1
|
Wharton K, Chidiac C, Lopez C, Hunsberger J, Rhee D, Cappiello C, Garcia AV. Enhanced Recovery After Surgery 2.0: Optimizing Pain Management in Nuss Procedure: Cryoablation and Nerve Block Strategies for Reduced Opioid Use. J Surg Res 2024; 301:563-571. [PMID: 39053171 DOI: 10.1016/j.jss.2024.07.003] [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: 10/24/2023] [Revised: 06/24/2024] [Accepted: 07/03/2024] [Indexed: 07/27/2024]
Abstract
INTRODUCTION Our study assesses the association between cryoablation, with and without nerve block supplementation, post-Nuss procedure pain, and opioid use in pectus excavatum (PE) patients. METHODS We conducted a retrospective cohort study at a single center for PE patients who underwent the Nuss procedure from 2017 to 2022. Outcomes included postoperative opioid use (measured in oral morphine milligram equivalent per kilogram [OME/kg]), average pain score (scale 0-10), and length of stay (LOS). RESULTS One hundred sixty-four patients (146 males and 18 females) were included, with 79 (48.2%) receiving neither cryoablation nor nerve block, 60 (36.6%) receiving intraoperative cryoablation alone, and 25 (15.2%) receiving both cryoablation and nerve block. The median age was 16 y. Nerve block recipients consumed fewer opioids during hospitalization than cryoablation alone and nonintervention groups (1.5 versus 2.3 versus 5.8 OME/kg, respectively, P < 0.0001). Average pain scores over the total LOS were lower in nerve block recipients (3.5 versus 3.8 versus 4.2, P = 0.03), particularly on postoperative day 0 (P = 0.002). Nerve block recipients had a shorter LOS than cryoablation alone and nonintervention groups (43.4 versus 54.7 versus 66.2 h, P < 0.0001). On multivariate analysis, cryoablation alone resulted in significantly less opioid use compared to no intervention (3.32 OME/kg reduction, 95% confidence interval -4.16 to -2.47, P < 0.0001). Addition of nerve block further reduced opioid use by 1.10 OME/kg (95% confidence interval -2.07 to -0.14, P = 0.04). CONCLUSIONS Cryoablation with nerve block supplementation is associated with reduced pain, opioid use, and LOS post-Nuss for PE repair compared to cases without cryoablation or with cryoablation only. Cryoablation with regional nerve blocks should be considered for Nuss repair under the enhanced recovery after surgery pathway.
Collapse
Affiliation(s)
- Kristin Wharton
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Charbel Chidiac
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carla Lopez
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joann Hunsberger
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel Rhee
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Clint Cappiello
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alejandro V Garcia
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| |
Collapse
|
2
|
Rook JM, Lee LK, Wagner JP, Sullins VF, Lee SL, Shekherdimian S, DeUgarte DA, Dichter CE, Jen HC. Six Years of Quality Improvement in Pectus Excavatum Repair: Implementation of Intercostal Nerve Cryoablation and ERAS Protocols for Patients Undergoing Nuss Procedure. J Pediatr Surg 2024:S0022-3468(24)00430-5. [PMID: 39117536 DOI: 10.1016/j.jpedsurg.2024.07.019] [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] [Received: 03/19/2024] [Revised: 06/20/2024] [Accepted: 07/14/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND The Nuss procedure for pectus excavatum is associated with prolonged hospitalizations due to pain. We evaluated implementation of intercostal nerve cryoablation and enhanced recovery after surgery (ERAS) protocols on outcomes of Nuss procedures performed over six years at a single institution. METHODS This retrospective cohort study included patients who underwent Nuss procedure from 10/2017 to 09/2023. Patients received epidurals prior to 06/2019, cryoablation from 06/2019 to 07/2021, and ERAS with cryoablation and intraoperative methadone administration after 07/2021. We used multivariable linear regression to evaluate length of stay (LOS), inpatient morphine milligram equivalents (MMEs), and discharge opioids. We assessed the balancing measures of operative time, postoperative pain scores, and complications. RESULTS We identified 62 patients; 15 who received epidurals, 18 cryoablation, and 29 cryoablation with ERAS. Cryoablation was associated with a 62.3% (p < 0.001) decrease in length of stay, an 86.6% (p < 0.001) decrease in inpatient MMEs, and a 72.9% (p < 0.001) decrease in discharge opioids. Cryoablation was additionally associated with 24.5% (p = 0.02) longer operative times and 46.4% (p = 0.04) higher postoperative day one pain scores. Subsequent implementation of an ERAS protocol was associated with a further 82.8% (p = 0.04) decrease in discharge opioids and a 25.0% (p = 0.04) decrease in postoperative day one pain scores. CONCLUSIONS Over six years of quality improvement efforts, we found the implementation of cryoablation and ERAS protocols to be associated with a significant decrease in length of stay and opioid exposures. Protocolized pain management and cryoablation may work synergistically to improve outcomes without compromising patient experience. LEVEL OF EVIDENCE Level III - Retrospective comparative study.
Collapse
Affiliation(s)
- Jordan M Rook
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Greater Los Angeles Veterans Administration Healthcare System, Los Angeles, CA, USA; UCLA National Clinician Scholars Program, Los Angeles, CA, USA; Department of Health Policy & Management, UCLA Fielding School of Public Health, USA.
| | - Lisa K Lee
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Justin P Wagner
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Veronica F Sullins
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Steven L Lee
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - Shant Shekherdimian
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Daniel A DeUgarte
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Christine E Dichter
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Howard C Jen
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| |
Collapse
|
3
|
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.
Collapse
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.
| |
Collapse
|
4
|
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.
Collapse
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.
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Chen LJ, Chen SH, Hsieh YL, Yu PC. Continuous nerve block versus thoracic epidural analgesia for post-operative pain of pectus excavatum repair: a systematic review and meta-analysis. BMC Anesthesiol 2023; 23:266. [PMID: 37559029 PMCID: PMC10410789 DOI: 10.1186/s12871-023-02221-x] [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] [Received: 05/22/2023] [Accepted: 07/26/2023] [Indexed: 08/11/2023] Open
Abstract
Surgery to repair pectus excavatum (PE) is often associated with severe postoperative pain, which can impact the length of hospital stay (LOS). While thoracic epidural analgesia (TEA) has traditionally been used for pain management in PE, its placement can sometimes result in severe neurological complications. Recently, paravertebral block (PVB) and erector spinae plane block (ESPB) have been recommended for many other chest and abdominal surgeries. However, due to the more severe and prolonged pain associated with PE repair, it is still unclear whether continuous administration of these blocks is as effective as TEA. Therefore, we conducted this systematic review and meta-analysis to demonstrate the equivalence of continuous PVB and ESPB to TEA.
Collapse
Affiliation(s)
- Li-Jung Chen
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No.289, Jianguo Rd., Xindian Dist, 231405, New Taipei City, Taiwan
| | - Shih-Hong Chen
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No.289, Jianguo Rd., Xindian Dist, 231405, New Taipei City, Taiwan
| | - Yung-Lin Hsieh
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No.289, Jianguo Rd., Xindian Dist, 231405, New Taipei City, Taiwan
| | - Po-Chuan Yu
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No.289, Jianguo Rd., Xindian Dist, 231405, New Taipei City, Taiwan.
| |
Collapse
|
7
|
Walter CM, Lee CS, Moore DL, Abbasian N, Clay SJ, Mecoli MD, Olbrecht VA, Batra M, Ding L, Yang F, Nair M, Huq A, Simpson BE, Brown RL, Garcia VF, Chidambaran V. Retrospective study comparing outcomes of multimodal epidural and erector spinae catheter pain protocols after pectus surgery. J Pediatr Surg 2023; 58:397-404. [PMID: 35907711 DOI: 10.1016/j.jpedsurg.2022.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/10/2022] [Accepted: 06/28/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION There are no optimal postoperative analgesia regimens for Nuss procedures. We compared the effectiveness of thoracic epidurals (EPI) and novel ambulatory erector spinae plane (ESP) catheters as part of multimodal pain protocols after Nuss surgery. METHODS Data on demographics, comorbidities, perioperative details, length of stay (LOS), in hospital and post discharge pain/opioid use, side effects, and emergency department (ED) visits were collected retrospectively in children who underwent Nuss repair with EPI (N = 114) and ESP protocols (N = 97). Association of the group with length of stay (LOS), in hospital opioid use (intravenous morphine equivalents (MEq)/kg over postoperative day (POD) 0-2), and oral opioid use beyond POD7 was analyzed using inverse probability of treatment weighting (IPTW) with propensity scores, followed by multivariable regression. RESULTS Groups had similar demographics. Compared to EPI, ESP had longer block time and higher rate of ketamine and dexmedetomidine use. LOS for ESP was 2 days IQR (2, 2) compared to 3 days IQR (3, 4) for EPI (p < 0.01). Compared to EPI, ESP group had higher opioid use (in MEq/kg) intraoperatively (0.32 (IQR 0.27, 0.36) vs. 0.28 (0.24, 0.32); p < 0.01) but lower opioid use on POD 0 (0.09 (IQR 0.04, 0.17) vs. 0.11 (0.08, 0.17); p = 0.03) and POD2 (0.00 (IQR 0.00, 0.00) vs. 0.04 (0.00, 0.06) ; p < 0.01). ESP group also had lower total in hospital opioid use (0.57 (IQR 0.42, 0.73) vs.0.82 (0.71, 0.91); p < 0.01), and shorter duration of post discharge opioid use (6 days (IQR 5,8) vs. 9 days (IQR 7,12) (p < 0.01). After IPTW adjustment, ESP continued to be associated with shorter LOS (difference -1.20, 95% CI: -1.38, -1.01, p < 0.01) and decreased odds for opioid use beyond POD7 (OR 0.11, 95% CI: 0.05, 0.24); p < 0.01). However, total in hospital opioid use in MEq/kg (POD0-2) was now similar between groups (difference -0.02 (95% CI: -0.09, -0.04); p = 0.50). The EPI group had higher incidence of emesis (29% v 4%, p < 0.01), while ESP had higher catheter malfunction rates (23% v 0%; p < 0.01) but both groups had comparable ED visits/readmissions. DISCUSSION/CONCLUSION Compared to EPI, multimodal ambulatory ESP protocol decreased LOS and postoperative opioid use, with comparable ED visits/readmissions. Disadvantages included higher postoperative pain scores, longer block times and higher catheter leakage/malfunction. LEVELS OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Charlotte M Walter
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Christopher S Lee
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - David L Moore
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Niekoo Abbasian
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Smokey J Clay
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States.
