 15 years (range, 4-33 years). The median postoperative hospital stay was 4 days (range, 2-6 days), with a median oral MME consumption of 45 mg (ranging from 0 to 1360 mg). Cryoanalgesia was performed in 38 patients, and epidural analgesia was administered to the remaining 26 patients. The cryoanalgesia group had a significantly lesser pain score, shorter postoperative hospital stay and lower oral MME consumption than the epidural analgesia group (5 vs 2; P < .001, 3 days vs 5 days; P < .001, 19 mg vs 634 mg; P < .001). Cryoanalgesia appears to reduce postoperative hospital stay and opioid consumption compared with epidural analgesia. The outcomes of this study indicate that cryoanalgesia might be a safe and effective method for pain control following MIRPE.
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Affiliation(s)
- Seung Hwan Song
- Department of Thoracic and Cardiovascular Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Duk Hwan Moon
- Department of Thoracic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yon Hee Shim
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyunjoo Jung
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sungsoo Lee
- Department of Thoracic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- *Correspondence: Sungsoo Lee, Department of Thoracic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonju-ro, Gangnam-gu, Seoul, Republic of Korea, 06273 (e-mail: )
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Rettig RL, Yang CJ, Ashfaq A, Sydorak RM. Cryoablation is associated with shorter length-of-stay and reduced opioid use after the Ravitch procedure. J Pediatr Surg 2022; 57:1258-1263. [PMID: 35379492 DOI: 10.1016/j.jpedsurg.2022.02.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE The use of intercostal nerve cryoablation (INC) is becoming increasingly common in patients undergoing pectus repair. This study sought to evaluate the use of INC compared to traditional use of thoracic epidural (TE) in patients undergoing the modified Ravitch procedure. METHODS A retrospective review of 37 patients undergoing the modified Ravitch repair with either INC or TE from March 2009 to July 2021 was conducted. The operations were performed by four surgeons who worked together at four different hospitals and have the same standardized practice. The primary outcome measure was hospital length of stay (LOS). Secondary variables included surgical time, total operating room time, operating room time cost, total hospital cost, inpatient opioid use, long term opioid use after discharge, and post-operative complications. RESULTS LOS decreased to 2.8 days in the INC group compared to 6 days in the TE group (p<0.0001). Surgical time and total OR time was increased in the INC group. The INC group experienced significantly lower hospital costs (p<0.01). Total hospital opioid administration was significantly lower in INC group, and there was a significant decrease in long term opioid use in the INC group (p<0.0001). CONCLUSIONS INC is a newer modality that decreases LOS, controls pain, and results in overall cost savings for patients undergoing the modified Ravitch procedure. We recommend that INC be included in the current practice for postoperative pain control in pectus disorder patients undergoing the modified Ravitch procedure.
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Affiliation(s)
- R Luke Rettig
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles, CA, 90027, USA
| | - Claire J Yang
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles, CA, 90027, USA
| | - Adeel Ashfaq
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles, CA, 90027, USA
| | - Roman M Sydorak
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles, CA, 90027, USA.
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Fraser JA, Briggs KB, Svetanoff WJ, Aguayo P, Juang D, Fraser JD, Snyder CL, Oyetunji TA, St Peter SD. Short and long term outcomes of using cryoablation for postoperative pain control in patients after pectus excavatum repair. J Pediatr Surg 2022; 57:1050-1055. [PMID: 35277249 DOI: 10.1016/j.jpedsurg.2022.01.051] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 01/31/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION We report the findings of a three-year prospective observational study elucidating long-term symptoms and complications of patients who underwent minimally invasive pectus excavatum repair with intercostal nerve cryoablation with specific attention to postoperative pain control associated with the cryoablation technique. METHODS Surveys were administered to patients who underwent bar placement for pectus excavatum with intercostal nerve cryoablation from 2017 to 2021 regarding pain scores, pain medication usage, and limitations to activity beginning on the day of surgery, on the day of discharge, and at two-week and three-month follow-up. RESULTS Of 110 patients, forty-eight (44%) completed the discharge survey; sharp pain and pressure on the first postoperative night were the most described pain characteristics, most frequently in the middle of the chest. On follow-up, 55% of patients reported tolerable residual pain at two weeks and 41% at three months, with 25% requiring intermittent pain medication at three months. There were three readmissions for inadequate pain control and 110 calls to the surgery clinic by three-month follow-up, most commonly for persistent pain and frequent popping sensation with movement. DISCUSSION Although cryoablation is an excellent pain control modality, these data suggest that patients underreport functional symptoms and experience more frequent discomfort and alteration of daily living activities.
