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Glenski TA, Taylor CM, Weisberg EL, Doyle NM, Melanson A. The implementation of a pectus bar insertion enhanced recovery after surgery pathway: A quality improvement initiative. Paediatr Anaesth 2024; 34:422-429. [PMID: 38217340 DOI: 10.1111/pan.14838] [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: 09/29/2023] [Revised: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 01/15/2024]
Abstract
BACKGROUND Pectus excavatum repair is associated with significant discomfort, and pain is a primary contributor to postoperative hospital length of stay. Recent advances in postoperative pain control include the use of intercostal cryoablation techniques that may now make it possible to discharge patients on the day of surgery. Unnecessary variation in patient care and noncompliance with care bundles may be a factor in extended length of stay. The global aim of this quality improvement initiative was to successfully implement an enhanced recovery after surgery (ERAS) pathway on patients undergoing pectus excavatum repair. The SMART aim was to have a greater than 70% compliance for the perioperative bundle elements within 1 year of the pathway implementation. METHODS Multiple Plan-Do-Study-Act (PDSA) cycles were designed to create and implement an ERAS pathway for patients undergoing a pectus bar insertion procedure. This multidisciplinary pathway was designed, managed, and implemented with key stakeholders from the Departments of Evidence Based Practice, Surgery, Anesthesiology, and Perioperative Nursing. Patient characteristics, outcomes, and compliance with elements of the pathway were measured for analysis for both the baseline and post-intervention groups with monthly automated reports. RESULTS After implementation of the ERAS pathway, data on the first 50 patients showed a 90% compliance with the perioperative bundle elements. Mean length of stay was significantly decreased from 33 h (95% CI [28.76, 37.31]) to 18 h (95% CI [14.54, 21.70]). There were zero readmissions within 24 hours for patients who were discharged on the day of surgery. CONCLUSION Employing a multidisciplinary approach in both planning and execution that standardized clinician practices and minimized unnecessary variation in patient care, an ERAS pathway for pectus bar insertion has been successfully established at our institution.
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Affiliation(s)
- Todd A Glenski
- Department of Anesthesiology, Department of Evidence Based Practice, Children's Mercy Kansas City, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Christian M Taylor
- Department of Anesthesiology, Children's Mercy Kansas City, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Emily L Weisberg
- Department of Anesthesiology, Children's Mercy Kansas City, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Nichole M Doyle
- Department of Anesthesiology, Children's Mercy Kansas City, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Andrea Melanson
- Department of Evidence Based Practice, Children's Mercy Kansas City, Kansas City, Missouri, USA
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King H, Morell AA, Luther E, Mendez Valdez MJ, Hernandez M, Makhoul V, Shah AH, Eichberg DE, Lu VM, Kader M, Patel N, Higgins D, Komotar RJ, Ivan ME. Evaluating Predictors of Successful Postoperative Day 1 Discharge Following Posterior Fossa Tumor Resection. World Neurosurg 2023; 179:e102-e109. [PMID: 37574194 DOI: 10.1016/j.wneu.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Current trends in surgical neuro-oncology show that early discharges are safe and feasible with shorter lengths of stay (LOS) and fewer thromboembolic complications, fewer hospital-acquired infections, reduced costs, and greater patient satisfaction. Traditionally, infratentorial tumor resections have been associated with longer LOS and limited data exist evaluating predictors of early discharge in these patients. The objective was to assess patients undergoing posterior fossa craniotomies for tumor resection and identify variables associated with postoperative day 1 (POD1) discharge. METHODS A retrospective review of posterior fossa craniotomies for tumor resection at our institution was performed from 2011 to 2020. Laser ablations, nontumoral pathologies, and biopsies were excluded. Demographic, clinical, surgical, and postoperative data were collected. RESULTS One hundred and seventy-three patients were identified and 25 (14.5%) were discharged on POD1. Median length of stay (LOS) was 6 days. The POD1 discharges had significantly better preoperative Karnofsky performance scores (P < 0.001) and modified Rankin scores (P = 0.002) and more frequently presented electively (P = 0.006) and without preoperative neurologic deficits (P = 0.021). No statistically significant difference in 30-day readmissions and rates of PE, UTI, and DVT was found. Univariate logistic regression identified better preoperative functional status, elective admission, and lack of preoperative hydrocephalus as predictors of POD1 discharge, however only the latter remained significant in the multivariable model (P = 0.001). CONCLUSIONS Discharging patients on POD1 is feasible following posterior fossa tumor resection in a select group of patients. Although we found that the only independent predictor for a longer LOS was preoperative hydrocephalus, larger, prospective studies are needed to confirm these findings.
