Postoperative pain management in pediatric patients undergoing minimally invasive repair of pectus excavatum: the role of intercostal block

Bibliometric and Visual Analysis of the Current Status and Trends of Postoperative Pain in Children from 1950-2021

Background

Postoperative pain in children has been overlooked for a long time. The knowledge structure, research hotspots and trends related to postoperative pain in children are unclear and have not been systematically summarized.

Purpose

We aimed to analyze the current state of research on postoperative pain in children and to conduct in-depth mining of the knowledge structure.

Methods

The PubMed database for publications on postoperative pain in children between 1950 and 2021 was searched. Bibliographic Item Co-Occurrence Matrix Builder (BICOMB) was performed to obtain the co-word matrix and co-occurrence matrix. The H-index method was used to extract high-frequency main Medical Subject Headings (MeSH) terms/subheadings.

Results

The high-frequency MeSH terms were analyzed by biclustering, strategic diagram and social network analyses. Totally, 4022 publications were retrieved. The analysis showed that 60 countries or regions published relevant documents, with the United States publishing the most significant number of papers. Totally, 811 journals published relevant papers, with Pediatric Anesthesia ranking first. Moreover, we extracted 43 high-frequency main MeSH terms/subheadings and clustered them into five categories: overview, aetiology and epidemiology, pharmacotherapy, opioid administration and dosing, and prevention and control of postoperative pain in children.

Conclusion

Pharmacological treatments, pain prevention and control are the focus of research and are becoming increasingly mature. Opioid stewardship and regional anesthesia is the trend and focus of future research. Our study offers a better understanding of the current status and knowledge structure of postoperative pain in children and provides a reference for improving postoperative pain management in children in the future.

Intercostal nerve cryoanalgesia in the treatment of pain in patients operated on by the modified Nuss method with the BackOnFeet application-a new strategy to improve outcomes

INTRODUCTION

The surgical Nuss correction of the funnel chest deformity is a painful procedure without an established consensus of pain relief methods. High doses and long duration of opioids requirements impedes the ERAS protocol introduction. The aim of this study was to evaluate the effectiveness of intraoperative intercostal nerve cryolysis in terms of pain management in relation to the routinely used multimodal analgesia in Poland. We also assessed the impact of using the proprietary "BackOnFeet" application on the quality of life of patients after surgery in relation to the ERAS protocol.

METHODS

The prospective, single-centre, non-randomised, before-after pilot study was conducted. Inclusion criteria were: funnel-shaped chest deformity, age range 11-18 years, first chest wall operation, agreement for the cryolysis and regional analgesia, no history of chronic painkillers use. The results of the "control group" (multimodal analgesia with regional analgesia commonly performed in Poland) were assessed. The interdisciplinary perioperative protocol with the "BackOnFeet" application and intraoperative intercostal nerve cryoanalgesia were introduced to the "intervention group".

RESULTS

Eighteen children were treated with standard protocol typical for Polish management and matched to eighteen patients who received cryoanalgesia and the "BackOnFeet" application access "intervention group". We noticed lower NRS points in first 24 h (p = 0.0048), shortening of time of opioid use (p = 0.0002), hospitalisation time (p = 0,01), improved quality of postoperative rehabilitation (p < 0.0001) and quality of life (p < 0.0001) among the "intervention group".

CONCLUSIONS

Intraoperative intercostal nerves cryolysis performed during the minimally invasive Nuss correction of funnel deformation in combination with bilateral is more effective in terms of acute pain management in relation to the routinely used multimodal analgesia in Poland, allowing for the shortening of time of opioid use, hospitalisation time, improved quality of postoperative rehabilitation and enabled ERAS protocol introduction. The use of the proprietary "BackOnFeet" application has a positive effect on the quality of life of patients after surgery.

Intercostal nerve cryoablation is associated with lower hospital cost during minimally invasive Nuss procedure for pectus excavatum

Minimally invasive repair of pectus excavatum (Nuss procedure) is associated with significant pain, and efforts to control pain impact resource utilization. Bilateral thoracic intercostal nerve cryoablation has been proposed as a novel technique to improve post-operative pain control, though the impact on hospital cost is unknown.

METHODS

We conducted a retrospective study of patients undergoing a Nuss procedure from 2016 to 2019. Patients who received cryoablation were compared to those that received traditional pain control (patient-controlled analgesia or epidural). Outcome variables included postoperative opioid usage (milligram morphine equivalents, MME), length of stay (LOS), and hospital cost.