| | - Marc D Mecoli
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Vanessa A Olbrecht
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Meenu Batra
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Lili Ding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, MLC 5041, 3333 Burnet Ave, Cincinnati, OH 45229, United States; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Fang Yang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, MLC 5041, 3333 Burnet Ave, Cincinnati, OH 45229, United States; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Manu Nair
- Summer Undergraduate Research Fellow, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States
| | - Abraar Huq
- Summer Undergraduate Research Fellow, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States
| | - Blair E Simpson
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, MLC 3024, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Rebeccah L Brown
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States; Division of Pediatric, General and Thoracic Surgery Department, Cincinnati Children's Hospital Medical Center, MLC 2023, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Victor F Garcia
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States; Division of Pediatric, General and Thoracic Surgery Department, Cincinnati Children's Hospital Medical Center, MLC 2023, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States.
| |
Collapse
|
8
|
A Retrospective Study Comparing Outcomes of Paravertebral Clonidine Infusion for Pediatric Patients Undergoing Nuss Procedure. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020193. [PMID: 36832322 PMCID: PMC9954470 DOI: 10.3390/children10020193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
INTRODUCTION The continuous paravertebral blockade as part of the multimodal pain protocol is an effective regional technique to control pain after the Nuss procedure. We investigated the effectiveness of clonidine as an adjunct to paravertebral ropivacaine infusion. METHODS We conducted a retrospective study of 63 patients who underwent Nuss procedures and received bilateral paravertebral catheters. Data on demographics, surgical, anesthesia, and block characteristics, numeric rating pain scores (NRS), opioids consumption, hospital length of stay, complications, and side effects from medication administration were collected in children who received paravertebral ropivacaine 0.2% infusion without (N = 45) and with clonidine (1 mcg/mL) (N = 18). RESULTS The two groups had similar demographics, although the clonidine group had higher Haller indices (6.5 (4.8, 9.4) vs. 4.8 (4.1, 6.6), p = 0.013). The clonidine group required less morphine equivalent/kg on postoperative day 2 (median, interquartile range 0.24 (0.22, 0.31) vs. 0.47 (0.29, 0.61) p = 0.002). There was no difference in median NRS pain scores. Both groups had similar catheter infusion durations, hospital length of stay, and complication rates. CONCLUSION A postoperative pain management plan that includes paravertebral analgesia, including clonidine as an adjunct, may be considered to minimize opioid administration for patients undergoing primary Nuss repair.
Collapse
|
9
|
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.
Collapse
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.
| |
Collapse
|
10
|
Patient-Controlled Intravenous Analgesia with or without Ultrasound-Guided Bilateral Intercostal Nerve Blocks in Children Undergoing the Nuss Procedure: A Randomized, Double-Blinded, Controlled Trial. Pain Res Manag 2022; 2022:5776833. [PMID: 35910406 PMCID: PMC9337970 DOI: 10.1155/2022/5776833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 04/19/2022] [Indexed: 11/29/2022]
Abstract
Background Two analgesic strategies have been described for pain treatment after the pectus excavatum surgery: the patient-controlled intravenous analgesia (PCIA) and ultrasound-guided intercostal nerve block. In this prospective, randomized and double-blinded trial and the short and long-term outcomes were compared in patients after surgery. Methods The children were randomized to either the intercostal or control group. Ultrasound-guided intercostal nerve block was with 0.25% ropivacaine and 5 mg dexamethasone in the intercostal group, while the control group was with 0.9% normal saline. The block was performed in the intercostal space corresponding to the lowest depression of the sternum and repeated bilaterally in the spaces above and below. Postoperatively, the children in the two-groups received PCIA with fentanyl for 48 hours. The primary outcome was a pain score on the postoperative day 1, as measured by the Visual Analogue Scale (VAS). Results Sixty children undergoing the Nuss procedure were enrolled in the trial. The mean differences in VAS scores between the two groups were 3.2 in the PACU (p < 0.001), 1.7 on postoperative day 1 (p < 0.001) and 0.7 on postoperative day 2 (p=0.015). The opioid consumption was significantly lower in the intercostal group during the postoperative 48 hours (p < 0.05). The anxiety and QOL scores in the intercostal group were significantly improved on some points of time (p < 0.05). The incidence of adverse events was markedly lower in the intercostal group during the postoperative 48 hours (p < 0.05). Conclusions Our results suggest ultrasound-guided intercostal nerve block with PCIA may be more effective than PCIA alone in children who underwent the Nuss procedure.
Collapse
|
11
|
Infectious complications of intercostal nerve cryoablation mediated by perioperative hypothermia during pediatric Nuss procedure. J Pediatr Surg 2022; 57:1083-1086. [PMID: 35232599 DOI: 10.1016/j.jpedsurg.2022.01.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/26/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Intercostal nerve cryoablation (cryoanalgesia) is increasingly used for pain control in minimally invasive repair of pectus excavatum (MIRPE) by Nuss procedure. Cryoanalgesia may lower core body temperature and increase the risk of postoperative infectious complications. We investigated cryoanalgesia effects on infectious complications following MIRPE. METHOD We performed a retrospective review of patients undergoing MIRPE at our institution. Patients treated via multimodal analgesia with cryoanalgesia (Cryo) were compared to patients treated via multimodal analgesia +/- elastomeric pain pumps (Non-cryo). Core body and intraoperative minimum/maximum temperatures were recorded. Primary outcomes were wound infection and pneumonia; secondary outcome was length of stay (LOS). Fisher's Exact and Mann-Whitney U tests compared proportions and medians respectively, p-value ≤ 0.05 being significant. RESULTS 80 patients were included, 35(43.7%) Cryo and 45(56.3%) Non-cryo. There were no significant differences in median [IQR] for age(15[13.3,16.0];p =0.86), number of bars inserted (2[1,2];p = 0.57), or operative time(123.5[98.3, 148.8]; p = 0.11) between the two groups. We found no significant differences in median [IQR] minimum temperature (35.4°C [35.0,35.8];p = 0.76), median change in intraoperative temperature (-0.13°C [-0.44,0.00];p = 0.94) or median recovery temperature (-1.10°C [-1.56,-0.65]; p = 0.59) between Cryo and Non-cryo. PACU temperature was significantly lower in the Cryo group, 36.4°C [36.2,36.6] p = 0.04. There were no postoperative wound infections in either group and no significant difference in incidence of postoperative pneumonia (8.57% versus 2.22%,p = 0.31) or median[IQR] for LOS (4[3,4];p = 0.57), between Cryo and Non-cryo patients. CONCLUSION Although cryoanalgesia for MIRPE resulted in lower core body temperature, there appears to be no significant difference between Cryo and Non-Cryo patients for LOS or infectious complications.
Collapse
|
12
|
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.
Collapse
|
13
|
Velayos M, Alonso M, Delgado-Miguel C, Estefanía-Fernández K, Muñoz-Serrano AJ, Santamaría MVL, Reinoso-Barbero F, De La Torre CA. Percutaneous Cryoanalgesia: A New Strategy for Pain Management in Pectus Excavatum Surgery. Eur J Pediatr Surg 2022; 32:73-79. [PMID: 34942673 DOI: 10.1055/s-0041-1740555] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION In recent years, pain protocols for pectus excavatum (PE) have incorporated cryoanalgesia through thoracoscopic approach. Since 2019, ultrasound-guided percutaneous cryoanalgesia (PCr) has been applied at our institution, either on the same day as the Nuss procedure or 48 hours before surgery. We carried out a preliminary retrospective review of patients with PE in whom PCr prior to surgery was performed at our institution between 2019 and 2021. MATERIALS AND METHODS Two groups were evaluated: PCr on the same day (PCrSD) and PCr 48 hours before surgery (PCr48). Despite PCr, patients were treated with "patient-controlled analgesia" (PCA) with opioids for at least 24 hours, switching to conventional intravenous analgesia and oral analgesia in the following days. Demographic, clinical-radiological variables, PCA opioid use, pain grade according to the visual analog scale (VAS), and length of stay (LOS) were compared between the groups. A total of 20 patients were included (12 with PCrSD and 8 with PCr48), without significant differences in demographics or clinical-radiological variables. The overall median time of PCr was 65 minutes (55-127), with no differences between the groups. RESULTS PCr48 group presented with significantly lower median number of hours of continuous PCA (24 vs. 32 hours; p = 0.031), lower median number of rescue boluses (11 vs. 18; p = 0.042), lower median VAS in the early postoperative hours (2 vs. 5.5; p = 0.043), and lower median LOS (3.5 vs. 5 days). CONCLUSION PCr performed 48 hours prior to surgery is more effective in terms of PCA requirements, VAS, and LOS when compared with cryoanalgesia on the same day.
Collapse
Affiliation(s)
- María Velayos
- Pediatric Surgery Department, La Paz University Hospital, Madrid, Spain
| | - Mercedes Alonso
- Children's Anesthesia and Resuscitation Department, La Paz University Hospital, Madrid, Spain
| | | | | | | | | | | | | |
Collapse
|
14
|
Eubanks AL, Grabski DF, Pollack J, Levin DE, McGahren E, Martin LW, Gander J. A multimodal protocol utilizing liposomal bupivacaine rib blocks leads to opioid reduction in patients undergoing the Nuss procedure. J Thorac Dis 2022; 13:6363-6372. [PMID: 34992816 PMCID: PMC8662494 DOI: 10.21037/jtd-21-1314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/09/2021] [Indexed: 12/05/2022]
Abstract
Background A major challenge associated with the Nuss procedure for pectus excavatum repair is postoperative pain control. Early Recovery Program (ERP) protocols for the Nuss procedure are becoming common, but there is a paucity of experience using liposomal bupivacaine (LB), a long-acting local anesthetic, for rib blocks in this setting. We investigated whether a protocol utilizing LB rib blocks decreased opioid use after the Nuss procedure while achieving equivalent pain control. Methods All adolescent patients undergoing the Nuss procedure at our institution between January 2013 and January 2021 were included. Patients were divided into a pre-intervention cohort (n=15), a transition cohort (n=4), and a post-intervention cohort (n=13). Patients in all groups received scheduled acetaminophen and non-steroidals postoperatively. The pre-intervention cohort received an opioid patient-controlled analgesia (PCA) pump postoperatively, with a transition to oral opiates. The transition and post-intervention cohorts received scheduled gabapentin in addition to intraoperative bilateral rib blocks with longer-acting local anesthetic. Rib blocks were performed using 0.25% Bupivacaine in the pre-intervention group. In the transition group, epinephrine (1 mg/kg) was added to 0.25% bupivacaine for the rib block. Following approval in patients aged 13–18 years, 1.3% LB (2.25 mg/kg) was given for a rib block in the post-intervention cohort. Results Demographic and clinical variables were equivalent in all groups. Post-intervention patients received 90% fewer opioids [median morphine equivalent (MME) mg/kg] compared to the pre-intervention cohort (0.8 vs. 8.2 MME mg/kg, P<0.0001), with no significant difference in pain scores between groups. Hospital length of stay was decreased among the intervention cohort (3 vs. 4 days, P=0.002). Conclusions Significant decreases in opioid use and length of stay after the Nuss procedure were achieved by the implementation of a multimodal ERP for pain management, without increase in patient-reported pain scores.