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Affiliation(s)
- Hunter King
- Department of Neurosurgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Alexis A Morell
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Evan Luther
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Mynor J Mendez Valdez
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
| | - Melissa Hernandez
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Vivien Makhoul
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ashish H Shah
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Daniel E Eichberg
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Victor M Lu
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Michael Kader
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Nitesh Patel
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Dominique Higgins
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ricardo J Komotar
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA; Sylvester Cancer Center, University of Miami Health System, Miami, Florida, USA
| | - Michael E Ivan
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA; Sylvester Cancer Center, University of Miami Health System, Miami, Florida, USA
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Lai K, Eldredge RS, Zobel M, Hargis-Villanueva A, Ostlie A, Padilla BE. Intercostal Nerve Cryoablation for Postoperative Pain Control in Pediatric Thoracic Surgery: A Scoping Review. J Laparoendosc Adv Surg Tech A 2023; 33:994-1004. [PMID: 37462727 DOI: 10.1089/lap.2023.0070] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
Background: Cryoanalgesia uses the application of cold temperatures to temporarily disrupt peripheral sensory nerve function for pain control. This review outlines the principles of cryoablation, clinical applications, and clinical data for its use in pediatric thoracic surgery. Methods: A comprehensive PubMed search was performed using the principal terms and combinations of cryoablation, cryoanalgesia, Nuss, Nuss repair, pectus, pectus excavatum, thoracic surgery, thoracotomy, and chest wall. Pediatric articles were reviewed and included if relevant. Adult articles were reviewed for supporting information as needed. Reference lists of included articles were reviewed for possible additional sources. Discussion: The scientific and clinical principles of cryoablation are outlined, followed by a focused review of current clinical application and outcome data. Conclusion: Postoperative pain is a major challenge following thoracic surgery. Cryoanalgesia is emerging as an adjunct in pediatric thoracic surgery, particularly for the Nuss procedure or minimally invasive repair of pectus excavatum. It effectively controls pain, decreasing postoperative opioid use and hospital length of stay with few short-term complications. Although more long-term studies are needed, early evidence suggests there is reliable return of sensation to the chest wall and long-term neuropathic pain is rare.
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Affiliation(s)
- Krista Lai
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - R Scott Eldredge
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Michael Zobel
- Division of Pediatric Surgery, University of California San Francisco, San Francisco, USA
| | | | - Andrew Ostlie
- Department of Child Health, University of Arizona School of Medicine, Tucson, Arizona, USA
| | - Benjamin E Padilla
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
- Department of Child Health, University of Arizona School of Medicine, Tucson, Arizona, USA
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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.
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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.