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Affiliation(s)
- James A Fraser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA
| | - Kayla B Briggs
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA
| | - Wendy Jo Svetanoff
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road Kansas City, Kansas City, MO 64108, USA
| | - David Juang
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road Kansas City, Kansas City, MO 64108, USA
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road Kansas City, Kansas City, MO 64108, USA
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road Kansas City, Kansas City, MO 64108, USA
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road Kansas City, Kansas City, MO 64108, USA
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road Kansas City, Kansas City, MO 64108, USA.
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Chidambaran V, Garcia VF, Brown RL. Are We Ready for Cryoablation in Children Undergoing Nuss Procedures? Anesth Analg 2022; 134:881-884. [PMID: 35299214 DOI: 10.1213/ane.0000000000005857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | - Victor F Garcia
- Department of Surgical Services, Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rebeccah L Brown
- Department of Surgical Services, Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Abstract
BACKGROUND Minimally invasive repair of pectus excavatum (MIRPE) involves placement of a transthoracic, retrosternal support bar under thoracoscopic guidance. Despite its minimally invasive technical approach, postoperative pain is a significant morbidity that often results in increased length of stay. Multi-modal pain control strategies have been used in the past with limited success. Recently, the use of intraoperative intercostal nerve cryoablation (CA) has been added. In the present study, we aim to evaluate the effects of CA on postoperative pain control, opioid requirements, and perioperative outcomes. STUDY DESIGN A single-center, retrospective chart review of all patients (less than 18 years old) who underwent MIRPE from 2009 to 2020 was performed. CA was started in June 2018. Data collection included demographics, preoperative characteristics, intraoperative findings, and postoperative outcomes. We hypothesized that CA would be associated with improved pain scores, lower doses of total inpatient opioid requirement, and shorter length of stay (LOS). RESULTS One hundred sixty-one patients met inclusion criteria: 75 underwent intraoperative CA and 86 underwent MIRPE without CA (NCA group). CA significantly decreased median LOS from 4 days in NCA to 2 days; the use of CA was the only significant predictor of LOS on linear regression. CA was also associated with decreased total PCA, intravenous opioid, and oral opioid dosages. There was no difference in inpatient pain scores and a slight increase in mean procedure time. However, CA was associated with significantly decreased postoperative complications. CONCLUSIONS The use of cryoablation during MIRPE significantly decreases LOS, perioperative opioid requirements, and postoperative complications, with a minimal increase in operative time. Cryoablation is an effective pain control modality in the surgical management of chest wall deformities in children.
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DiFiore JW, Robertson JO, Chhabada S, DeRoss AL, Hossain MS, Rincon-Cruz L, Sung W. Next day discharge after the Nuss procedure using intercostal nerve cryoablation, intercostal nerve blocks, and a perioperative ERAS pain protocol. J Pediatr Surg 2022; 57:213-218. [PMID: 34823843 DOI: 10.1016/j.jpedsurg.2021.10.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/23/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Nuss procedure for pectus excavatum has historically been associated with significant postoperative pain, which has been the major factor contributing to hospital length of stay (LOS). METHODS A single-institution, prospective study of 40 consecutive patients undergoing Nuss bar placement for pectus excavatum between November 2019 and January 2021 was conducted to assess the effectiveness of a multimodality pain management protocol. All patients received T3-T8 intercostal nerve cryoablation (INC), T3-T8 bupivacaine intercostal nerve blocks, Exparel at the skin incisions, and management with a perioperative analgesia regimen that minimized narcotic usage. The primary outcome was LOS. Secondary outcomes included opioid use, pain scores, and time to sensory recovery. RESULTS 37/40 patients (92.5%) were discharged home on postoperative day (POD) 1, and 3/40 (7.5%) were discharged on POD 2 (mean LOS = 1.1 days). The median average postoperative pain score was 2/10. After eliminating IVPCA from our protocol, total oral morphine equivalent (OME) decreased by 73% (55.5 mg to 15 mg) with no change in pain scores or discharge timing. CONCLUSIONS INC combined with bupivacaine intercostal nerve blocks and a pre- and post-hospital analgesia protocol facilitated discharge one day after the Nuss procedure, achieved excellent pain control, and eliminated the need for intravenous opioids.