Collapse
Affiliation(s)
- Alicia L Eubanks
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - David F Grabski
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Jessica Pollack
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Daniel E Levin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eugene McGahren
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Linda W Martin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Jeffrey Gander
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| |
Collapse
|
15
|
Ren Y, Zheng T, Hua L, Zhang F, Ma Y, Zhang J. The Effect of Ultrasound-Guided Erector Spinae Plane Block versus Thoracic Epidural Block on Postoperative Analgesia After Nuss Surgery in Paediatric Patients: Study Protocol of a Randomized Non-Inferiority Design Trial. J Pain Res 2021; 14:3047-3055. [PMID: 34611435 PMCID: PMC8487277 DOI: 10.2147/jpr.s332078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/23/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose The Nuss procedure is a recognized treatment for adolescent pectus excavatum that results in severe postoperative pain. Erector spinae plane block (ESPB) is a novel technique that provides postoperative analgesia and reduces opioid consumption. Our aim is to explore whether ESPB produces analgesia similar to thoracic epidural anaesthesia (TEA) in paediatric patients undergoing Nuss procedure. Study Design and Methods This randomized, controlled, non-inferiority trial will enrol 300 paediatric patients undergoing Nuss surgery. Participants will be randomly assigned 1:1 to receive ESPB or TEA preoperatively. The primary, joint endpoint is the average numeric rating scale (NRS) score and cumulative sufentanil consumption. The secondary endpoints are pain scores and sufentanil consumption at different time points after surgery, analgesia-related side effects, and other postoperative complications. Data will be analysed by the intention-to-treat principle. Discussion This study investigates the effect of ESPB on postoperative opioid consumption and pain scores and intend to provide a new strategy of analgesia management for Nuss procedure in paediatric patients.
Collapse
Affiliation(s)
- Yi Ren
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, People's Republic of China
| | - Tiehua Zheng
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, People's Republic of China
| | - Lei Hua
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, People's Republic of China
| | - Fuzhou Zhang
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, People's Republic of China
| | - Yangwei Ma
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, People's Republic of China
| | - Jianmin Zhang
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, People's Republic of China
| |
Collapse
|
16
|
Heo MH, Kim JY, Kim JH, Kim KW, Lee SI, Kim KT, Park JS, Choe WJ, Kim JH. Epidural analgesia versus intravenous analgesia after minimally invasive repair of pectus excavatum in pediatric patients: a systematic review and meta-analysis. Korean J Anesthesiol 2021; 74:449-458. [PMID: 34344147 PMCID: PMC8497911 DOI: 10.4097/kja.21133] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 08/04/2021] [Indexed: 11/10/2022] Open
Abstract
Background Postoperative pain control after the minimally invasive repair of pectus excavatum (MIRPE) is essential, but there is a controversy about a better analgesic method between epidural and intravenous (IV) analgesia. This systematic review and meta-analysis aimed to compare the effect of epidural versus IV analgesia following MIRPE. Methods We searched PubMed, MEDLINE, EMBASE, Cochrane Central Register, and ClinicalTrials.gov for randomized control trials (RCTs) dated up to 31st May 2021. The primary outcome was the area under the curve (AUC) of the weighted mean visual analog scale (VAS) after MIRPE. The secondary outcomes were postoperative nausea, operation time, total operating room time, and postoperative length of hospital stay. Results Four RCTs involving 243 patients were finally included in this meta-analysis. The AUC of the weighted mean VAS was 343.62 in the epidural group and 375.24 in IV group. Epidural group showed lower VAS than IV group at 12 hours (mean difference -0.99 [95% CI: -1.52, -0.47], P = 0.001, I2 = 0%), at 24 hours (mean difference -0.65 [95% CI: -1.15, -0.16], P = 0.009, I2 = 0%), and 48 hours (mean difference -0.81 [95% CI: -1.61, -0.01], P = 0.046, I2 = 46%) after the surgery. Conclusion Epidural analgesia after the MIRPE had a better analgesic effect than IV analgesia from 12 hours to 48 hours after surgery, and AUC of VAS was lower in the epidural group. However, IV analgesia may also be a viable option, and physicians should wisely choose analgesic modalities after MIRPE.
Collapse
Affiliation(s)
- Min Hee Heo
- Department of Anesthesiology and Pain Medicine, Inje University Ilsan Paik Hospital, Goyang, Gyeonggi- do, Republic of Korea
| | - Ji Yeon Kim
- Department of Anesthesiology and Pain Medicine, Inje University Ilsan Paik Hospital, Goyang, Gyeonggi- do, Republic of Korea
| | - Jung Hyeon Kim
- Department of Anesthesiology and Pain Medicine, Inje University Ilsan Paik Hospital, Goyang, Gyeonggi- do, Republic of Korea
| | - Kyung Woo Kim
- Department of Anesthesiology and Pain Medicine, Inje University Ilsan Paik Hospital, Goyang, Gyeonggi- do, Republic of Korea
| | - Sang Il Lee
- Department of Anesthesiology and Pain Medicine, Inje University Ilsan Paik Hospital, Goyang, Gyeonggi- do, Republic of Korea
| | - Kyung-Tae Kim
- Department of Anesthesiology and Pain Medicine, Inje University Ilsan Paik Hospital, Goyang, Gyeonggi- do, Republic of Korea
| | - Jang Su Park
- Department of Anesthesiology and Pain Medicine, Inje University Ilsan Paik Hospital, Goyang, Gyeonggi- do, Republic of Korea
| | - Won Joo Choe
- Department of Anesthesiology and Pain Medicine, Inje University Ilsan Paik Hospital, Goyang, Gyeonggi- do, Republic of Korea
| | - Jun Hyun Kim
- Department of Anesthesiology and Pain Medicine, Inje University Ilsan Paik Hospital, Goyang, Gyeonggi- do, Republic of Korea
| |
Collapse
|
17
|
Beltsios ET, Mitsos SL, Panagiotopoulos NT. Pectus excavatum and scoliosis: a review about the patient's surgical management. Gen Thorac Cardiovasc Surg 2020; 68:1225-1233. [PMID: 32990868 DOI: 10.1007/s11748-020-01496-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
Although Nuss procedure is performed with satisfactory results, there has been a controversy in the literature regarding the effect of a Nuss procedure on the spine. This review article aims to perform an updated overview of the literature about the effect of pectus excavatum correction at the spine and the management of patients with both pectus excavatum and scoliosis. Although acquired scoliosis has been rarely reported after a Nuss procedure, studies show that the Nuss procedure can have a beneficial effect in mild coexisting scoliosis especially when it is performed during the adolescence. The management of cases presented with both pectus excavatum and scoliosis depends on the severity of pre-operative scoliosis and demands detailed evaluation of the spine pre and postoperatively. In the rare condition of post-operative scoliosis following a Nuss procedure, the removal of the metallic bar and conservative measures may have satisfactory results on the spine.
Collapse
Affiliation(s)
- Eleftherios T Beltsios
- Department of Thoracic Surgery, University College London Hospitals (UCLH), London, UK. .,Department of Medicine, Faculty of Health Sciences, University of Thessaly, Biopolis, 41500, Larissa, Greece.
| | - Sofoklis L Mitsos
- Department of Thoracic Surgery, University College London Hospitals (UCLH), London, UK
| | | |
Collapse
|
18
|
Zobel MJ, Ewbank C, Mora R, Idowu O, Kim S, Padilla BE. The incidence of neuropathic pain after intercostal cryoablation during the Nuss procedure. Pediatr Surg Int 2020; 36:317-324. [PMID: 31760443 DOI: 10.1007/s00383-019-04602-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2019] [Indexed: 01/02/2023]
Abstract
PURPOSE Intercostal nerve cryoblation during the Nuss procedure for pectus excavatum decreases pain, opiate requirement, and hospital length of stay (LOS) compared to thoracic epidural analgesia. However, long-term complications of cryoablation, including neuropathic pain development, are not well studied. METHODS We conducted a multi-institutional retrospective review of patients following intercostal nerve cryoablation during Nuss bar insertion (11/2015-7/2018). Patients completed the Leeds Assessment of Neuropathic Symptoms and Signs, a validated questionnaire for detecting neuropathic symptoms. Primary outcome was neuropathic pain development. Secondary outcomes included duration of chest numbness and LOS. T test was performed; p < 0.05 is significant. RESULTS 43 patients underwent intercostal cryoablation during the Nuss procedure. Ages at repair ranged 11-47 years (median 16). Patients were grouped by age: ≤ 21 years (30 patients) or older (13 patients). Mean LOS was shorter for the younger group, 2.0 versus 3.9 days (p = 0.03). No patients in the younger group, and three in the older, experienced neuropathic pain. Mean time to numbness resolution was shorter for the younger group, 3.4 versus 10.8 months (p = 0.003). CONCLUSION In pediatric patients, intercostal cryoablation provides effective analgesia following the Nuss procedure with minimal risk of post-operative neuropathic pain. Adult patients are at greater risk of experiencing neuropathic pain and prolonged numbness.