RESULTS

Thirty-five of 73 patients studied (48%) received intercostal nerve cryoablation. LOS (1.0 vs 4.0 days, p < 0.01) and total hospital cost ($21,924 versus $23,694, p = 0.04) were decreased in the cryoablation cohort, despite longer operative time (152 vs 74 min, p < 0.01). Cryoablation was associated with decreased opioid usage (15.0 versus 148.6 MME, p < 0.01) during the 24 h following surgery and this persisted over the entire postoperative period, including discharge opioid prescription (112.5 vs 300.0 MME, p < 0.01).

CONCLUSION

Bilateral intercostal nerve cryoablation is associated with decreased postoperative opioid usage and decreased resource utilization in pediatric patients undergoing a minimally invasive Nuss procedure for pectus excavatum.

LEVEL OF EVIDENCE

Retrospective comparative study, level III.

Cryoablation is associated with shorter length of stay and reduced opioid use in pectus excavatum repair

PURPOSE

The use of intercostal nerve cryoablation (INC) is becoming increasingly common in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate the use of INC compared to traditional use of thoracic epidural (TE).

METHODS

A retrospective review of 79 patients undergoing PE repair with either INC or TE from May 2009 to December 2019 was conducted. The operations were performed by four surgeons who worked together at four different hospitals and have the same standardized practice. The primary outcome measure was hospital length of stay (LOS). Secondary variables included surgical time, total operating room time, operating room time cost, total hospital cost, inpatient opioid use, long-term opioid use after discharge, and postoperative complications.

RESULTS

LOS decreased to 2.5 days in the INC group compared to 5 days in the TE group (p < 0.0001). Surgical time was increased in the INC group, but there was no difference in total OR time. The INC group experienced significantly lower hospital costs. Total hospital opioid administration was significantly lower in INC group, and there was a significant decrease in long-term opioid use in the INC group.

CONCLUSIONS

INC is a newer modality that decreases LOS, controls pain, and results in overall cost savings. We recommend that INC be included in the current practice for postoperative pain control in PE patients undergoing Nuss procedure.

Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion

IMPORTANCE

Opioids are frequently prescribed to children and adolescents after surgery. Prescription opioid misuse is associated with high-risk behavior in youth. Evidence-based guidelines for opioid prescribing practices in children are lacking.

OBJECTIVE

To assemble a multidisciplinary team of health care experts and leaders in opioid stewardship, review current literature regarding opioid use and risks unique to pediatric populations, and develop a broad framework for evidence-based opioid prescribing guidelines for children who require surgery.

EVIDENCE REVIEW

Reviews of relevant literature were performed including all English-language articles published from January 1, 1988, to February 28, 2019, found via searches of the PubMed (MEDLINE), CINAHL, Embase, and Cochrane databases. Pediatric was defined as children younger than 18 years. Animal and experimental studies, case reports, review articles, and editorials were excluded. Selected articles were graded using tools from the Oxford Centre for Evidence-based Medicine 2011 levels of evidence. The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument was applied throughout guideline creation. Consensus was determined using a modified Delphi technique.

FINDINGS

Overall, 14 574 articles were screened for inclusion, with 217 unique articles included for qualitative synthesis. Twenty guideline statements were generated from a 2-day in-person meeting and subsequently reviewed, edited, and endorsed externally by pediatric surgical specialists, the American Pediatric Surgery Association Board of Governors, the American Academy of Pediatrics Section on Surgery Executive Committee, and the American College of Surgeons Board of Regents. Review of the literature and guideline statements underscored 3 primary themes: (1) health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids, (2) nonopioid analgesic use should be optimized in the perioperative period, and (3) patient and family education regarding perioperative pain management and safe opioid use practices must occur both before and after surgery.

CONCLUSIONS AND RELEVANCE

These are the first opioid-prescribing guidelines to address the unique needs of children who require surgery. Health care professionals caring for children and adolescents in the perioperative period should optimize pain management and minimize risks associated with opioid use by engaging patients and families in opioid stewardship efforts.

Use of cryoanalgesia for pain management for the modified ravitch procedure in children

BACKGROUND

Intercostal cryoablation(IC) for pain management in children undergoing Nuss Procedure has been previously described. We evaluated postoperative outcomes following Modified Ravitch procedure for pectus disorders comparing IC to thoracic epidural(TE).

MATERIALS AND METHODS

Single-center retrospective review of pediatric patients (age < 21) undergoing Modified Ravitch procedure (January 2015-March 2019) with either IC(9), or TE(20) analgesia. Primary outcome was length of stay (LOS) and secondary outcomes were inpatient opioid use (in oral morphine equivalents per kilogram; OME/kg), pain scores on each postoperative day (POD), discharge prescriptions, and complications. Pairwise comparisons made with Mann-Whitney U test or Fisher Exact test as appropriate. Two-tailed p values <0.05 were considered significant.