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Abbasi RK, Cossu AE, Tanner B, Castelluccio P, Hamilton M, Brown J, Herrmann J. Liposomal bupivacaine reduces opioid requirements following Ravitch repair for pectus excavatum. J Anaesthesiol Clin Pharmacol 2023; 39:392-396. [PMID: 38025581 PMCID: PMC10661631 DOI: 10.4103/joacp.joacp_336_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 12/23/2021] [Accepted: 01/09/2022] [Indexed: 12/01/2023] Open
Abstract
Background and Aims The management of post-operative pain after surgical repair of pectus excavatum with the Ravitch procedure is challenging. Although previous studies have compared various methods of pain control in these patients, few have compared different local anesthetics. This retrospective analysis compares the use of bupivacaine to its longer-acting form, liposomal bupivacaine, in patients who had undergone pectus excavatum repair with the Ravitch method. Material and Methods Eleven patients who received local infiltration with liposomal bupivacaine were matched to 11 patients who received local infiltration utilizing bupivacaine with epinephrine. The primary outcome was total morphine milligram equivalents per kilogram body weight (MME/kg) over the complete length of hospital stay. Secondary outcomes included total cumulative diazepam, acetaminophen, ondansetron, and NSAID dose per kilogram body weight (mg/kg) over the course of the hospital stay, chest tube drainage (ml/kg body weight), number of post-operative hours until the first bowel movement, Haller Index, patient request for magnesium hydroxide, average pain scores from post-operative day 1 to post-operative day 5, and length of hospital stay. Continuous variables were reported as medians with inter-quartile ranges, and categorical values were reported as percentages and frequencies. Results The total MME/kg [1.7 (1.2-2.4) vs 2.9 (2.0-3.9), P = 0.007] and hydromorphone (mg/kg) [0.1 (0.0-0.2) vs 0.3 (0.1-0.4), P = 0.006] use in the liposomal bupivacaine group versus bupivacaine with epinephrine was significantly reduced over total length of hospital stay. Similarly, there was a reduction in diazepam use in the liposomal bupivacaine group versus the bupivacaine group [0.4 (0.1-0.8) vs 0.6 (0.4-0.7), P = 0.249], but this did not reach statistical significance. The total dose of ondansetron (mg/kg) was not statistically different when comparing the liposomal bupivacaine group to the bupivacaine group [0.3 (0.0-0.5) vs 0.3 (0.2-0.6), P = 0.332]. Interestingly, the total dose of acetaminophen (mg/kg) was statistically increased in the liposomal bupivacaine group compared to the bupivacaine with epinephrine group [172 (138-183) vs 74 (55-111), P = 0.007]. Additionally, the total chest tube drainage (ml/kg) was significantly reduced in the liposomal bupivacaine group [9.3 (7.5-10.6) vs 12.8 (11.3-18.5), P = 0.027]. Finally, the percentage of patients without requests for magnesium hydroxide to promote laxation was significantly higher in the liposomal bupivacaine group than in the bupivacaine group (63.6% vs 18.2%, P = 0.027). Conclusion The use of liposomal bupivacaine for local infiltration in patients who undergo the Ravitch procedure for pectus repair offers advantages over plain bupivacaine, including reduced opioid consumption and opioid-related side effects. However, more data are needed to understand the significance of these findings.
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Affiliation(s)
- Rania K. Abbasi
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Anne E. Cossu
- Department of Anesthesia, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Brandon Tanner
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Peter Castelluccio
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Matthew Hamilton
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John Brown
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeremy Herrmann
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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Fiorelli S, Menna C, Andreetti C, Peritore V, Rocco M, De Blasi RA, Rendina EA, Massullo D, Ibrahim M. Bilateral Ultrasound-Guided Erector Spinae Plane Block for Pectus Excavatum Surgery: A Retrospective Propensity-Score Study. J Cardiothorac Vasc Anesth 2022; 36:4327-4332. [PMID: 36163156 DOI: 10.1053/j.jvca.2022.08.018] [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: 04/07/2022] [Revised: 08/17/2022] [Accepted: 08/22/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Pectus excavatum (PE) repair is burdened by severe postoperative pain. This retrospective study aimed to determine whether the