Collapse
Affiliation(s)
- Michael J Zobel
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, 550 16th Street, Fifth Floor, San Francisco, CA, 94158-0570, USA
| | - Clifton Ewbank
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, 550 16th Street, Fifth Floor, San Francisco, CA, 94158-0570, USA
| | - Roberta Mora
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, 550 16th Street, Fifth Floor, San Francisco, CA, 94158-0570, USA
| | - Olajire Idowu
- Division of Pediatric Surgery, Department of Surgery, UCSF Benioff Children's Hospital Oakland, 747 52nd Street, Oakland, CA, 94609, USA
| | - Sunghoon Kim
- Division of Pediatric Surgery, Department of Surgery, UCSF Benioff Children's Hospital Oakland, 747 52nd Street, Oakland, CA, 94609, USA
| | - Benjamin E Padilla
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, 550 16th Street, Fifth Floor, San Francisco, CA, 94158-0570, USA.
| |
Collapse
|
19
|
Zuidema WP, Oosterhuis JWA, van der Heide SM, de Lange-de Klerk E, van der Steeg AFW, van Heurn ELWE. Correlation of Preoperative State Anxiety and Pain Six Weeks After Surgical Correction of Pectus Excavatum. Anesth Pain Med 2020; 10:e98969. [PMID: 32337168 PMCID: PMC7158239 DOI: 10.5812/aapm.98969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/30/2019] [Accepted: 01/24/2020] [Indexed: 11/24/2022] Open
Abstract
Background Pain is a major concern in the early postoperative phase after correction of pectus excavatum. Most studies only focus on pain management in the first days after surgery and describe methods to alleviate the pain immediately postoperatively. The severity of postoperative pain may be influenced by anxiety. So far, few studies have looked into the relationship between anxiety and postoperative pain after pectus excavatum correction. Objectives This study aimed to investigate the correlation between preoperative anxiety and late postoperative pain scores. Methods This was a prospective cohort study. Anxiety was assessed with the State and Trait Anxiety Inventory questionnaire. Visual analogue scale (VAS) for pain scores assessed the pain at rest and activity. Anxiety was measured before surgery and pain scores six weeks after surgery. A hierarchical linear regression analysis was performed to investigate the correlation between baseline anxiety and pain measurements six weeks after surgery. Results In this study, 136 patients were included. State anxiety was not associated with postoperative pain (mean of pain on activity and in rest), only with pain on activity after six weeks. Age and sex were not effect modifiers in any of the models. Relevant confounding factors, although not significant, consisted of trait, sex, minor complications, epidural duration, major complications, and the number of stabilizer plates. The explained variance of state anxiety on VAS for pain scores was minimum after 6 weeks. Conclusions Preoperative anxiety does not appear to influence postoperative pain after PE correction.
Collapse
Affiliation(s)
- Wietse P. Zuidema
- Department of Pediatric Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Corresponding Author: Department of Pediatric Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands, Tel: +31-204444444, Fax: +31-204444512,
| | - Jan WA Oosterhuis
- Department of Thoracic Surgery, Haaglanden Medical Center, The Hague, The Netherlands
| | - Stefan M van der Heide
- Department of Cardio-Thoracic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Elly de Lange-de Klerk
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Alida FW van der Steeg
- Department of Pediatric Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Ernst LWE van Heurn
- Department of Pediatric Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| |
Collapse
|
20
|
Graves CE, Moyer J, Zobel MJ, Mora R, Smith D, O'Day M, Padilla BE. Intraoperative intercostal nerve cryoablation During the Nuss procedure reduces length of stay and opioid requirement: A randomized clinical trial. J Pediatr Surg 2019; 54:2250-2256. [PMID: 30935731 PMCID: PMC6920013 DOI: 10.1016/j.jpedsurg.2019.02.057] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/29/2019] [Accepted: 02/22/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Minimally-invasive repair of pectus excavatum by the Nuss procedure is associated with significant postoperative pain, prolonged hospital stay, and high opiate requirement. We hypothesized that intercostal nerve cryoablation during the Nuss procedure reduces hospital length of stay (LOS) compared to thoracic epidural analgesia. DESIGN This randomized clinical trial evaluated 20 consecutive patients undergoing the Nuss procedure for pectus excavatum between May 2016 and March 2018. Patients were randomized evenly via closed-envelope method to receive either cryoanalgesia or thoracic epidural analgesia. Patients and physicians were blinded to study arm until immediately preoperatively. SETTING Single institution, UCSF-Benioff Children's Hospital. PARTICIPANTS 20 consecutive patients were recruited from those scheduled for the Nuss procedure. Exclusion criteria were age < 13 years, chest wall anomaly other than pectus excavatum, previous repair or other thoracic surgery, and chronic use of pain medications. MAIN OUTCOMES AND MEASURES Primary outcome was postoperative LOS. Secondary outcomes included total operative time, total/daily opioid requirement, inpatient/outpatient pain score, and complications. Primary outcome data were analyzed by the Mann-Whitney U-test for nonparametric continuous variables. Other continuous variables were analyzed by two-tailed t-test, while categorical data were compared via Chi-squared test, with alpha = 0.05 for significance. RESULTS 20 patients were randomized to receive either cryoablation (n = 10) or thoracic epidural (n = 10). Mean operating room time was 46.5 min longer in the cryoanalgesia group (p = 0.0001). Median LOS decreased by 2 days in patients undergoing cryoablation, to 3 days from 5 days (Mann-Whitney U, p = 0.0001). Cryoablation patients required significantly less inpatient opioid analgesia with a mean decrease of 416 mg oral morphine equivalent per patient (p = 0.0001), requiring 52%-82% fewer milligrams on postoperative days 1-3 (p < 0.01 each day). There was no difference in mean pain score between the groups at any point postoperatively, up to one year, and no increased incidence of neuropathic pain in the cryoablation group. No complications were noted in the cryoablation group; among patients with epidurals, one patient experienced a symptomatic pneumothorax and another had urinary retention. CONCLUSIONS AND RELEVANCE Intercostal nerve cryoablation during the Nuss procedure decreases hospital length of stay and opiate requirement versus thoracic epidural analgesia, while offering equivalent pain control. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level I.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Benjamin E. Padilla
- Corresponding author at: University of California, San Francisco Department of Surgery Division of Pediatric Surgery 550 16th St, Fifth Floor San Francisco, CA 94158-0570 United States. (B.E. Padilla)
| |
Collapse
|
21
|
Parrado R, Lee J, McMahon LE, Clay C, Powell J, Kang P, Notrica DM, Ostlie DJ, Bae JO. The Use of Cryoanalgesia in Minimally Invasive Repair of Pectus Excavatum: Lessons Learned. J Laparoendosc Adv Surg Tech A 2019; 29:1244-1251. [DOI: 10.1089/lap.2019.0203] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Raphael Parrado
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
- Department of Child Health, University of Arizona College of Medicine, Phoenix, Arizona
- Department of Surgery, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | - Justin Lee
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
- Department of Child Health, University of Arizona College of Medicine, Phoenix, Arizona
- Department of Surgery, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | - Lisa E. McMahon
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
- Department of Child Health, University of Arizona College of Medicine, Phoenix, Arizona
- Department of Surgery, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | - Conner Clay
- University of Arizona College of Medicine, Phoenix, Arizona
| | - Jordan Powell
- University of Arizona College of Medicine, Phoenix, Arizona
| | - Paul Kang
- Department of Epidemiology and Biostatistics, University of Arizona College of Public Health, Phoenix, Arizona
| | - David M. Notrica
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
- Department of Child Health, University of Arizona College of Medicine, Phoenix, Arizona
- Department of Surgery, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | - Daniel J. Ostlie
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
- Department of Child Health, University of Arizona College of Medicine, Phoenix, Arizona
- Department of Surgery, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | - Jae-O Bae
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
- Department of Child Health, University of Arizona College of Medicine, Phoenix, Arizona
- Department of Surgery, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| |
Collapse
|
22
|
Use of the bilateral erector spinae (ESP) block for postoperative analgesia following the removal of the Nuss bar. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2019. [DOI: 10.1097/cj9.0000000000000109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
23
|
Muhly WT, Beltran RJ, Bielsky A, Bryskin RB, Chinn C, Choudhry DK, Cucchiaro G, Fernandez A, Glover CD, Haile DT, Kost-Byerly S, Schnepper GD, Zurakowski D, Agarwal R, Bhalla T, Eisdorfer S, Huang H, Maxwell LG, Thomas JJ, Tjia I, Wilder RT, Cravero JP. Perioperative Management and In-Hospital Outcomes After Minimally Invasive Repair of Pectus Excavatum. Anesth Analg 2019; 128:315-327. [DOI: 10.1213/ane.0000000000003829] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
24
|
Manworren RC, Anderson MN, Girard ED, Ruscher KA, Verissimo AM, Palac H, Weiss R, Rader C, Hight D. Postoperative Pain Outcomes After Nuss Procedures: Comparison of Epidural Analgesia, Continuous Infusion of Local Anesthetic, and Preoperative Self-Hypnosis Training. J Laparoendosc Adv Surg Tech A 2018; 28:1234-1242. [DOI: 10.1089/lap.2017.0699] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Renee C.B. Manworren
- Department of Nursing, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Matthew N. Anderson
- Department of Neurosurgery, Rhode Island Hospital, Brown University, Providence, Rhode Island
| | - Eric D. Girard
- Department of Surgery, School of Medicine, University of Louisville, Louisville, Kentucky
| | - Kimberly A. Ruscher
- Department of Pediatric Surgery, Sacred Heart at Riverbend, Springfield, Oregon
| | - Ana Maria Verissimo
- Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford, Connecticut
- Department of Surgery, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Hannah Palac
- Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Center for Behavorial Intervention Technologies, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Richard Weiss
- Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford, Connecticut
- Department of Surgery, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Christine Rader
- Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford, Connecticut
- Department of Surgery, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Donald Hight
- Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford, Connecticut
- Department of Surgery, University of Connecticut School of Medicine, Farmington, Connecticut
| |
Collapse
|
25
|
Morikawa N, Laferriere N, Koo S, Johnson S, Woo R, Puapong D. Cryoanalgesia in Patients Undergoing Nuss Repair of Pectus Excavatum: Technique Modification and Early Results. J Laparoendosc Adv Surg Tech A 2018; 28:1148-1151. [PMID: 29672193 DOI: 10.1089/lap.2017.0665] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE The Nuss procedure for surgical correction of pectus excavatum often causes severe postoperative pain. Cryoanalgesia of intercostal nerves is an alternative modality for pain control. We describe our modification of the cryoICE™ probe that allows for nerve ablation through the ipsilateral chest along with early results utilizing this technique. METHODS To allow for ipsilateral nerve ablation, a 20-French chest tube was cut and secured to the cryoICE probe, thus providing insulation for the malleable end of the probe. A 3-year retrospective review of patients undergoing Nuss repair at our institution was performed. Patients who received cryoanalgesia (cryo, n = 6) were compared with a historical control cohort who did not receive cryoanalgesia (nocryo, n = 13) during Nuss repair. Hospital length of stay, postoperative narcotic requirement (PNR), and highest postoperative pain score were collected. RESULTS Both cohorts were similar regarding age, BMI, and pectus index. The cryo group had a significantly less PNR (6.4 versus 17.9 doses, P = .05) and was discharged on average >1 day earlier than nocryo patients (3.7 versus 2.2 days, P = .01). No complications occurred in either group. CONCLUSIONS Our technique modification simplifies previously described approaches to intercostal nerve cryoablation. Patients undergoing this adjunct benefit with less PNR and a faster discharge time.