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Affiliation(s)
- John W DiFiore
- Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, 9500 Euclid Avenue / A12-329, Cleveland, OH 44195, USA.
| | - Jason O Robertson
- Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, 9500 Euclid Avenue / A12-329, Cleveland, OH 44195, USA
| | | | - Anthony L DeRoss
- Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, 9500 Euclid Avenue / A12-329, Cleveland, OH 44195, USA
| | - Mir S Hossain
- Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, 9500 Euclid Avenue / A12-329, Cleveland, OH 44195, USA
| | - Lorena Rincon-Cruz
- Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, 9500 Euclid Avenue / A12-329, Cleveland, OH 44195, USA
| | - Wai Sung
- Department of Pediatric Anesthesiology, Cleveland Clinic Children's, Cleveland, OH, USA
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Ultrasound-guided erector spinae plane block versus thoracic epidural analgesia: Postoperative pain management after Nuss repair for pectus excavatum. J Pediatr Surg 2022; 57:207-212. [PMID: 34949445 DOI: 10.1016/j.jpedsurg.2021.10.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 10/23/2021] [Indexed: 01/22/2023]
Abstract
AIM OF THE STUDY Postoperative pain management is a significant challenge in patients undergoing Nuss repair for pectus excavatum chest wall deformity. Therapeutic anesthetic options primarily include patient-controlled intravenous analgesia, thoracic epidural analgesia (TEA), and cryoanalgesia. However, TEA is limited to inpatient use and both TEA and cryoanalgesia can result in neurologic injury. The novel technique of ultrasound-guided erector spinae plane regional analgesia has been used recently in our patients undergoing the Nuss repair and has shown impressive pain relief, but without the potential complications of other modalities. Erector spinae plane block (ESPB) postoperative pain management outcomes were studied as compared to TEA. METHODS Thirty consecutive patients with severe pectus excavatum undergoing Nuss repair and placement of ultrasound-guided ESPB were each paired to a historical cohort control patient with TEA postoperative pain management. The cohort patient match was defined by age (± 2 years), gender, and CT pectus index (± 15%). Study variables included hospital length of stay (LOS), pain scores, and pain medication usage. RESULTS Pain scores as measured by area under the curve per hour (Day 1: 2.72 (SD = 1.37) vs. 3.90 (SD = 1.81), P = 0.006; Day 2: 2.83 (SD = 1.32) vs. 3.97 (SD = 1.82), P = 0.007) and oral morphine equivalent (OME) pain medication usage (Day 1: 11.9 (SD = 4.9) vs 56.0 (SD = 32.2), P < 0.001; Day 2: 14.7 (SD = 7.1) vs. 38.0 (SD = 21.7), P < 0.001) were higher for the first two postoperative days in the ESPB group. However, mean hospital LOS was nearly one day shorter for ESPB patients (3.78 (SD = 0.82) vs. 2.90 (SD = 0.87), P < 0.001) who were discharged home with the catheter in place until removal, typically at 5-7 days postoperatively. CONCLUSION Ultrasound-guided ESPB is thus a feasible, safe, and effective alternative to TEA in postoperative pain management after Nuss repair and results in decreased hospital stay. LEVEL OF EVIDENCE III.
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Sun RC, Mehl SC, Anbarasu CR, Portuondo JI, Espinoza AF, Whitlock R, Mazziotti MV. Intercostal cryoablation during Nuss procedure: A large volume single surgeon's experience and outcomes. J Pediatr Surg 2021; 56:2229-2234. [PMID: 33853732 DOI: 10.1016/j.jpedsurg.2021.03.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 02/09/2021] [Accepted: 03/05/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recent studies have shown intercostal cryoablation(IC) during the Nuss procedure decreases hospital length of stay(LOS) and opioid administration. However, few studies have also evaluated the risk of postoperative complications related to IC. METHODS We performed a single center retrospective analysis of all patients who underwent Nuss procedure by one surgeon from 2/2016 to 2/2020, comparing intraoperative IC to other pain management modalities(non-IC). Primary outcomes were postoperative complications, hospital LOS, and opioid administration. Multivariate analysis was performed with outcomes reported as regression coefficients(RC) or odds ratios(OR) with 95% confidence interval. RESULTS IC was associated with decreased hospital LOS (RC -1.91[-2.29 to -1.54], less hospital opioid administration (RC -4.28[-5.13 to -3.43]), and less discharge opioid administration (RC -3.82[-5.23 to -2.41]). With respect to postoperative complications, IC decreased the odds of urinary retention (OR 0.16[0.06 to 0.44]); however, increased the odds of slipped bars requiring reoperation (OR 36.65[5.04-266.39]). CONCLUSIONS Our single surgeon experience controls for surgeon variability and demonstrates intraoperative IC for the Nuss procedure is an effective pain management modality that decreases hospital LOS and opioid use during hospitalization and at discharge; however, it is associated with increased odds of slipped bars requiring reoperation. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Raphael C Sun
- Department of Surgery, Division of Pediatric Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States; Department of Surgery, Baylor College of Medicine, Houston, TX, United States.