analgesic effect of ultrasound-guided erector spinae plane block (ESPB) plus standard intravenous analgesia (SIVA) might be superior to SIVA alone in pain control after PE surgical repair via Ravitch or Nuss technique. DESIGN A retrospective cohort study. SETTING At a university hospital. PARTICIPANTS All participants were scheduled for surgical repair of PE. INTERVENTIONS From January 2017 to December 2019, all patients who received ESPB plus SIVA or SIVA alone were investigated retrospectively. A 2:1 propensity-score matching analysis considering preoperative variables was used to compare analgesia efficacy in 2 groups. All patients received a 24-hour continuous infusion of tramadol, 0.1 mg/kg/h, and ketorolac, 0.05 mg/kg/h, via elastomeric pump, and morphine, 2 mg, intravenously as a rescue drug. The ESPB group received preoperative bilateral ESPB block. Postoperative pain, reported using a numerical rating scale at 1, 12, 24, and 48 hours after surgery; the number of required rescue doses; total postoperative morphine milligram equivalents consumption; and the incidence of postoperative nausea and vomit were analyzed. MEASUREMENT AND MAIN RESULTS A total of 105 patients were identified for analysis. Propensity-score matching resulted in 38 patients in the SIVA group and 19 patients in the ESPB group. Postoperative pain, the number of rescue doses, and postoperative nausea and vomit incidences were lower in the ESPB group (p < 0.005). CONCLUSIONS Erector spinae plane block may be an effective option for pain management after surgical repair of PE as part of a multimodal approach. This study showed good perioperative analgesia, opioid sparing, and reduced opioid-related adverse effects.
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Affiliation(s)
- Silvia Fiorelli
- Anesthesia and Intensive Care Medicine, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.
| | - Cecilia Menna
- Thoracic Surgery, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Claudio Andreetti
- Thoracic Surgery, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Valentina Peritore
- Thoracic Surgery, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Monica Rocco
- Anesthesia and Intensive Care Medicine, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Roberto Alberto De Blasi
- Anesthesia and Intensive Care Medicine, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Erino Angelo Rendina
- Thoracic Surgery, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Domenico Massullo
- Anesthesia and Intensive Care Medicine, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Mohsen Ibrahim
- Thoracic Surgery, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
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Fenikowski D, Tomaszek L. Intravenous Morphine Infusion versus Thoracic Epidural Infusion of Ropivacaine with Fentanyl after the Ravitch Procedure-A Single-Center Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11291. [PMID: 36141560 PMCID: PMC9517208 DOI: 10.3390/ijerph191811291] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To compare the efficacy of analgesia with intravenous infusion of morphine and thoracic epidural infusion of ropivacaine with fentanyl in pediatric patients after the Ravitch procedure. METHODS Postoperative analgesia was achieved by intravenous morphine infusion with a dose of 0.02-0.06 mg/kg per hour (intravenous group, n = 56) or thoracic epidural infusion of 0.2% ropivacaine and fentanyl 5 µg/mL with a flow rate of 0.1 mL/kg per hour (epidural group, n = 40). Furthermore, the multimodal pain management protocol included paracetamol, non-steroidal anti-inflammatory drugs, and metamizole as a rescue drug. The primary outcomes included pain scores (according to the Numerical Rating Scale, range 0-10), while the secondary outcomes included consumption of the rescue drug, anxiety, postoperative side effects, and patient satisfaction. The observation period lasted from postoperative day 0 to postoperative day 3. RESULTS Median average and maximal pain scores at rest, during deep breathing, and coughing were significantly lower in the intravenous group compared to the epidural group (p < 0.05). The effect size was medium (Cohen's d ranged from 0.5 to 0.7). Patients receiving morphine required significantly lower numbers of metamizole doses than in the epidural group (median 1 vs. 3; p = 0.003; Cohen's d = 0.6). Anxiety, postoperative side effects, and patient satisfaction were similar in both groups (p > 0.05). CONCLUSIONS An intravenous infusion of morphine may offer better postoperative analgesia than a thoracic epidural infusion of ropivacaine with fentanyl.