RESULTS

Patient characteristics were similar. LOS was shorter with IC compared to TE (4 days versus 6; p < 0.006). Postoperative opioid use was not significantly different (IC: 1.5 OME/kg versus TE: 1.1; p = 0.10). There was improved pain control on POD 2 in patients who underwent IC (median pain score 3 versus 4; p < 0.0004). There was no difference in discharge prescription (IC: 3.3 OME/kg; TE: 4.8; p = 0.19) or complication rate (IC: 55.6%, TE:50%; p = 1.0).

CONCLUSIONS

IC during the Modified Ravitch reduced LOS compared to TE with improved pain control starting on POD 2, with similar narcotic utilization and complication rates.

LEVEL OF EVIDENCE

Treatment Study, Level III (Retrospective comparative study).

Analgesic Effectiveness of Perioperative Ultrasound-Guided Serratus Anterior Plane Block Combined with General Anesthesia in Patients Undergoing Video-Assisted Thoracoscopic Surgery: A Systematic Review and Meta-analysis

Objective

To investigate whether perioperative ultrasound-guided serratus anterior plane block (SAPB) combined with general anesthesia is more effective and safer than current analgesic techniques for postoperative analgesia after video-assisted thoracoscopic surgery (VATS).

Methods

PubMed, the Cochrane Library, and EMBASE were searched for clinical trials published up to July 31, 2019. Outcomes, including operative duration, postoperative pain scores, postoperative analgesia use, patient satisfaction with analgesia, time to chest tube removal, length of stay, and adverse effects were analyzed.

Results

Four clinical trials, including 262 patients, met inclusion criteria. Ultrasound-guided SAPB reduced pain scores at zero, 15, 30, 45, and 60 minutes in the postoperative anesthesia care unit (all P &lt; 0.05) and at one, two, six, 12, and 24 hours in the ward (all P &lt; 0.001). Additionally, postoperatively, morphine consumption at 15 and 30 minutes, overall morphine consumption, and total consumption (morphine plus tramadol) were significantly lower in the SAPB cohort (P  &lt; 0.05). Similarly, postoperative tramadol consumption at one, two, six, 12, and 24 hours was also lower in this cohort (all P  &lt; 0.05). The postoperative consumption of fentanyl, tramadol, and total morphine in patient-controlled analgesia (PCA) at 24 hours was significantly reduced (P &lt; 0.05). Moreover, SAPB provided better patient satisfaction with analgesia (P = 0.0038). However, no statistically significant difference was found in duration of operation, time to chest tube removal, length of stay, or side effects (all P &gt; 0.05).

Conclusions

Perioperative ultrasound-guided SAPB combined with general anesthesia provided more effective postoperative analgesia after VATS. However, no significant advantage was found regarding side effects.

First national survey on opioids prescribing practices of Canadian pediatric surgeons

PURPOSE

Prescription opioid misuse has become a public health concern globally. In Canada, little is known about the national prescription patterns in children. The purpose of the present study was to evaluate the opioid prescribing practices of pediatric surgeons in Canada.

METHODS

Following ethical approval, an electronic questionnaire was administered to all pediatric surgeons currently practicing in Canada. Questions included surgeon practice information, patterns of opioid prescription at discharge based on the type of surgery, type of opioid prescribed, and availability of training for surgeons/families.

RESULTS

Fifty-eight questionnaires were completed (response rate: 84%) by surgeons from 8 out of 8 Canadian provinces with pediatric surgery coverage. 33% of responders prescribed opioids (most commonly morphine) for day surgeries and 73% of Pediatric Surgeons prescribed opioids for major surgeries. Most responders (84%) declared that at their institution there was no formal training for residents/fellows in pain control and opioid prescribing. Similarly, 57% reported no education for families about opioids at discharge.

CONCLUSION

This first national survey on opioid prescribing practices across Canada reveals that opioids were prescribed to pediatric patients following a broad range of minor and major surgical procedures. Moreover, there seems to be a lack of education for surgeons and families about opioid use.

TYPE OF STUDY

Descriptive, cross-sectional, practice survey.

LEVEL OF EVIDENCE

Level 5.

Atrial septal defect closure via mini-thoracotomy in pediatric patients: Postoperative analgesic effect of intercostal nerve block

Background

In this study, we evaluated the efficacy of intercostal nerve block for postoperative pain management in pediatric patients undergoing atrial septal defect closure through a right lateral mini-thoracotomy.