| | - Steven C Mehl
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Centura R Anbarasu
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Jorge I Portuondo
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Andres F Espinoza
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Richard Whitlock
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Mark V Mazziotti
- Department of Surgery, Division of Pediatric Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States; Department of Surgery, Baylor College of Medicine, Houston, TX, United States
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Arshad SA, Ferguson DM, Garcia EI, Hebballi NB, Buchanan AC, Tsao K. Cryoanalgesia is Associated With Decreased Postoperative Opioid Use in Minimally Invasive Repair of Pectus Excavatum. J Surg Res 2021; 271:1-6. [PMID: 34814047 DOI: 10.1016/j.jss.2021.10.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 09/24/2021] [Accepted: 10/10/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Postoperative pain control is challenging after pectus excavatum repair. We aimed to understand the impact that cryoanalgesia had on opioid utilization and outcomes of pediatric patients undergoing minimally invasive repair of pectus excavatum (MIRPE). METHODS A single-center retrospective cohort study was conducted of all patients (< 18 y) who underwent MIRPE (2011-2019). Patients receiving cryoanalgesia were compared to those who did not. The primary outcome was total postoperative, inpatient, opioid use, measured as milligrams of oral morphine equivalents per kilogram (OME/kg). Univariate and multivariable analyses were performed. RESULTS Of 35 patients, 20 received cryoanalgesia (57%). Baseline characteristics were similar. Patients who received cryoanalgesia had a lower opioid requirement: median 2.3 mg OME/kg (IQR 1.2-3.1), versus 4.9 mg OME/kg (IQR 2.9-5.8), P < 0.001. Accounting for receipt of cryoanalgesia, epidural, and/or patient-controlled analgesia, cryoanalgesia was associated with a 3.3 mg OME/kg reduction in opioid use (P < 0.001). Median length of stay (LOS) was shorter in cryoanalgesia patients: 3.1 d (IQR 2.3-3.4), versus 5.1 d (IQR 4.3-5.4), P < 0.001. Complications within 90 d were similar between groups. CONCLUSIONS Cryoanalgesia is an effective adjunctive pain control modality for patients undergoing MIRPE. Use of cryoanalgesia was associated with lower postoperative opioid requirements and shorter LOS, without increased short-term complications, and should be considered for enhanced recovery after MIRPE.
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Affiliation(s)
- Seyed A Arshad
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas.
| | - Dalya M Ferguson
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas.
| | - Elisa I Garcia
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas.
| | - Nutan B Hebballi
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas.
| | - Allison C Buchanan
- Department of Anesthesiology, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas.
| | - KuoJen Tsao
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas.
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35
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Mijatovic D, Bhalla T, Farid I. Post-thoracotomy analgesia. Saudi J Anaesth 2021; 15:341-347. [PMID: 34764841 PMCID: PMC8579496 DOI: 10.4103/sja.sja_743_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 07/10/2020] [Indexed: 11/05/2022] Open
Abstract
Thoracotomy is considered one of the most painful operative procedures. Due to anatomical complexity, post-thoracotomy pain requires multimodal perioperative treatment to adequately manage to ensure proper postoperative recovery. There are several different strategies to control post-thoracotomy pain including interventional techniques, such as neuraxial and regional injections, and conservative treatments including medications, massage therapy, respiratory therapy, and physical therapy. This article describes different strategies and evidence base for their use.