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Affiliation(s)
- Dariusz Fenikowski
- Department of Thoracic Surgery, Institute of Tuberculosis and Lung Diseases, Rabka-Zdrój Branch, 34-700 Rabka-Zdrój, Poland
| | - Lucyna Tomaszek
- Department of Thoracic Surgery, Institute of Tuberculosis and Lung Diseases, Rabka-Zdrój Branch, 34-700 Rabka-Zdrój, Poland
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Kraków, Poland
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Rettig RL, Yang CJ, Ashfaq A, Sydorak RM. Cryoablation is associated with shorter length-of-stay and reduced opioid use after the Ravitch procedure. J Pediatr Surg 2022; 57:1258-1263. [PMID: 35379492 DOI: 10.1016/j.jpedsurg.2022.02.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE The use of intercostal nerve cryoablation (INC) is becoming increasingly common in patients undergoing pectus repair. This study sought to evaluate the use of INC compared to traditional use of thoracic epidural (TE) in patients undergoing the modified Ravitch procedure. METHODS A retrospective review of 37 patients undergoing the modified Ravitch repair with either INC or TE from March 2009 to July 2021 was conducted. The operations were performed by four surgeons who worked together at four different hospitals and have the same standardized practice. The primary outcome measure was hospital length of stay (LOS). Secondary variables included surgical time, total operating room time, operating room time cost, total hospital cost, inpatient opioid use, long term opioid use after discharge, and post-operative complications. RESULTS LOS decreased to 2.8 days in the INC group compared to 6 days in the TE group (p<0.0001). Surgical time and total OR time was increased in the INC group. The INC group experienced significantly lower hospital costs (p<0.01). Total hospital opioid administration was significantly lower in INC group, and there was a significant decrease in long term opioid use in the INC group (p<0.0001). CONCLUSIONS INC is a newer modality that decreases LOS, controls pain, and results in overall cost savings for patients undergoing the modified Ravitch procedure. We recommend that INC be included in the current practice for postoperative pain control in pectus disorder patients undergoing the modified Ravitch procedure.
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Affiliation(s)
- R Luke Rettig
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles, CA, 90027, USA
| | - Claire J Yang
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles, CA, 90027, USA
| | - Adeel Ashfaq
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles, CA, 90027, USA
| | - Roman M Sydorak
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles, CA, 90027, USA.
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9
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Mohan SC, Siegel E, Tran H, Ozcan L, Alban R, Shariff S, Mirocha J, Chung A, Giuliano A, Dang C, Anand K, Shane R, Amersi F. Effects of paravertebral blocks versus liposomal bupivacaine on hospital utilization after mastectomy with reconstruction. Am J Surg 2022; 224:938-942. [DOI: 10.1016/j.amjsurg.2022.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 04/13/2022] [Accepted: 04/19/2022] [Indexed: 11/25/2022]
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10
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Ultrasound-guided erector spinae plane block versus thoracic epidural analgesia: Postoperative pain management after Nuss repair for pectus excavatum. J Pediatr Surg 2022; 57:207-212. [PMID: 34949445 DOI: 10.1016/j.jpedsurg.2021.10.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 10/23/2021] [Indexed: 01/22/2023]
Abstract
AIM OF THE STUDY Postoperative pain management is a significant challenge in patients undergoing Nuss repair for pectus excavatum chest wall deformity. Therapeutic anesthetic options primarily include patient-controlled intravenous analgesia, thoracic epidural analgesia (TEA), and cryoanalgesia. However, TEA is limited to inpatient use and both TEA and cryoanalgesia can result in neurologic injury. The novel technique of ultrasound-guided erector spinae plane regional analgesia has been used recently in our patients undergoing the Nuss repair and has shown impressive pain relief, but without the potential complications of other modalities. Erector spinae plane block (ESPB) postoperative pain management outcomes were studied as compared to TEA. METHODS Thirty consecutive patients with severe