Methods

Between January 2016 and January 2019, a total of 63 pediatric patients (37 males, 26 females; mean age 34.8±26.8 months; range, 2 to 96 months) who underwent corrective congenital heart surgery for atrial septal defect closure through a right lateral mini-thoracotomy were retrospectively reviewed. The patients were divided into two groups as those (Group 1, n=33) receiving intercostal nerve block and general anesthesia and those (Group 2, n=30) receiving general anesthesia alone. Intravenous morphine at a dose of 0.03 mg/kg was applied as rescue analgesia to the patients with a Ramsay Sedation Scale score of >4 and Children"s Hospital of Eastern Ontario Pain Scale score of >7. The total analgesic requirement, adverse effects, duration of mechanical ventilation and length of stay in the intensive care unit were recorded.

Results

The mean duration of mechanical ventilation and intensive care unit stay was shorter in Group 1 compared to Group 2 (3.6±1.3 vs. 9.4±2.1 h; 23±2.6 vs. 30±7.2 h, respectively) (p<0.0001). The need for postoperative rescue analgesia was statistically significantly lower in Group 1 compared to Group 2 (0.3±0.5 mg vs. 1.1±0.9 mg, respectively) (p=0.003). The mean total morphine consumption was also lower in Group 1 compared to Group 2 (4.0±2.2 mg vs. 9.0±3.4 mg, respectively) (p<0.0001).

Conclusion

Intercostal nerve block before thoracotomy closure in pediatric patients undergoing atrial septal defect repair under mini-thoracotomy provides early extubation, shorter mechanical ventilation duration and intensive care unit stay, and reduced analgesic requirements.

Short-term Outcomes After Pectus Excavatum Repair in Adults and Children

BACKGROUND

Pectus excavatum is a common congenital chest wall deformity often repaired during adolescence, although a subset of patients undergo repair as adults. The goal of our study was to determine the effects of age at repair and repair technique on short-term surgical outcomes.

MATERIALS AND METHODS

We performed a cohort study of patients in the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Project pediatric (age<18 y) and adult databases who underwent pectus excavatum repair. The primary outcome was the incidence of 30-d complications. Secondary outcomes included length of stay, reoperation, and readmission. Multivariable logistic regression was used to estimate the independent effects of patient age and type of repair on postoperative outcomes.

RESULTS

Of the 2268 subjects included, 2089 (92.1%) were younger than 18 y. Overall, 3.4% of patients suffered a 30-d complication, and the risk was similar between age groups (risk ratio [RR], 0.69; 95% confidence interval [CI], 0.08-5.03; P = 0.731). Steroid therapy was an independent risk factor for complications (RR, 8.0; 95% CI, 1.9-19.7; P = 0.006). Median length of stay was 4 d (interquartile range, 3-5) and was similar between age groups. Risk for readmission and reoperation were 2.8% and 1.5%, respectively, and were similar for pediatric and adult patients. When comparing minimally invasive repair with and without thoracoscopy, risk for 30-d complications was lower among patients repaired with thoracoscopy (RR, 0.56; CI, 0.32-0.96; P = 0.034).

CONCLUSIONS

Pediatric and adult patients experience comparable rates of postoperative complications, readmission, and reoperation after pectus excavatum repair. Use of thoracoscopy during minimally invasive repair is associated with lower risk of complications. These findings suggest that thoracoscopy should be used routinely for minimally invasive repair of pectus excavatum.

Ultrasound-Guided Serratus Anterior Plane Block for Pain Management Following Minimally Invasive Repair of Pectus Excavatum

OBJECTIVE

The Nuss procedure is a preferred technique for minimally invasive repair of pectus excavatum (MIRPE), but it is associated with significant postoperative pain. We assessed the efficacy and safety of an ultrasound-guided bilateral serratus anterior plane block (SAPB) for relieving acute pain from MIRPE.

DESIGN

A retrospective cohort study.

SETTING

This study was conducted at the Marmara University Pendik Training and Research Hospital, Turkey.

PARTICIPANTS

All participants were scheduled for MIRPE.

INTERVENTIONS

This study was conducted from November 2017 to May 2018. Postoperative pain control was achieved with bilateral SAPB done after induction of anesthesia and IV PCA in 50 patient (SABP group) and with only IV PCA in 45 patients (Control group). SAPB was achieved, targeting the interfascial plane between the serratus anterior and latissimus dorsi muscles, with a single injection of 30 mL (20 mL if patient weighed < 40 kg) of 0.25% bupivacaine and 0.5% lidocaine into each side. Pain scores were recorded for 24 h.

MEASUREMENT AND MAIN RESULTS

Patients in the Control group had a higher demand (mean difference, 61; 95% confidence interval [CI] 30.5-136; P < 0.0001) and delivery dose (mean difference, 25; 95% CI 15-41.5 P = 0.001) during the first postoperative 24 h. SAPB did not affect the median (interquartile range) length of hospital stay: 5 (5-7) days vs. 5 (4-6) days, (P =0.085).

CONCLUSIONS

Bilateral single-injection SAPB in patients undergoing MIRPE decreases pain and opioid consumption during the early postoperative period.