Collapse
Affiliation(s)
- Nicole Morikawa
- 1 University of Hawaii John A. Burns School of Medicine , Honolulu, Hawaii
| | - Nicole Laferriere
- 2 Department of General Surgery, Tripler Army Medical Center , Honolulu, Hawaii
| | - Sylvia Koo
- 3 University of Hawaii at Manoa , Honolulu, Hawaii
| | - Sidney Johnson
- 4 Department of Pediatric Surgery, Kapiolani Medical Center for Women and Children , Honolulu, Hawaii
| | - Russell Woo
- 4 Department of Pediatric Surgery, Kapiolani Medical Center for Women and Children , Honolulu, Hawaii
| | - Devin Puapong
- 4 Department of Pediatric Surgery, Kapiolani Medical Center for Women and Children , Honolulu, Hawaii
| |
Collapse
|
26
|
Anesthesia for Nuss Procedures (Pectus Deformity). Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
27
|
Shah SB, Hariharan U, Bhargava AK, Darlong LM. Anesthesia for minimally invasive chest wall reconstructive surgeries: Our experience and review of literature. Saudi J Anaesth 2017; 11:319-326. [PMID: 28757834 PMCID: PMC5516496 DOI: 10.4103/sja.sja_13_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Minimal access procedures have revolutionized the field of surgery and opened newer challenges for the anesthesiologists. Pectus carinatum or pigeon chest is an uncommon chest wall deformity characterized by a protruding breast bone (sternum) and ribs caused by an overgrowth of the costal cartilages. It can cause a multitude of problems, including severe pain from an intercostal neuropathy, respiratory dysfunction, and psychologic issues from the cosmetic disfigurement. Pulmonary function indices, namely, forced expiratory volume over 1 s, forced vital capacity, vital capacity, and total lung capacity are markedly compromised in pectus excavatum. Earlier, open surgical correction in the form of the Ravitch procedure was followed. Currently, in the era of minimally invasive surgery, Nuss technique (pectus bar procedure) is a promising step in chest wall reconstructive surgery for pectus excavatum. Reverse Nuss is a corrective, minimally invasive surgery for pectus carinatum chest deformity. A tailor-made anesthetic technique for this new procedure has been described here based on the authors’ personal experience and thorough review of literature based on Medline, Embase, and Scopus databases search.
Collapse
Affiliation(s)
| | - Uma Hariharan
- Department of Anaesthesia and Intensive Care, Dr. Ram Manohar Lohia Hospital and PGIMER, CHS, New Delhi, India
| | | | - Laleng M Darlong
- Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| |
Collapse
|
28
|
Graves CE, Hirose S, Raff GW, Iqbal CW, Imamura-Ching J, Christensen D, Fechter R, Kwiat D, Harrison MR. Magnetic Mini-Mover Procedure for pectus excavatum IV: FDA sponsored multicenter trial. J Pediatr Surg 2017; 52:913-919. [PMID: 28342579 DOI: 10.1016/j.jpedsurg.2017.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 03/09/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE The Magnetic Mini-Mover Procedure (3MP) is a minimally invasive treatment for prepubertal patients with pectus excavatum. This multicenter trial sought to supplement safety and efficacy data from an earlier pilot trial. METHODS Fifteen patients with pectus excavatum had a titanium-enclosed magnet implanted on the sternum. Externally, patients wore a custom-fitted magnetic brace. Patients were monitored closely for safety. Efficacy was determined by the Haller Index (HI) and satisfaction surveys. After 2 years, the implant was removed. RESULTS Mean patient age was 12 years (range 8-14), and mean pretreatment HI was 4.7 (range 3.6-7.4). The device was successfully implanted in all patients. Mean treatment duration was 25 months (range 18-33). Posttreatment chest imaging in 13 patients indicated that HI decreased in 5, remained stable in 2, and increased in 6. Seven out of 15 patients had breakage of the implant's titanium cables because of fatigue fracture. Eight out of 13 patients were satisfied with their chest after treatment. CONCLUSION The 3MP is a safe, minimally invasive, outpatient treatment for prepubertal patients with pectus excavatum. However, the magnetic implant design led to frequent device breakage, confounding analysis. The HI indicated mixed efficacy, although surveys indicated most patients perceived a benefit. STUDY TYPE/LEVEL OF EVIDENCE Case series, treatment study. Level IV.
Collapse
Affiliation(s)
- Claire E Graves
- Division of Pediatric Surgery, UCSF Benioff Children's Hospital, 550 16th Street, 5th Floor, Box 0570, San Francisco, CA 94143, United States
| | - Shinjiro Hirose
- Davis Health System, Department of Surgery, University of California, 2315 Stockton Blvd., OP512, Sacramento, CA 95817, United States; Department of Surgery, Shriners Hospital for Children-Northern California, 2425 Stockton Blvd., Sacramento, CA 95817, United States
| | - Gary W Raff
- Davis Health System, Department of Surgery, University of California, 2315 Stockton Blvd., OP512, Sacramento, CA 95817, United States; Department of Surgery, Shriners Hospital for Children-Northern California, 2425 Stockton Blvd., Sacramento, CA 95817, United States
| | - Corey W Iqbal
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Rd., Kansas City, MO 64108, United States
| | - Jill Imamura-Ching
- Division of Pediatric Surgery, UCSF Benioff Children's Hospital, 550 16th Street, 5th Floor, Box 0570, San Francisco, CA 94143, United States
| | - Darrell Christensen
- Department of Orthopaedic Surgery, UCSF Medical Center, 400 Parnassus Ave, Level B1, Room A096, San Francisco, CA 94143, United States
| | - Richard Fechter
- Division of Pediatric Surgery, UCSF Benioff Children's Hospital, 550 16th Street, 5th Floor, Box 0570, San Francisco, CA 94143, United States
| | - Dillon Kwiat
- Division of Pediatric Surgery, UCSF Benioff Children's Hospital, 550 16th Street, 5th Floor, Box 0570, San Francisco, CA 94143, United States
| | - Michael R Harrison
- Division of Pediatric Surgery, UCSF Benioff Children's Hospital, 550 16th Street, 5th Floor, Box 0570, San Francisco, CA 94143, United States.
| |
Collapse
|
29
|
Graves C, Idowu O, Lee S, Padilla B, Kim S. Intraoperative cryoanalgesia for managing pain after the Nuss procedure. J Pediatr Surg 2017; 52:920-924. [PMID: 28341230 DOI: 10.1016/j.jpedsurg.2017.03.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 03/09/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cryoanalgesia prevents pain by freezing the affected peripheral nerve. We report the use of intraoperative cryoanalgesia during the Nuss procedure for pectus excavatum and describe our initial experience, modifications of technique, and lessons learned. MATERIALS AND METHODS We retrospectively reviewed the medical records of patients who received cryoanalgesia during the Nuss procedure between June 1, 2015, and April 30, 2016, at our institutions and analyzed modifications in surgical technique during this early adoption period. RESULTS Eight male and two female patients underwent the Nuss procedure with cryoanalgesia. The mean postoperative length of stay (LOS) was 2days (range 1-3). Average inpatient pain scores were 3.4, 3.2, and 4.6 on postoperative days 1-3, respectively (N=10, 7, and 2). At a 1-week postoperative visit, mean pain score was 1.1 (N=6). Compared to the preceding 15 Nuss patients at our institution, who were treated with a thoracic epidural, postoperative LOS was significantly shorter with cryoanalgesia (2.0±0.82 vs. 6.3±1.3days, P<0.001). We modified our technique for patient habitus and adopted single-lung ventilation for improved visualization. CONCLUSIONS Cryoanalgesia may be the ideal pain management strategy for Nuss patients because it is effective and long lasting. Intraoperative application is easily integrated into the Nuss procedure. STUDY TYPE Treatment study: case series; Evidence level IV.
Collapse
Affiliation(s)
- Claire Graves
- Division of Pediatric Surgery, UCSF Benioff Children's Hospitals, Oakland and San Francisco, CA
| | - Olajire Idowu
- Division of Pediatric Surgery, UCSF Benioff Children's Hospitals, Oakland and San Francisco, CA
| | - Sang Lee
- Department of Cardiothoracic Surgery, Regional Medical Center, San Jose, CA
| | - Benjamin Padilla
- Division of Pediatric Surgery, UCSF Benioff Children's Hospitals, Oakland and San Francisco, CA
| | - Sunghoon Kim
- Division of Pediatric Surgery, UCSF Benioff Children's Hospitals, Oakland and San Francisco, CA.
| |
Collapse
|
30
|
Beltran R, Veneziano G, Bhalla T, Kenney B, Tumin D, Bissonnette B, Tobias JD. Postoperative pain management in patients undergoing thoracoscopic repair of pectus excavatum: A retrospective analysis of opioid consumption and adverse effects in adolescents. Saudi J Anaesth 2017; 11:427-431. [PMID: 29033723 PMCID: PMC5637419 DOI: 10.4103/sja.sja_339_17] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction: Although the Nuss procedure provides excellent cosmetic results for the correction of pectus excavatum, the provision of analgesia following such procedures can be challenging. Methods: The current study retrospectively reviews our experience over a 2.5 year period with thoracic epidural analgesia (TE), paravertebral blockade (PVB), and intravenous opioids delivered via patient-controlled analgesia (PCA) to provide postoperative analgesia. Results: The study cohort included 30 patients (mean age = 15.6 ± 1.5 years), 15 of whom were treated with PCA, 8 with TE, and 7 with PVB. There were no significant differences in pain scores between the 3 groups at any time point during the first 3 postoperative days. Compared to PCA, the PVB group had lower opioid consumption over the first 24 hours of hospitalization by 1.7 mg/kg morphine equivalents (95% CI of difference: 0.1, 3.3; p=0.035); but had higher opioid consumption by 2.0 mg/kg morphine equivalents than the TE group (95% CI of difference: 0.3, 3.7; p=0.024). There were no differences in opioid consumption between PVB and PCA or between PVB and TE at 48 or 72 hours. The number of intraoperative hypotension episodes was significantly lower in the PCA group when compared to the PVB group (p=0.001), with no difference between the PVB and TE groups. Conclusions: The use of regional anesthesia should be considered a viable option for the relief of postoperative pain in pediatric patients following the Nuss procedure albeit with a higher incidence of intraoperative hemodynamic effects. A randomized, prospective, study powered to compare all 3 techniques against one another would be necessary to confirm the significance of these findings.