pectus excavatum undergoing Nuss repair and placement of ultrasound-guided ESPB were each paired to a historical cohort control patient with TEA postoperative pain management. The cohort patient match was defined by age (± 2 years), gender, and CT pectus index (± 15%). Study variables included hospital length of stay (LOS), pain scores, and pain medication usage. RESULTS Pain scores as measured by area under the curve per hour (Day 1: 2.72 (SD = 1.37) vs. 3.90 (SD = 1.81), P = 0.006; Day 2: 2.83 (SD = 1.32) vs. 3.97 (SD = 1.82), P = 0.007) and oral morphine equivalent (OME) pain medication usage (Day 1: 11.9 (SD = 4.9) vs 56.0 (SD = 32.2), P < 0.001; Day 2: 14.7 (SD = 7.1) vs. 38.0 (SD = 21.7), P < 0.001) were higher for the first two postoperative days in the ESPB group. However, mean hospital LOS was nearly one day shorter for ESPB patients (3.78 (SD = 0.82) vs. 2.90 (SD = 0.87), P < 0.001) who were discharged home with the catheter in place until removal, typically at 5-7 days postoperatively. CONCLUSION Ultrasound-guided ESPB is thus a feasible, safe, and effective alternative to TEA in postoperative pain management after Nuss repair and results in decreased hospital stay. LEVEL OF EVIDENCE III.
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11
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Rettig RL, Rudikoff AG, Annie Lo HY, Lee CW, Vazquez WD, Rodriguez K, Shaul DB, Conte AH, Banzali FM, Sydorak RM. Same-day discharge following the Nuss repair: A comparison. J Pediatr Surg 2022; 57:135-140. [PMID: 34670678 DOI: 10.1016/j.jpedsurg.2021.09.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/08/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Intercostal Nerve Cryoablation (INC) has significantly improved pain control following the Nuss repair of pectus excavatum (PE). This study sought to evaluate patients undergoing the Nuss repair with INC compared to the Nuss repair with an ERAS protocol, INC, and intercostal nerve blocks (INB). METHODS In June 2020, a new protocol was implemented involving surgery, anesthesia, nursing, physical therapy, and child life with the goal of safe same day discharge for patients undergoing the Nuss repair. They were compared to a control group who underwent the Nuss repair with INC alone in 2017-2019. The primary outcome measure was hospital length of stay (LOS) in hours, secondary outcomes were number of patients discharged on postoperative day (POD) 0, and returns to the emergency department (ED), urgent care (UC), and operating room (OR). RESULTS The characteristics between the groups were the same (Table 1). The mean LOS was 11.8 h in the INB group versus 58.2 h in the INC group, p < 0.01. 10 of 15 patients in the INB group went home on POD 0 (average of 5.5 h postop), versus 0 patients in the INC only group, p < 0.01. Five patients in the INB stayed overnight. Two patients stayed owing to anxiety, one owing to urinary retention, one owing to nausea, and one owing to drowsiness. None stayed for pain control. Four patients in the INC group returned to the ED for pain control, versus 0 in the INB group, and 1 patient in the INB returned to UC for constipation. CONCLUSIONS The majority of patients undergoing the Nuss repair of PE with a multidisciplinary regimen of pre and postoperative nursing education, precise intraoperative anesthesia care, performance of direct vision INB and INC, as well as careful surgery can go home on the day of surgery without adverse outcomes or unanticipated returns to the hospital. LEVEL-OF-EVIDENCE Level II.
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Affiliation(s)
- R Luke Rettig
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA
| | - Andrew G Rudikoff
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles, CA 90027 USA
| | - Hoi Yee Annie Lo
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA
| | - Constance W Lee
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA
| | - Walter D Vazquez
- Department of Pediatric Surgery, Kaiser Permanente San Diego Medical Center, 9455 Clairemont Mesa Blvd, San Diego, CA 92123 USA
| | - Karen Rodriguez
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA
| | - Donald B Shaul
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA
| | - Antonio Hernandez Conte
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles, CA 90027 USA
| | - Franklin M Banzali
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles, CA 90027 USA
| | - Roman M Sydorak
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA.