Progressive reduction of hospital length of stay following minimally invasive repair of pectus excavatum: A retrospective comparison of three analgesia modalities, the role of addressing patient anxiety, and reframing patient expectations

PURPOSE

Management of postoperative pain is a significant challenge following the Nuss procedure. Epidurals, PCAs, and newer analgesia modalities have been used elsewhere without demonstrating consistent improvement in the reported length of hospital stays (LOS). We reviewed a large single surgeon experience identifying three different methods of analgesia used over time to highlight marked improvement in patient LOS.

METHODS

IRB approval was obtained and patient clinical information was retrospectively reviewed from 2001 to 2017. The primary outcome variable was length of hospital stay. An expanded preoperative consultation reviews the issue of pain, the negative impact of anxiety on recovery, and our current success of shortened hospital stays with our patients.

RESULTS

One hundred and seventy-three patients representing three different analgesia approaches had a LOS of 4.4 days (epidural); 2.2 days (PCA/intercostal nerve block); and 1.6 days (scheduled oral pain meds/intercostal nerve blocks). The current LOS for patients is 1.0 day. Patients successfully stop using narcotics by the end of the first week postoperatively.

CONCLUSIONS

Intraoperative intercostal nerve blocks, scheduled postoperative pain medications, and enhanced preoperative consultation aimed to educate patients about anxiety and reframe patient pain expectations have collectively decreased LOS, and reduced postoperative narcotic usage.

TYPE OF STUDY

Clinical research LEVEL OF EVIDENCE: Level III.

Regional anesthesia to ameliorate postoperative analgesia outcomes in pediatric surgical patients: an updated systematic review of randomized controlled trials

Regional anesthesia is becoming increasingly popular among anesthesiologists in the management of postoperative analgesia following pediatric surgery. The main objective of this review was to systematically evaluate the last 5 years of randomized controlled trials on the role of regional anesthesia techniques in alleviating postoperative pain associated with various pediatric surgical procedures. Forty studies on 2,408 pediatric patients were evaluated. The majority of the articles published from 2013 to 2017 reported that the use of regional anesthesia minimized postoperative pain and reduced opioid consumption. Only a few surgical procedures (cholecystectomy, inguinal hernia repair, and non-laparoscopic major abdominal surgery) reported no significant difference in the postoperative pain relief compared with the standard anesthetic management. The growing number of randomized controlled trials in the pediatric literature is very promising; however, additional confirmation is needed to reinforce the use of specific regional anesthesia techniques to provide optimal postoperative pain relief for a few surgical procedures (reconstructive ear surgery, chest wall deformity, hypospadias, umbilical hernia, cleft palate repair) in pediatric patients. More randomized controlled trials are needed to establish regional anesthesia as an essential component of postoperative analgesia management in children.

Intercostal Nerve Blockade with Exparel® Results in Lower Opioid Usage during the First 24 Hours after Video-Assisted Thorascopic Surgery

Liposomal bupivacaine (LipoB) provides prolonged local anesthetic effects and has seen usage in several fields of surgery. We review our experience using LipoB intraoperatively for intercostal nerve blocks after video-assisted throacoscopic surgery (VATS). A retrospective, single-center review was conducted for patients undergoing VATS from August 2012 to December 2014. Patients those who received LipoB as an intercostal nerve block were compared with patients who received blocks with standard bupivacaine. Opiate amounts used within the first six hours and then subsequent 18,48, and 72 hours were converted into morphine equivalents for comparison. Forty-seven patients met inclusion criteria: 21 receiving LipoB intercostal nerve block and 26 controls. Groups were similar for age, diabetes, hypertension, chronic kidney disease, body mass index and American Society of Anesthesiologists scores. The LipoB group had a larger portion of males (P < 0.02). Postoperatively, morphine equivalent usage was significantly less in the LipoB group compared with the standard bupivacaine within the first six hours after surgery (15.62 vs 52.41, P = 0.001) and in the subsequent 18 hours (28.98 vs 65.17, P = 0.01). After the first 24 hours there was not a significant difference in opiate usage between the two groups. There was no difference in length of stay between the two groups. In our study group of VATS patients, an intercostal nerve block with LipoB significantly reduced the usage of postoperative opioids in the first 24 hours only when compared with standard bupivacaine.

Comparing outcomes with thoracic epidural and intercostal nerve cryoablation after Nuss procedure

BACKGROUND

This study aimed to evaluate postoperative outcomes after minimally invasive repair of pectus excavatum (Nuss procedure) using video-assisted intercostal nerve cryoablation (INC) compared to thoracic epidural (TE).