Collapse
Affiliation(s)
- Ralph Beltran
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology, The Ohio State University, Columbus, Ohio, USA
| | - Giorgio Veneziano
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology, The Ohio State University, Columbus, Ohio, USA
| | - Tarun Bhalla
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology, The Ohio State University, Columbus, Ohio, USA
| | - Brian Kenney
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Dmitry Tumin
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Bruno Bissonnette
- Department of Anesthesia and Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology, The Ohio State University, Columbus, Ohio, USA
| |
Collapse
|
31
|
Frawley G, Frawley J, Crameri J. A review of anesthetic techniques and outcomes following minimally invasive repair of pectus excavatum (Nuss procedure). Paediatr Anaesth 2016; 26:1082-1090. [PMID: 27510834 DOI: 10.1111/pan.12988] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pectus excavatum (PE) is the most common congenital chest wall deformity, occurring in 1 : 1000 children with a male to female ratio of 4 : 1. Several procedures have been described to manage this deformity, including cartilage resection with sternal osteotomy (the Ravitch procedure) and a minimally invasive repair technique (the Nuss procedure). While initially described as a nonthoracoscopic technique, the current surgical approach of the Royal Childrens Hospital involves thoracoscopic assistance. Postoperative pain is significant in patients undergoing the pectus repair and multiple analgesic regimens have been advocated with continuous thoracic epidural infusions and opioid infusions the most common. Some authors have advocated patient-controlled analgesia (PCA), paravertebral nerve blocks (PVNB), and wound infusion catheters as alternatives. AIMS The primary aim of this study was to assess our experience with postoperative pain and analgesia requirements associated with the minimally invasive repair of pectus excavatum in children. METHODS This is a retrospective cohort study with a contemporaneous comparison group examining patients treated between January 2005 and December 2015 for minimally invasive repair of pectus excavatum by the Nuss procedure. RESULTS Two hundred and seventeen patients [mean age 14.9 (sd 1.9) years] with pectus excavatum treated at the Royal Childrens Hospital between 2005 and 2015 were identified. All patients were managed with thoracic epidural analgesia and intravenous morphine infusions. The epidural was effective in the postanesthesia care unit in 97.3% (failure to place an epidural rate was 4 (1.9%); no block on awakening 0.9%). A further 4 (1.8%) were removed within 24 h. The mean morphine equivalent dose in the first 24 h was 0.8 mg·kg-1 ·day-1 . PCA was continued for a mean of 3.8 days and the total mean morphine equivalent dose was 2.2 mg·kg-1 ·day-1 . Minor complications occurred in 67 (30.9%) with postoperative nausea and vomiting in 36 patients (16.6%) and urinary retention requiring an indwelling catheter in 40 patients (18.4%). CONCLUSION An epidural-based analgesic regime is associated with low pain scores and few acute complications. The continuation of morphine analgesia after the first postoperative day is common but associated with an increased incidence of urinary retention and nausea and vomiting.
Collapse
Affiliation(s)
- Geoff Frawley
- Department of Paediatric Anaesthesia and Pain Management, Royal Childrens Hospital, Melbourne, Vic., Australia. .,Department of Paediatrics, University of Melbourne, Parkville, Vic., Australia. .,Murdoch Childrens Research Institute, Critical Care and Neurosciences Theme, Parkville, Vic., Australia.
| | - Jacinta Frawley
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic., Australia
| | - Joe Crameri
- Department of Paediatric and Neonatal Surgery, Royal Childrens Hospital, Melbourne, Vic., Australia
| |
Collapse
|
32
|
Jaroszewski DE, Temkit M, Ewais MM, Luckritz TC, Stearns JD, Craner RC, Gaitan BD, Ramakrishna H, Thunberg CA, Weis RA, Myers KM, Merritt MV, Rosenfeld DM. Randomized trial of epidural vs. subcutaneous catheters for managing pain after modified Nuss in adults. J Thorac Dis 2016; 8:2102-10. [PMID: 27621865 DOI: 10.21037/jtd.2016.06.62] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Minimally invasive repair of pectus excavatum (MIRPE) is now performed in adults. Managing adult patients' pain postoperatively has been challenging due to increased chest wall rigidity and the pressure required for supporting the elevated sternum. The optimal pain management regimen has not been determined. We designed this prospective, randomized trial to compare postoperative pain management and outcomes between thoracic epidural analgesia (TEA) and bilateral subcutaneous infusion pump catheters (On-Q). METHODS Patients undergoing MIRPE (modified Nuss) underwent random assignment to TEA or On-Q group. Both groups received intravenous, patient-controlled opioid analgesia, with concomitant delivery of local anesthetic. Primary outcomes were length of stay (LOS), opioid use, and pain scores. RESULTS Of 85 randomly assigned patients, 68 completed the study [52 men, 76.5%; mean (range) age, 32.2 (20.0-58.0) years; Haller index, 5.9 (range, 3.0-26.7)]. The groups were equally matched for preoperative variables; however, the On-Q arm had more patients (60.3%). No significant differences were found between groups in mean daily pain scores (P=0.52), morphine-equivalent opioid usage (P=0.28), or hospital stay 3.5 vs. 3.3 days (TEA vs. On-Q; P=0.55). Thirteen patients randomized to TEA refused the epidural and withdrew from the study because they perceived greater benefit of the On-Q system. CONCLUSIONS Postoperative pain management in adults after MIRPE can be difficult. Both continuous local anesthetic delivery by TEA and On-Q catheters with concomitant, intravenous, patient-controlled anesthesia maintained acceptable analgesia with a reasonable LOS. In our cohort, there was preference for the On-Q system for pain management.
Collapse
Affiliation(s)
- Dawn E Jaroszewski
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - M'hamed Temkit
- Department of Biostatistics, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - MennatAllah M Ewais
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Todd C Luckritz
- Department of Pharmacy, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Joshua D Stearns
- Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Ryan C Craner
- Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Brantley D Gaitan
- Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Harish Ramakrishna
- Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | | | - Ricardo A Weis
- Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Kelly M Myers
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Marianne V Merritt
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - David M Rosenfeld
- Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| |
Collapse
|
33
|
Choudhry DK, Brenn BR, Sacks K, Reichard K. Continuous chest wall ropivacaine infusion for analgesia in children undergoing Nuss procedure: a comparison with thoracic epidural. Paediatr Anaesth 2016; 26:582-9. [PMID: 27061848 DOI: 10.1111/pan.12904] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pain following Nuss procedure is severe and its management is challenging. Many different pain treatment modalities are currently being used, but none of them have been found to be ideal. AIM In this retrospective review, we compare our current multimodal approach, which involves continuous ropivacaine infusion through chest wall catheters (CWC), intravenous patient-controlled analgesia (IV-PCA), and adjunctive medications (gabapentin and clonidine), with the technique that we used in the past, the thoracic epidural catheter (TEC). METHODS Following IRB approval, we performed a retrospective analysis of data on 32 patients who underwent the Nuss procedure at our institution. All children were divided into two groups: TEC group: 0.2% ropivacaine and hydromorphone 10 mcg·ml(-1) epidural infusion (n = 15) and CWC group (with IV-PCA and adjuncts [gabapentin + clonidine]): 0.2% ropivacaine infusion and hydromorphone PCA, oral gabapentin, and transdermal clonidine patch (n = 17). RESULTS Both the groups were demographically similar. Average numeric pain scores were higher in the CWC group only on the day of surgery (mean ± sd: 3.79 ± 1.58 vs 2.68 ± 1.30; 95% CI: -2.16 to -0.05). Pain scores on postoperative day 1 (mean ± sd: 3.40 ± 1.59 vs 3.35 ± 1.32; 95% CI: -1.11 to 1.01), day 2 (mean± sd: 3.39 ± 1.79 vs 2.99 ± 1.06; 95% CI: -1.50 to 0.70), and on the day of discharge (DOD) (mean± sd: 3.25 ± 1.84 vs 3.99 ± 1.28; 95% CI: -0.42 to 1.89) were comparable between the groups. The CWC group needed fewer changes in the therapeutic regimen to maintain acceptable pain relief, had lower incidence of nausea and vomiting, had shorter anesthesia time, total OR time, and hospital length of stay. CONCLUSION TEC provided better analgesia following the Nuss procedure only on the day of surgery. On the subsequent days until discharge, pain scores were comparable. However, CWC offered other advantages: it was less labor intensive and had fewer side effects, shorter OR time, and shorter hospital stay.
Collapse
Affiliation(s)
- Dinesh K Choudhry
- Department of Anesthesiology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - B Randall Brenn
- Department of Anesthesiology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Karen Sacks
- Department of Anesthesiology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Kirk Reichard
- Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| |
Collapse
|
34
|
Siddiqui A, Tse A, Paul JE, Fitzgerald P, Teh B. Postoperative epidural analgesia for patients undergoing pectus excavatum corrective surgery: a 10-year retrospective analysis. Local Reg Anesth 2016; 9:25-33. [PMID: 27307763 PMCID: PMC4889096 DOI: 10.2147/lra.s80710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Managing postoperative pain in patients undergoing minimally invasive pectus excavatum repair (Nuss procedure) is challenging but essential in facilitating ambulation and minimizing the length of stay. Although multiple epidural regimens with varying opioids are presently used for pain management, there is currently no clinical consensus regarding which epidural regimen provides the best analgesia outcomes with the fewest side effects. This 10-year retrospective cohort study was performed to compare the quality of analgesia and the incidence of side effects associated with the three most common epidural regimens used at a tertiary care children’s hospital, in patients undergoing the Nuss procedure. Methods Seventy-two pediatric patients were identified as having been treated with one of three epidural regimens for postoperative pain management following the Nuss procedure: Group A (n=12) received 0.125% bupivacaine and 5 µg/mL fentanyl, Group B (n=21) received 0.125% bupivacaine and 10 µg/mL hydromorphone, and Group C (n=39) received 0.1% ropivacaine and 20 µg/mL hydromorphone. Our primary outcome was maximal daily pain scores (numerical rating scale 0–10), with an analytical focus on postoperative day 1 scores. The primary outcome was analyzed using linear regression. The secondary outcomes included the length of stay, side-effect profiles as reflected by the number of treatments for nausea and pruritus, pain scores according to epidural site insertion, occurrence of breakthrough pain, and presence of severe pain throughout their hospital stay. Secondary outcomes were analyzed using linear or logistic regression adjusted for pain scores at baseline. The criterion for statistical significance was set a priori at alpha =0.05. Results Group A had significantly higher day-1 pain scores (score 5.42/10) than Group B (4.52/10; P=0.030) and Group C (4.49/10; P=0.015) after adjusting for baseline pain and age. No significant difference in maximum daily pain scores was found between groups during postoperative days 2–5. Among secondary outcomes, Group C had a significantly lower incidence of nausea/vomiting than Group B (P=0.003). There was also significantly more severe pain in Group A than in Group C (P=0.031). No significant difference was found between the three groups for the incidence of pruritus, critical events, breakthrough pain, or patient satisfaction. Conclusion There is no significant difference in managing postoperative pain overall between the three epidural regimens employed at our center. However, in managing day-1 postoperative pain and minimizing nausea/vomiting, our study suggests that a hydromorphone–ropivacaine epidural regimen appears to have more favorable results than a fentanyl–bupivacaine regimen or a hydromorphone–bupivacaine regimen.