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Thoracic epidural-based Enhanced Recovery After Surgery (ERAS) pathway for Nuss repair of pectus excavatum shortened length of stay and decreased rescue intravenous opiate use. Pediatr Surg Int 2021; 37:1191-1199. [PMID: 34089071 DOI: 10.1007/s00383-021-04934-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND PCA- and block-based enhanced recovery after surgery (ERAS) pathways have been shown to decrease hospital length of stay (HLOS) and opiate use following Nuss Repair for Pectus Excavatum (NRPE). No thoracic epidural-based ERAS pathway has demonstrated similar benefits. METHODS In this pre-post single-center study, data were retrospectively collected for patients ≤ 21 years undergoing NRPE from May 2015 to August 2019. Univariate and multivariate methods were used to evaluate whether implementation of a thoracic epidural-based ERAS in April 2017 was associated with HLOS, opiate use, or pain scores. RESULTS There were 110 patients: 35 pre- and 75 post-ERAS. HLOS decreased from median 4.8 (1.1) to 3.3 (0.6) days with ERAS (p < 0.001). Use of rescue intravenous opiates decreased from 35.3% pre- to 9.3% with ERAS (p = 0.013). When adjusted for baseline characteristics, ERAS was associated with a 1.3 ± 0.2 day decrease in HLOS and 0.188 times the odds of rescue intravenous opiate use (p = 0.011). CONCLUSIONS Pain scores, ED visits, and readmissions did not change with ERAS (p > 0.05). Implementation of a thoracic epidural-based ERAS following NRPE was associated with decreased HLOS and need for any rescue intravenous opiates without a change in pain scores, ED visits, or readmission.
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13
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Rettig RL, Rudikoff AG, Lo HYA, Shaul DB, Banzali FM, Conte AH, Sydorak RM. Cryoablation is associated with shorter length of stay and reduced opioid use in pectus excavatum repair. Pediatr Surg Int 2021; 37:67-75. [PMID: 33210165 DOI: 10.1007/s00383-020-04778-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/04/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The use of intercostal nerve cryoablation (INC) is becoming increasingly common in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate the use of INC compared to traditional use of thoracic epidural (TE). METHODS A retrospective review of 79 patients undergoing PE repair with either INC or TE from May 2009 to December 2019 was conducted. The operations were performed by four surgeons who worked together at four different hospitals and have the same standardized practice. The primary outcome measure was hospital length of stay (LOS). Secondary variables included surgical time, total operating room time, operating room time cost, total hospital cost, inpatient opioid use, long-term opioid use after discharge, and postoperative complications. RESULTS LOS decreased to 2.5 days in the INC group compared to 5 days in the TE group (p < 0.0001). Surgical time was increased in the INC group, but there was no difference in total OR time. The INC group experienced significantly lower hospital costs. Total hospital opioid administration was significantly lower in INC group, and there was a significant decrease in long-term opioid use in the INC group. CONCLUSIONS INC is a newer modality that decreases LOS, controls pain, and results in overall cost savings. We recommend that INC be included in the current practice for postoperative pain control in PE patients undergoing Nuss procedure.
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Affiliation(s)
- R Luke Rettig
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Andrew G Rudikoff
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Hoi Yee Annie Lo
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Donald B Shaul
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Franklin M Banzali
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Antonio Hernandez Conte
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Roman M Sydorak
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA. .,Kaiser Permanente Los Angeles Medical Center, 4760 Sunset Blvd, 3rd Floor, Los Angeles, CA, 90027, USA.