MATERIALS AND METHODS

We performed a single center retrospective review of pediatric patients who underwent Nuss procedure with INC (n = 19) or TE (n = 13) from April 2015 to August 2017. Preoperative, intraoperative, and postoperative characteristics were collected. The primary outcome was length of stay (LOS) and secondary outcomes were intravenous and oral opioid use, pain scores, and complications. Opioids were converted to oral morphine milligram equivalents per kilogram (oral morphine equivalent [OME]/kg). Mann-Whitney U test was used for continuous and chi-squared analysis for categorical variables.

RESULTS

There were no significant differences in patient characteristics, except Haller Index (INC: median [interquartile range] 4.3 [3.6-4.9]; TE: 3.2 [2.8-4.0]; P = 0.03). LOS was shorter with INC (INC: 3 [3-4] days; TE: 6 [5-7] days; P < 0.001). Opioid use was higher intraoperatively (INC: 1.08 [0.87-1.37] OME/kg; TE: 0.46 [0.37-0.67] OME/kg; P = 0.002) and unchanged postoperatively (INC: 1.78 [1.26-3.77] OME/kg; TE: 1.82 [1.05-3.37] OME/kg; P = 0.80), and prescription doses were lower at discharge in INC (INC: 30 [30-40] doses; TE: 42 [40-60] doses; P = 0.005). There was no significant difference in postoperative complications (INC: 42.1%; TE: 53.9%; P = 0.51).

CONCLUSIONS

INC during Nuss procedure reduced LOS, shifting postoperative opioid use earlier during admission. This may reflect the need for improved early pain control until INC takes effect. Prospective evaluation after INC is needed to characterize long-term pain medication requirements.

Cryoanalgesia in Patients Undergoing Nuss Repair of Pectus Excavatum: Technique Modification and Early Results

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.

Comparison of Ultrasonography-guided Bilateral Intercostal Nerve Blocks and Conventional Patient-controlled Intravenous Analgesia for Pain Control After the Nuss Procedure in Children: A Prospective Randomized Study

Objectives:

Patients experience severe pain after pectus excavatum (PE) surgery. The aim of this prospective, randomized study was to compare analgesic effects of ultrasonography-guided bilateral intercostal nerve blocks (UG-ICNBs) with those of conventional patient-controlled intravenous analgesia (PCIA) on acute pain after the Nuss procedure for PE repair in children.

Methods:

A prospective randomized study was performed in children with PE who were scheduled for the Nuss procedure. Participants were randomly assigned to receive either UG-ICNBs or PCIA for postoperative analgesia. Faces Pain Scale-Revised scores, opioid consumption, analgesia-associated side effects (respiratory depression, pruritus, nausea, vomiting) during the first 24 hours, and lengths of stay in the postanesthesia care unit (PACU) and hospital were recorded after the surgery.

Results:

Sixty-two children undergoing the Nuss procedure were enrolled in the trial. Faces Pain Scale-Revised scores were significantly decreased in the UG-ICNBs group compared with the PCIA group for up to 6 hours after surgery. The opioid doses required in the PACU and during the first 24 hours after surgery were significantly greater in the PCIA group compared with the UG-ICNBs group. Accordingly, patients in the UG-ICNBs group showed a lower incidence of analgesia-associated side effects and faster PACU discharge compared with the PCIA group.

Conclusions:

Our study suggests that UG-ICNBs might be more effective than PCIA for postoperative analgesia in children who undergo the Nuss procedure for PE.

Subcutaneous local anesthetic infusion could eliminate use of epidural analgesia after the Nuss procedure

AIM

To compare outcomes of continuous subcutaneous infusion of local anesthetic and epidural analgesia following the Nuss procedure.

PATIENTS & METHODS

A retrospective chart review compared patients managed with subcutaneous local anesthetic infusion (n = 12) versus thoracic epidural (n = 19) following the Nuss procedure from March 2013 to June 2015.

RESULTS

There was no difference in hospital length of stay or days on intravenous narcotics. Epidural catheter placement prolonged operating room time (146.58 ± 28.30 vs 121.42 ± 21.98 min, p = 0.01). Average pain scores were slightly higher in the subcutaneous infusion group (3.72 ± 1.62 vs 2.35 ± 0.95, p = 0.02), but of negligible clinical significance.

CONCLUSION

Continuous subcutaneous infusion of local anesthetic could eliminate the need for thoracic epidural for pain management after the Nuss procedure.

A retrospective comparison of thoracic epidural infusion and multimodal analgesia protocol for pain management following the minimally invasive repair of pectus excavatum

BACKGROUND

Pain management following minimally invasive repair of pectus excavatum is variable. We recently adopted a comprehensive multimodal analgesic protocol that standardizes perioperative analgesic management. We hypothesized that patients managed with this protocol would use more opioids postoperatively, have similar pain control, and shorter length of stay compared to patients managed with thoracic epidural infusion.