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Affiliation(s)
- Desimir Mijatovic
- Pain Center, Akron Children's Hospital, Department of Anesthesia and Pain Medicine, Akron, Ohio, USA
| | - Tarun Bhalla
- Pain Center, Akron Children's Hospital, Department of Anesthesia and Pain Medicine, Akron, Ohio, USA
| | - Ibrahim Farid
- Pain Center, Akron Children's Hospital, Department of Anesthesia and Pain Medicine, Akron, Ohio, USA
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36
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Jeziorczak PM, Frenette RS, Aprahamian CJ. Liposomal Bupivacaine Injection in Nuss Procedure Allows Narcotic Avoidance and Improved Outcomes. J Laparoendosc Adv Surg Tech A 2021; 31:1384-1388. [PMID: 34748425 DOI: 10.1089/lap.2021.0357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The Nuss procedure has provided a minimally invasive surgical solution for pectus excavatum with excellent long-term outcomes. However, opioid avoidance, cost reduction, and length of stay (LOS) still offer room for improvement. The focus of this study is to identify the impact of Bupivacaine liposome injectable suspension (Exparel) on outcomes. Methods: A retrospective review at a Pediatric specialty hospital from October 1, 2014 to December 31, 2019 was performed. All patients underwent a Nuss procedure (n = 19) for pectus excavatum. The cohort comprised a control group that did not use liposomal Bupivacaine (Standard, n = 9) and an interventional group that received liposomal Bupivacaine (n = 10). Nonparametric Wilcoxon rank-sum tests and chi-squared or Fisher's exact tests were used to assess significance (P < .05). Results: Overall, the entire population was 68.4% male and had an average age of 15 years. There was a significant difference between the Standard and Liposomal Bupivacaine groups for total cost ($60,746 versus $13,289), total Morphine Milligram Equivalents (MME) (282 versus 76.8 MME) and Epidural Catheter usage (100% versus 0%). There was also a significant difference between groups for LOS (5.00 days versus 3.00 days) and Foley catheter usage (100% versus 20%). Conclusions: There is a significant impact of liposomal Bupivacaine usage on epidural catheter avoidance and opioid administration correlating with a significantly decreased total cost and decreased LOS. While more study is necessary, liposomal Bupivacaine for Nuss procedure offers improvement of postoperative patient outcomes and drastic cost savings.
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Affiliation(s)
- Paul M Jeziorczak
- OSF Healthcare-Children's Hospital of Illinois, Peoria, Illinois, USA.,Department of Surgery, University of Illinois College of Medicine Peoria, Peoria, Illinois, USA
| | - Riley S Frenette
- OSF Healthcare-Children's Hospital of Illinois, Peoria, Illinois, USA.,Kirksville College of Osteopathic Medicine, AT Still University, Kirksville, Missouri, USA
| | - Charles J Aprahamian
- OSF Healthcare-Children's Hospital of Illinois, Peoria, Illinois, USA.,Department of Surgery, University of Illinois College of Medicine Peoria, Peoria, Illinois, USA
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Arshad SA, Hatton GE, Ferguson DM, Li LT, Austin MT, Tsao K. Cryoanalgesia enhances recovery from minimally invasive repair of pectus excavatum resulting in reduced length of stay: A case-matched analysis of NSQIP-Pediatric patients. J Pediatr Surg 2021; 56:1099-1102. [PMID: 33853733 DOI: 10.1016/j.jpedsurg.2021.03.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/12/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Pain control is challenging after minimally invasive repair of pectus excavatum (MIRPE). Cryoanalgesia, which temporarily ablates peripheral nerves, improves pain control and may accelerate post-operative recovery. We hypothesized that cryoanalgesia would be associated with shorter length of stay (LOS) in children undergoing MIRPE. METHODS A matched cohort study was conducted of children (<18 years) who underwent MIRPE 2016-2018, using the National Surgical Quality Improvement Program-Pediatric database. Each patient who received cryoanalgesia during MIRPE was matched to four controls (no cryoanalgesia). Univariate and multilevel regression analyses were performed. RESULTS Thirty-five patients who received cryoanalgesia during MIRPE were matched to 140 controls. Patients who received cryoanalgesia had a LOS reduction with similar secondary outcomes (operative time, rates of complication, reoperation, and readmission). On multilevel regression adjusted for matched groups, cryoanalgesia was associated with a 1.3-day reduction in LOS (95% CI -1.8 to -0.8, p < 0.001). On sensitivity analysis excluding patients with complications, cryoanalgesia remained associated with a LOS reduction. CONCLUSIONS Cryoanalgesia is a promising adjunct in the care of pediatric patients undergoing MIRPE. Utilization is associated with a shorter LOS without an increase in operative time or complications. Cryoanalgesia should be considered for inclusion in enhanced recovery strategies for patients undergoing MIRPE.