Collapse
Affiliation(s)
- Asad Siddiqui
- Department of Anesthesia, University of Toronto, Toronto, Canada
| | - Andrew Tse
- Department of Anesthesia, University of Ottawa, Ottawa, Canada
| | - James E Paul
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Peter Fitzgerald
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Bernice Teh
- Canterbury Anesthetic Services, Victoria, Australia
| |
Collapse
|
35
|
Loftus PD, Elder CT, Russell KW, Spanos SP, Barnhart DC, Scaife ER, Skarda DE, Rollins MD, Meyers RL. Paravertebral regional blocks decrease length of stay following surgery for pectus excavatum in children. J Pediatr Surg 2016; 51:149-53. [PMID: 26577910 DOI: 10.1016/j.jpedsurg.2015.10.037] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 10/09/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE Management of postoperative pain following repair of pectus excavatum has traditionally included thoracic epidural analgesia, narcotics, and benzodiazepines. We hypothesized that the use of intercostal or paravertebral regional blocks could result in decreased inpatient length of stay (LOS). METHODS We conducted a retrospective cohort study of 137 patients (118 Nuss and 19 Ravitch - Nuss and Ravitch patients were analyzed separately) who underwent surgical repair of pectus excavatum with pain management via epidural, intercostal, or paravertebral analgesia from January 2009-December 2012. Measured outcomes included LOS, pain scores, benzodiazepine/narcotic requirements, emesis, professional fees, hospital cost, and total cost. RESULTS In the Nuss patients, LOS was significantly reduced in the paravertebral group (p<0.005) and the intercostal group (p<0.005) compared to the epidural group, but was paradoxically countered by a nonsignificant increase in total cost (p=0.09). While benzodiazepine doses/day was not increased in the paravertebral group (p=0.08), an increase was seen in narcotic use (p<0.005). Despite increased narcotic use, no differences were seen in emesis between epidural and paravertebral use. Compared to epidural, pain scores were higher for both intercostal and paravertebral on day one (p<0.005), but equivalent for paravertebral on day three (p=0.62). The Ravitch group was too small for detailed independent statistical analysis but followed the same overall trend seen in the Nuss patients. CONCLUSION Our use of paravertebral continuous infusion pain catheters for pectus excavatum repair was an effective alternative to epidural analgesia resulting in shorter LOS but not a decrease in overall cost.
Collapse
Affiliation(s)
- Patrick D Loftus
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Craig T Elder
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Katie W Russell
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Stephen P Spanos
- Division of Pediatric Anesthesiology, University of Utah, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Douglas C Barnhart
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Eric R Scaife
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT, USA
| | - David E Skarda
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Michael D Rollins
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Rebecka L Meyers
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT, USA.
| |
Collapse
|
36
|
Li G, Jiang Z, Xiao H, Wang M, Hu F, Xie X, Mei J. A novel modified Nuss procedure for pectus excavatum: a new steel bar. Ann Thorac Surg 2015; 99:1788-92. [PMID: 25952207 DOI: 10.1016/j.athoracsur.2014.12.060] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 12/06/2014] [Accepted: 12/16/2014] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this article is to introduce a new modified Nuss procedure for pectus excavatum and to describe the configuration of the new steel bar. DESCRIPTION We applied a novel method with a new steel bar for minimally invasive surgical correction of pectus excavatum. The procedure was performed with a new steel bar through bilateral thoracic minimally invasive incisions using a thoracoscope for guidance. The bar was installed or removed by pushing and pulling without turning it over. EVALUATION One hundred forty-seven patients with pectus excavatum underwent this novel modified Nuss procedure. All patients had a satisfactory orthopedic result at discharge. There was no perioperative death or cardiac perforation. During the follow-up period, 134 patients underwent bar removal. Of the 134 cases, the initial orthopedic and functional results were excellent in 121 patients (90.3%) and good in 13 patients (9.7%). No patient had recurrence. CONCLUSIONS This novel modified Nuss procedure is a safe, effective, and convenient treatment for pectus excavatum.
Collapse
Affiliation(s)
- Guoqing Li
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zhaolei Jiang
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Haibo Xiao
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Mingsong Wang
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Fengqing Hu
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiao Xie
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ju Mei
- Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
| |
Collapse
|
37
|
Tabata Y, Matsui H, Sakamoto T, Noguchi M. Bilateral diaphragm paralysis after simultaneous cardiac surgery and Nuss procedure in the infant. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2015. [DOI: 10.1016/j.epsc.2014.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
38
|
Lukosiene L, Macas A, Trepenaitis D, Kalibatiene L, Malcius D, Barauskas V. Single shot intercostal block for pain management in pediatric patients undergoing the Nuss procedure: a double-blind, randomized, controlled study. J Pediatr Surg 2014; 49:1753-7. [PMID: 25487477 DOI: 10.1016/j.jpedsurg.2014.09.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 09/05/2014] [Indexed: 11/18/2022]
Abstract
PURPOSE The aim of this study was to investigate the efficacy of a single shot intercostal block for pain control in pediatric patients undergoing the Nuss procedure. METHODS A double-blind, randomized, controlled study was performed. Thirty patients received a single shot bilateral intercostal block with levobupivacaine (L group) and 30 patients with 0.9 % saline (S group). Standardized baseline analgesia was applied for all patients. Morphine consumption, pain scores, respiratory depression, nausea and vomiting, and urinary retention were recorded every 3h for 48h after surgery. RESULTS The loading dose of morphine was lower (p<0.00001) in the L group. There were significantly lower morphine doses up to 6h after surgery and VAS scores up to 3h after surgery in the L group (p<0.001 and p=0.0003, respectively). The incidence of nausea and vomiting was lower in the L group (<0.00001). The incidence of urinary retention was lower in the L group (p=0.019). CONCLUSIONS A single shot IB is an effective additional treatment for pediatric patients undergoing the Nuss procedure and results in the reduced consumption of morphine, less postoperative pain, and fewer opioid-related adverse effects.
Collapse
Affiliation(s)
- Laura Lukosiene
- Lithuanian University of Health Sciences, Medical Academy, Lithuania.
| | - Andrius Macas
- Lithuanian University of Health Sciences, Medical Academy, Lithuania.
| | | | - Lina Kalibatiene
- Lithuanian University of Health Sciences, Medical Academy, Lithuania.
| | - Dalius Malcius
- Lithuanian University of Health Sciences, Medical Academy, Lithuania.
| | | |
Collapse
|
39
|
MUHLY WT, MAXWELL LG, CRAVERO JP. Pain management following the Nuss procedure: a survey of practice and review. Acta Anaesthesiol Scand 2014; 58:1134-9. [PMID: 25087774 DOI: 10.1111/aas.12376] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pectus excavatum is the most common congenital chest wall deformity. The Nuss procedure is frequently used for surgical correction and this technique has been associated with severe and prolonged post-operative pain. At the present time, the optimal analgesic strategy for managing patients following this procedure has not been determined. METHODS A web-based survey was sent to representatives from 108 primarily pediatric hospitals in North America, Europe, Asia and Australia. One individual per institution was contacted to complete the survey on behalf of their department. RESULTS Survey response rate was 54% and 55 institutions reported using the Nuss procedure for correction of pectus excavatum. Annual case volume is less than or equal to 25 cases in 57% of institutions, and the most common age of patients is 14 to 17 years old. A clinical protocol for patient post-operative pain management is used in 45% of institutions. Thoracic epidural is utilized as a primary analgesic modality by 91% of institutions. Concomitant use of intravenous patient-controlled analgesia is reported by 27% of institutions. Nine respondents (16%) reported that they had recently stopped performing epidurals because of surgeon preference. Referral of one or more patients annually for chronic pain management was reported in 22% of surveys. CONCLUSIONS Post-operative pain management following the Nuss procedure is variable and poorly characterized. Clinical trials or large observational registries comparing the safety and efficacy of primary modalities and long-term outcomes are needed to enable evidence-based decision-making for the management of these patients.
Collapse
Affiliation(s)
- W. T. MUHLY
- Department of Anesthesiology and Critical Care Medicine; The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA USA
| | - L. G. MAXWELL
- Department of Anesthesiology and Critical Care Medicine; The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA USA
| | - J. P. CRAVERO
- Department of Anesthesiology, Perioperative and Pain Medicine; Boston Children's Hospital, Harvard School of Medicine; Boston MA USA
| |
Collapse
|
40
|
Stroud AM, Tulanont DD, Coates TE, Goodney PP, Croitoru DP. Epidural analgesia versus intravenous patient-controlled analgesia following minimally invasive pectus excavatum repair: a systematic review and meta-analysis. J Pediatr Surg 2014; 49:798-806. [PMID: 24851774 PMCID: PMC5315444 DOI: 10.1016/j.jpedsurg.2014.02.072] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 02/13/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND/PURPOSE The minimally invasive pectus excavatum repair (MIPER) is a painful procedure. The ideal approach to postoperative analgesia is debated. We performed a systematic review and meta-analysis to assess the efficacy and safety of epidural analgesia compared to intravenous Patient Controlled Analgesia (PCA) following MIPER. METHODS We searched MEDLINE (1946-2012) and the Cochrane Library (inception-2012) for randomized controlled trials (RCT) and cohort studies comparing epidural analgesia to PCA for postoperative pain management in children following MIPER. We calculated weighted mean differences (WMD) for numeric pain scores and summarized secondary outcomes qualitatively. RESULTS Of 699 studies, 3 RCTs and 3 retrospective cohorts met inclusion criteria. Compared to PCA, mean pain scores were modestly lower with epidural immediately (WMD -1.04, 95% CI -2.11 to 0.03, p=0.06), 12 hours (WMD -1.12; 95% CI -1.61 to -0.62, p<0.001), 24 hours (WMD -0.51, 95%CI -1.05 to 0.02, p=0.06), and 48 hours (WMD -0.85, 95% CI -1.62 to -0.07, p=0.03) after surgery. We found no statistically significant differences between secondary outcomes. CONCLUSIONS Epidural analgesia may provide superior pain control but was comparable with PCA for secondary outcomes. Better designed studies are needed. Currently the analgesic technique should be based on patient preference and institutional resources.