AIMS

We retrospectively compared opioid consumption, pain scores, and length of stay between a cohort of patients managed with our multimodal analgesic protocol and a cohort managed with a thoracic epidural infusion.

METHODS

This retrospective cohort comparison includes patients, 8 to 21 years of age, managed with either thoracic epidural infusion (n = 21) or multimodal analgesic protocol (n = 29) following minimally invasive repair of pectus excavatum from January 1, 2011 through September 15, 2015. The primary outcome, total daily opioid consumption in morphine equivalents, is presented as an average by postoperative day. Secondary outcomes included median daily pain score and length of stay.

RESULTS

Patients were similar in age, weight, sex, and physical status. Patients managed with thoracic epidural infusion received less opioid (morphine equivalents-mg/kg) intraoperatively compared to multimodal analgesic protocol (difference of mean [95% confidence interval] 0.22 [0.16-0.28] P ≤ .01) but required more total opioid through postoperative day 3 (difference of mean [95% confidence interval] 1.2 [0.26-2.14] P = .01). We did not observe a difference in pain scores. Median length of stay was 1 day less in patients managed with multimodal analgesic protocol (difference of median [95% confidence interval] 1 [0.3-1.7] P = .003).

CONCLUSION

Implementation of a standardized comprehensive multimodal analgesic protocol following minimally invasive repair of pectus excavatum resulted in equivalent analgesia with a modest reduction in length of stay when compared to thoracic epidural. We did not observe an opioid sparing effect in our thoracic epidural which may reflect technique variability.

Surgical site infection related to use of elastomeric pumps in pectus excavatum repair. Lessons learned from root cause analysis

BACKGROUND

Pectus excavatum repair (PEX) is among the most painful thoracic procedures performed. Continuous peripheral nerve blockade (CPNB) is known to be efficacious in optimizing pain control while limiting narcotic use in adult thoracic procedures. It was introduced in May 2015 as a bridge to oral pain control in children undergoing PEX. Consequently, the surgical site infection (SSI) rate increased from 2.7% to 27.7%.

METHODS

SSI surveillance followed national guidelines. The abrupt increase prompted root cause analysis and cessation of CPNB use. A dynamic systems model of SSI in PEX was developed. Statistical analysis compared SSI outcomes with and without CPNB.

RESULTS

From May 2015 to June 2015, 21 PEX were performed; 11 with CPNB. 6 SSIs were observed. Use of CPNB significantly (p=0.008) increased SSI incidence. Haller index, number of bars, usage of Fiberwire®, methicillin resistant S. aureus colonization and length of stay did not differ. Root cause analysis revealed the proximity of CPNB catheters to the wound, the use of CPNB with implanted hardware and a delayed utilization of CPNB catheters to be of concern.

CONCLUSION

Introduction of CPNB coincided with a significant increase in SSI. Further study is needed to assess the safety of CPNB in pediatric PEX.

LEVEL OF EVIDENCE

Level III treatment study.

Introduction of a novel ultrasound-guided extrathoracic sub-paraspinal block for control of perioperative pain in Nuss procedure patients

BACKGROUND

A safe and effective method of multilevel thoracic pain control remains an elusive goal in patients undergoing the Nuss procedure. The aim of our study was to develop a nonopioid centered approach using a novel regional technique as part of a quality improvement initiative.

METHODS

The proposed ultrasound-guided technique positions multi-perforated soaker catheter deep to the paraspinal muscles from T2 to T11. The project was conducted in two phases. First, a cadaveric dissection was performed to establish the pathway of spread of local anesthetic in vivo. Second, a pilot double blind randomized control project was conducted to evaluate effectiveness of the technique in ten patients and to derive parameters necessary for the definitive future study. Outcomes were evaluated based on the narcotic requirement, pain scores and functional measures.

RESULTS

Placement of the catheters in two cadavers demonstrated reliable positioning in the subparaspinal tissue plane, and multilevel dye spread along the intercostal nerve path. In addition, a potential route of spread toward the paravertebral space along the canal accommodating dorsal ramus of the thoracic nerve was demonstrated. The pilot trial demonstrated a trend in decreased cumulative hydromorphone requirement in comparison to the control group at both 24h (0.19±0.09mg/kg vs. 0.13±0.08mg/kg p=0.72) and 48h (0.37±0.2mg/kg vs. 0.3±0.12mg/kg p=0.37). Functional performance ability was higher in the treatment group on both POD#1 (6.7±1.8 vs. 4.8±1 p=0.0495) and POD#2 (8.9±0.8 vs. 6.5±1.2 p=0.04). Pain scores were similar among the two groups (p=0.96).