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Affiliation(s)
- Seyed A Arshad
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston 77030, TX, United States
| | - Gabrielle E Hatton
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston 77030, TX, United States
| | - Dalya M Ferguson
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston 77030, TX, United States
| | - Linda T Li
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston 77030, TX, United States
| | - Mary T Austin
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston 77030, TX, United States
| | - KuoJen Tsao
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston 77030, TX, United States.
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38
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Cha PI, Min JG, Patil A, Choi J, Kothary NN, Forrester JD. Efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain after surgery or trauma: systematic review. Trauma Surg Acute Care Open 2021; 6:e000690. [PMID: 34079913 PMCID: PMC8137159 DOI: 10.1136/tsaco-2021-000690] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/04/2021] [Accepted: 04/24/2021] [Indexed: 11/03/2022] Open
Abstract
Background There is a critical need for non-narcotic analgesic adjuncts in the treatment of thoracic pain. We evaluated the efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain, specifically addressing the applicability of intercostal cryoneurolysis for pain control after chest wall trauma. Methods A systematic review was performed through searches of PubMed, EMBASE, and the Cochrane Library. We included studies involving patients of all ages that evaluated the efficacy of intercostal cryoneurolysis as a pain adjunct for chest wall pathology. Quantitative and qualitative synthesis was performed. Results Twenty-three studies including 570 patients undergoing cryoneurolysis met eligibility criteria for quantitative analysis. Five subgroups of patients treated with intercostal cryoneurolysis were identified: pectus excavatum (nine studies); thoracotomy (eight studies); post-thoracotomy pain syndrome (three studies); malignant chest wall pain (two studies); and traumatic rib fractures (one study). There is overall low-quality evidence supporting intercostal cryoneurolysis as an analgesic adjunct for chest wall pain. A majority of studies demonstrated decreased inpatient narcotic use with intercostal cryoneurolysis compared with conventional pain modalities. Intercostal cryoneurolysis may also lead to decreased hospital length of stay. The procedure did not definitively increase operative time, and risk of complications was low. Conclusions Given the favorable risk-to-benefit profile, both percutaneous and thoracoscopic intercostal cryoneurolysis may serve as a worthwhile analgesic adjunct in trauma patients with rib fractures who have failed conventional medical management. However, further prospective studies are needed to improve quality of evidence. Level of evidence Level IV systematic reviews and meta-analyses.
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Affiliation(s)
- Peter I Cha
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Jung Gi Min
- Stanford University School of Medicine, Stanford, California, USA
| | | | - Jeff Choi
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Nishita N Kothary
- Section of Interventional Radiology, Department of Radiology, School of Medicine, Stanford University, Stanford, California, USA
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Rettig RL, Rudikoff AG, Lo HYA, Shaul DB, Banzali FM, Conte AH, Sydorak RM. Cryoablation is associated with shorter length of stay and reduced opioid use in pectus excavatum repair. Pediatr Surg Int 2021; 37:67-75. [PMID: 33210165 DOI: 10.1007/s00383-020-04778-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/04/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The use of intercostal nerve cryoablation (INC) is becoming increasingly common in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate the use of INC compared to traditional use of thoracic epidural (TE). METHODS A retrospective review of 79 patients undergoing PE repair with either INC or TE from May 2009 to December 2019 was conducted. The operations were performed by four surgeons who worked together at four different hospitals and have the same standardized practice. The primary outcome measure was hospital length of stay (LOS). Secondary variables included surgical time, total operating room time, operating room time cost, total hospital cost, inpatient opioid use, long-term opioid use after discharge, and postoperative complications. RESULTS LOS decreased to 2.5 days in the INC group compared to 5 days in the TE group (p < 0.0001). Surgical time was increased in the INC group, but there was no difference in total OR time. The INC group experienced significantly lower hospital costs. Total hospital opioid administration was significantly lower in INC group, and there was a significant decrease in long-term opioid use in the INC group. CONCLUSIONS INC is a newer modality that decreases LOS, controls pain, and results in overall cost savings. We recommend that INC be included in the current practice for postoperative pain control in PE patients undergoing Nuss procedure.