Collapse
Affiliation(s)
- Andrea M Stroud
- The Dartmouth Institute of Health Policy & Clinical Practice, Geisel School of Medicine and Dartmouth Hitchcock Medical Center, Lebanon, NH 03756, USA.
| | - Darena D Tulanont
- The Dartmouth Institute of Health Policy & Clinical Practice, Geisel School of Medicine, Hanover, NH 03755, USA
| | - Thomasena E Coates
- The Dartmouth Institute of Health Policy & Clinical Practice, Geisel School of Medicine, Hanover, NH 03755, USA
| | - Philip P Goodney
- Section of Vascular Surgery, Department of Surgery, Geisel School of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH 03756, USA
| | - Daniel P Croitoru
- Section of Pediatric Surgery, Department of Surgery, Geisel School of Medicine, Children's Hospital at Dartmouth, Dartmouth Hitchcock Medical Center, Lebanon, NH 03756, USA
| |
Collapse
|
41
|
Perioperative strategies and technical modifications to the Nuss repair for pectus excavatum in pediatric patients: a large volume, single institution experience. J Pediatr Surg 2014; 49:575-82. [PMID: 24726116 DOI: 10.1016/j.jpedsurg.2013.11.058] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 10/19/2013] [Accepted: 11/17/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND The safety and efficacy of minimally invasive pectus excavatum repair have been demonstrated over the last twenty years. However, technical details and perioperative management strategies continue to be debated. The aim of the present study is to review a large single-institution experience with the modified Nuss procedure. METHODS A retrospective review was performed of patients who underwent primary pectus excavatum repair at a single tertiary hospital via a modified Nuss procedure that included: no thoracoscopy, retrosternal dissection achieved via a left-to-right thoracic approach, four-point stabilization of the bar, and no routine epidural analgesia. Data collected included demographics, preoperative symptoms, operative characteristics, hospital charges and postoperative outcomes. RESULTS A total of 336 pediatric patients were identified. No cardiac perforations occurred and the rate of pericarditis was 0.6%. Contemporary rates of bar displacement have fallen to 1.2%. Routine use of chlorhexidine scrub reduced superficial site infections to 0.7%. Two patients (0.6%) with severe recurrence required reoperation. Bars were removed after an average period of 31.7(SD 13.2) months, with satisfactory cosmetic and functional results in 94.9% of cases. CONCLUSIONS We report here a single-institution large volume experience, including modifications to the Nuss procedure that make the technique simpler and safer, improve results, and minimize hospital charges.
Collapse
|
42
|
Johnson WR, Fedor D, Singhal S. Systematic review of surgical treatment techniques for adult and pediatric patients with pectus excavatum. J Cardiothorac Surg 2014; 9:25. [PMID: 24506826 PMCID: PMC3922335 DOI: 10.1186/1749-8090-9-25] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Accepted: 02/04/2014] [Indexed: 11/16/2022] Open
Abstract
This compares outcome measures of current pectus excavatum (PEx) treatments, namely the Nuss and Ravitch procedures, in pediatric and adult patients. Original investigations that stratified PEx patients based on current treatment and age (pediatric=0-21; adult 17-99) were considered for inclusion. Outcome measures were: operation duration, analgesia duration, blood loss, length of stay (LOS), outcome ratings, complications, and percentage requiring reoperations. Adult implant patients (18.8%) had higher reoperation rates than adult Nuss or Ravitch patients (5.3% and 3.3% respectively). Adult Nuss patients had longer LOS (7.3 days), more strut/bar displacement (6.1%), and more epidural analgesia (3 days) than adult Ravitch patients (2.9 days, 0%, 0 days). Excluding pectus bar and strut displacements, pediatric and adult Nuss patients tended to have higher complication rates (pediatric - 38%; adult - 21%) compared to pediatric and adult Ravitch patients (12.5%; 8%). Pediatric Ravitch patients clearly had more strut displacements than adult Ravitch patients (0% and 6.4% respectively). These results suggest significantly better results in common PEx surgical repair techniques (i.e. Nuss and Ravitch) than uncommon techniques (i.e. Implants and Robicsek). The results suggest slightly better outcomes in pediatric Nuss procedure patients as compared with all other groups. We recommend that symptomatic pediatric patients with uncomplicated PEx receive the Nuss procedure. We suggest that adult patients receive the Nuss or Ravitch procedure, even though the long-term complication rates of the adult Nuss procedure require more investigation.
Collapse
Affiliation(s)
- William Rainey Johnson
- Department of Surgery, Thoracic Surgery Research Laboratory, Perelman School of Medicine, Philadelphia, PA, USA
| | - David Fedor
- Department of Surgery, Thoracic Surgery Research Laboratory, Perelman School of Medicine, Philadelphia, PA, USA
| | - Sunil Singhal
- Department of Surgery, Thoracic Surgery Research Laboratory, Perelman School of Medicine, Philadelphia, PA, USA
| |
Collapse
|
43
|
Complications related to the Nuss procedure: minimizing risk with operative technique. J Pediatr Surg 2013; 48:1044-8. [PMID: 23701780 DOI: 10.1016/j.jpedsurg.2013.02.025] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Accepted: 02/03/2013] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Pectus Excavatum (PEx) is the most frequent congenital chest wall deformity; surgical correction has a complication rate of 10%-50%. The purpose of this study was to evaluate outcomes in a recent cohort of pediatric patients from a single institution and investigate factors associated with complications. METHODS A review of all patients with PEx treated with a Nuss procedure from 2003 to 2011 was performed. Complications included hemo/pneumothorax, infection, bar migration, and operative injury. Chi-square, Student's t-test, and logistic regression were performed. RESULTS The study included 127 Nuss patients with a the median age of 15.2 years (5.4-18.7) and a mean Haller index of 4.2 (+1.6). The total complication rate was 26% and bar migration rate was 18%. The use of a stabilizer was associated with fewer overall complications (17% vs 41%,p=0.006), decreased reoperation (16% vs 41%,p=0.003), decreased readmission (15% vs 39%,p=0.004), and decreased bar migration rate (9% vs 36%,p=0.001) compared to patients without a stabilizer. On multivariate analysis, the use of a stabilizer (OR 0.18,p=0.011,95% CI 0.049-0.68) and the use of a pericostal suture (OR 0.19,p=0.03,95% CI 0.41-0.85) were associated with decreased rates of bar migration. CONCLUSION The use of a lateral stabilizer and pericostal sutures decreased complication and reoperation rates for the Nuss procedure.
Collapse
|
44
|
Ghionzoli M, Brandigi E, Messineo A, Messeri A. Pain and anxiety management in minimally invasive repair of pectus excavatum. Korean J Pain 2012; 25:267-71. [PMID: 23091689 PMCID: PMC3468805 DOI: 10.3344/kjp.2012.25.4.267] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 06/29/2012] [Accepted: 06/29/2012] [Indexed: 11/25/2022] Open
Abstract
The Nuss procedure for the correction of Pectus Excavatum (PE) is associated with intense postoperative pain. Our strategy to control early postoperative pain is to combine epidural with intravenous analgesia. Our aim was to analyse our pain control strategy by reviewing all the PE cases treated at our institution. Sixty consecutive patients, aged between 12 and 26 years old, received the PE operation at our institution from January, 2007 to September, 2010. The median age was 16 (12-27) with a male/female ratio of about 7/1. An epidural catheter was employed in all the cases, with 38 patients (63%) requiring additional drugs to control pain, which remained in place for 74 hours (72-96). The pain score was higher in male patients, but lower in those younger than 16 years old. Moreover, patients that consumed benzodiazepines had a significant decrease in cumulative opioid intake (P = 0.0408). Both gender and age had an impact on pain control, while we noticed a synergistic effect between opiates and tranquillizers.
Collapse
Affiliation(s)
- Marco Ghionzoli
- Department of Pediatric Surgery, Children's Hospital A. Meyer, Florence, Italy
| | | | | | | |
Collapse
|
45
|
Sohn VY, Zenger D, Steele SR. Pain Management in the Pediatric Surgical Patient. Surg Clin North Am 2012; 92:471-85, vii. [DOI: 10.1016/j.suc.2012.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
46
|
St Peter SD, Weesner KA, Weissend EE, Sharp SW, Valusek PA, Sharp RJ, Snyder CL, Holcomb GW, Ostlie DJ. Epidural vs patient-controlled analgesia for postoperative pain after pectus excavatum repair: a prospective, randomized trial. J Pediatr Surg 2012; 47:148-53. [PMID: 22244408 DOI: 10.1016/j.jpedsurg.2011.10.040] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 10/08/2011] [Indexed: 11/25/2022]
Abstract
PURPOSE Management of postoperative pain is a challenge after the minimally invasive repair of pectus excavatum. Pain is usually managed by either a thoracic epidural or patient-controlled analgesia with intravenous narcotics. We conducted a prospective, randomized trial to evaluate the relative merits of these 2 pain management strategies. METHODS After obtaining permission/assent (Institutional Review Board no. 06 08 128), patients were randomized to either epidural or patient-controlled analgesia with fixed protocols for each arm. The primary outcome variable was length of stay with a power of .8 and α of .05. RESULTS One hundred ten patients were enrolled. There was no difference in length of stay between the 2 arms. A longer operative time, more calls to anesthesia, and greater hospital charges were found in the epidural group. Pain scores favored epidural for the few days and favored patient-controlled analgesia thereafter. The epidural catheter could not be placed or was removed within 24 hours in 12 patients (22%). CONCLUSIONS There is longer operating room time, increase in calls to anesthesia, and greater hospital charges with epidural analgesia after repair of pectus excavatum. Pain scores favor the epidural approach early in the postoperative course and patient-controlled analgesia later.
Collapse
Affiliation(s)
- Shawn D St Peter
- Department of Surgery, The Children's Mercy Hospital, Kansas City, MO 64108, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|