CONCLUSIONS

We describe a new technique to treat multilevel thoracic pain following the Nuss procedure that is reproducible, safe, allows diminished opioid use and enhances functional recovery.

Intercostal nerve cryoablation versus thoracic epidural catheters for postoperative analgesia following pectus excavatum repair: Preliminary outcomes in twenty-six cryoablation patients

BACKGROUND

Multimodal pain management strategies are used for analgesia following pectus excavatum repair. However, the optimal regimen has not been identified. We describe our early experience with intercostal cryoablation for pain management in children undergoing the Nuss procedure and compare early cryoablation outcomes to our prior outcomes using thoracic epidural analgesia.

METHODS

A multi-institutional, retrospective review of fifty-two patients undergoing Nuss bar placement with either intercostal cryoablation (n=26) or thoracic epidural analgesia (n=26) from March 2013 to January 2016 was conducted. The primary outcome was hospital length of stay. Secondary outcomes included telemetry unit monitoring time, total intravenous narcotic use, duration of intravenous narcotic use, and postoperative complications.

RESULTS

Patients who underwent intercostal cryoablation had a significant reduction in the mean hospital length of stay, time in a monitored telemetry bed, total use of intravenous narcotics, and the duration of intravenous narcotic administration when compared to thoracic epidural patients. Cryoablation patients had a slightly higher rate of postoperative complications.

CONCLUSION

Intercostal cryoablation is a promising technique for postoperative pain management in children undergoing repair of pectus excavatum. This therapy results in reduced time to hospital discharge, decreased intravenous narcotic utilization, and has eliminated epidurals from our practice.

LEVEL OF EVIDENCE

Retrospective study - level III.

A review of anesthetic techniques and outcomes following minimally invasive repair of pectus excavatum (Nuss procedure)

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.

Anaesthetic considerations for pectus repair surgery

Repair of pectus is one of the most common congenital abnormality for which patient presents for thoracic surgery. In recent years, innovative minimally invasive techniques involving video assisted thoracoscopy for pectus repair have become the norm. Similarly, anaesthetic techniques have evolved to include principles of enhanced recovery, multimodal analgesia and innovative ultrasound guided neuraxial and nerve blocks. Adequate anaesthetic set up and monitoring including the use of real time intraoperative monitoring with transesophageal echocardiography (TOE) has enabled the anaesthetist to enhance patient safety by providing instantaneous imaging of cardiac compression and complications during surgery. In this review article we aim to provide non-systematic review and institutional experience of our anaesthetic strategy to provide effective peri-operative care in this patient group.

Endogenous opiates and behavior: 2014

This paper is the thirty-seventh consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2014 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (endogenous opioids and receptors), and the roles of these opioid peptides and receptors in pain and analgesia (pain and analgesia); stress and social status (human studies); tolerance and dependence (opioid mediation of other analgesic responses); learning and memory (stress and social status); eating and drinking (stress-induced analgesia); alcohol and drugs of abuse (emotional responses in opioid-mediated behaviors); sexual activity and hormones, pregnancy, development and endocrinology (opioid involvement in stress response regulation); mental illness and mood (tolerance and dependence); seizures and neurologic disorders (learning and memory); electrical-related activity and neurophysiology (opiates and conditioned place preferences (CPP)); general activity and locomotion (eating and drinking); gastrointestinal, renal and hepatic functions (alcohol and drugs of abuse); cardiovascular responses (opiates and ethanol); respiration and thermoregulation (opiates and THC); and immunological responses (opiates and stimulants). This paper is the thirty-seventh consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2014 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (endogenous opioids and receptors), and the roles of these opioid peptides and receptors in pain and analgesia (pain and analgesia); stress and social status (human studies); tolerance and dependence (opioid mediation of other analgesic responses); learning and memory (stress and social status); eating and drinking (stress-induced analgesia); alcohol and drugs of abuse (emotional responses in opioid-mediated behaviors); sexual activity and hormones, pregnancy, development and endocrinology (opioid involvement in stress response regulation); mental illness and mood (tolerance and dependence); seizures and neurologic disorders (learning and memory); electrical-related activity and neurophysiology (opiates and conditioned place preferences (CPP)); general activity and locomotion (eating and drinking); gastrointestinal, renal and hepatic functions (alcohol and drugs of abuse); cardiovascular responses (opiates and ethanol); respiration and thermoregulation (opiates and THC); and immunological responses (opiates and stimulants).

Paravertebral regional blocks decrease length of stay following surgery for pectus excavatum in children

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.

A novel modified Nuss procedure for pectus excavatum: a new steel bar

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.

Single shot intercostal block for pain management in pediatric patients undergoing the Nuss procedure: a double-blind, randomized, controlled study

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.