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Affiliation(s)
- R Luke Rettig
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Andrew G Rudikoff
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Hoi Yee Annie Lo
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Donald B Shaul
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Franklin M Banzali
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Antonio Hernandez Conte
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Roman M Sydorak
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA. .,Kaiser Permanente Los Angeles Medical Center, 4760 Sunset Blvd, 3rd Floor, Los Angeles, CA, 90027, USA.
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40
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Daemen JHT, de Loos ER, Vissers YLJ, Bakens MJAM, Maessen JG, Hulsewé KWE. Intercostal nerve cryoablation versus thoracic epidural for postoperative analgesia following pectus excavatum repair: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2020; 31:486-498. [PMID: 32929487 DOI: 10.1093/icvts/ivaa151] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Minimally invasive pectus excavatum repair via the Nuss procedure is associated with significant postoperative pain that is considered as the dominant factor affecting the duration of hospitalization. Postoperative pain after the Nuss procedures is commonly controlled by thoracic epidural analgesia. Recently, intercostal nerve cryoablation has been proposed as an alternative method with long-acting pain control and shortened hospitalization. The subsequent objective was to systematically review the outcomes of intercostal nerve cryoablation in comparison to thoracic epidural after the Nuss procedure. METHODS Six scientific databases were searched. Data concerning the length of hospital stay, operative time and postoperative opioid usage were extracted. If possible, data were submitted to meta-analysis using the mean of differences, random-effects model with inverse variance method and I2 test for heterogeneity. RESULTS Four observational and 1 randomized study were included, enrolling a total of 196 patients. Meta-analyses demonstrated a significantly shortened length of hospital stay [mean difference -2.91 days; 95% confidence interval (CI) -3.68 to -2.15; P < 0.001] and increased operative time (mean difference 40.91 min; 95% CI 14.42-67.40; P < 0.001) for cryoablation. Both analyses demonstrated significant heterogeneity (both I2 = 91%; P < 0.001). Qualitative analysis demonstrated the amount of postoperative opioid usage to be significantly lower for cryoablation in 3 out of 4 reporting studies. CONCLUSIONS Intercostal nerve cryoablation during the Nuss procedure may be an attractive alternative to thoracic epidural analgesia, resulting in shortened hospitalization. However, given the low quality and heterogeneity of studies, more randomized controlled trials are needed.
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Affiliation(s)
- Jean H T Daemen
- Department of Thoracic Surgery, Zuyderland Medical Centre, Heerlen, Netherlands
| | - Erik R de Loos
- Department of Thoracic Surgery, Zuyderland Medical Centre, Heerlen, Netherlands
| | - Yvonne L J Vissers
- Department of Thoracic Surgery, Zuyderland Medical Centre, Heerlen, Netherlands
| | - Maikel J A M Bakens
- Department of Thoracic Surgery, Zuyderland Medical Centre, Heerlen, Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands.,Faculty of Health, Medicine and Life Sciences (FHML), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
| | - Karel W E Hulsewé
- Department of Thoracic Surgery, Zuyderland Medical Centre, Heerlen, Netherlands
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41
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The impact of an enhanced recovery perioperative pathway for pediatric pectus deformity repair. Pediatr Surg Int 2020; 36:1035-1045. [PMID: 32696123 DOI: 10.1007/s00383-020-04695-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE Pediatric repair of chest wall deformities is associated with significant pain, morbidity, and resource utilization. We sought to determine outcomes of a perioperative enhanced recovery after surgery (ERAS) pathway for patients undergoing minimally invasive (Nuss) and traditional (Ravitch) corrective procedures. METHODS Our ERAS protocol was implemented in 2015. We performed a retrospective review of patients for Nuss or Ravitch procedures before and after ERAS implementation. Combined and procedure segregated bivariate analyses were conducted on postoperative outcomes and resource utilization. RESULTS There are 17 patients in the pre-intervention group (Nuss = 13 and Ravitch = 4) compared to 38 patients in the post-intervention group (Nuss = 28 and Ravitch = 10). Protocol implementation increased utilization of pre-operative non-narcotic medication. The combined and Nuss post-intervention groups had a significant decrease in epidural duration and time to enteral medications, but had increased total postoperative opioid usage. The Ravitch post-intervention group had a significant decrease in intra-operative narcotics and discharge pain scores. There were no differences in length of stay or complications. CONCLUSION Implementation of our ERAS protocol standardized pectus perioperative care, but did not improve postoperative opioid usage, complications, or resource utilization. Alterations in the protocol may lead to achieving desired goals of better pain management and decreased resource utilization.
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