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Xie J, Mooney DP, Cravero J. Comparison of regional analgesia techniques for pleurodesis pain in pediatric patients. Paediatr Anaesth 2020; 30:1102-1108. [PMID: 32780896 DOI: 10.1111/pan.13996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/28/2020] [Accepted: 08/07/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mechanical pleurodesis can prevent recurrence of spontaneous pneumothorax but is associated with significant postoperative pain. Adequate pain control is not only beneficial for patient comfort but also critical for mobilization and pulmonary recovery. Thoracic epidural catheters and paravertebral blocks have been used to alleviate pain after thoracoscopic surgery. However, no studies have evaluated the safety and efficacy of paravertebral block vs epidural analgesia vs no block in children undergoing pleurodesis. METHODS In this retrospective case series review, data were extracted from a single institution's integrated patient outcome database on children who underwent thoracoscopic pleurodesis from 2013 to 2018. Demographics, operative indication, procedure performed, and perioperative pain management were assessed by chart review. Patients whose operation was converted to thoracotomy, who had an underlying diagnosis of chronic pain, or who underwent pleurodesis for other indications were excluded. The primary outcomes were postoperative pain scores and opioid consumption. Secondary outcomes included psot anesthesia care unit length of stay, hospital length of stay, functional outcomes during recovery, and any adverse events. RESULTS 66 patients met inclusion criteria: 23 received thoracic epidurals, 34 received paravertebral blocks, and 9 received no epidural/paravertebral block. Patient characteristics did not significantly differ among groups. Although mean pain scores were statistically significantly lower in the epidural group on post-op day 1, all three groups' pain scores were in the 1 to 3 out of 10 range during the entire postoperative period. Thus, this statistical significance had little clinical significance as all groups had good pain control. The epidural group had significantly lower opioid consumption on post-op days 0 - 2 compared to paravertebral block. No adverse events related to epidural or paravertebral block were noted. DISCUSSION We present the an analysis of epidural vs paravertebral block (with comparison to no regional analgesia) following pleurodesis in children. Pain is well managed, regardless of the method; however, additional systemic opioid consumption was decreased in the epidural analgesia cohort. Prospective trials and comparisons with other analgesic techniques for pediatric thoracic surgeries are needed. CONCLUSIONS Thoracic epidural analgesia offers a reduction in opioid use in the first two post-op days after pleurodesis but did not produce a clinically significant reduction in pain scores in comparison with paravertebral block or no block.
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Affiliation(s)
- James Xie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard School of Medicine, Boston, MA, USA
| | - David P Mooney
- Department of Surgery, Boston Children's Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Joseph Cravero
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard School of Medicine, Boston, MA, USA
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15
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The impact of an enhanced recovery perioperative pathway for pediatric pectus deformity repair. Pediatr Surg Int 2020; 36:1035-1045. [PMID: 32696123 DOI: 10.1007/s00383-020-04695-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE Pediatric repair of chest wall deformities is associated with significant pain, morbidity, and resource utilization. We sought to determine outcomes of a perioperative enhanced recovery after surgery (ERAS) pathway for patients undergoing minimally invasive (Nuss) and traditional (Ravitch) corrective procedures. METHODS Our ERAS protocol was implemented in 2015. We performed a retrospective review of patients for Nuss or Ravitch procedures before and after ERAS implementation. Combined and procedure segregated bivariate analyses were conducted on postoperative outcomes and resource utilization. RESULTS There are 17 patients in the pre-intervention group (Nuss = 13 and Ravitch = 4) compared to 38 patients in the post-intervention group (Nuss = 28 and Ravitch = 10). Protocol implementation increased utilization of pre-operative non-narcotic medication. The combined and Nuss post-intervention groups had a significant decrease in epidural duration and time to enteral medications, but had increased total postoperative opioid usage. The Ravitch post-intervention group had a significant decrease in intra-operative narcotics and discharge pain scores. There were no differences in length of stay or complications. CONCLUSION Implementation of our ERAS protocol standardized pectus perioperative care, but did not improve postoperative opioid usage, complications, or resource utilization. Alterations in the protocol may lead to achieving desired goals of better pain management and decreased resource utilization.
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16
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Pilkington M, Harbaugh CM, Hirschl RB, Geiger JD, Gadepalli SK. Use of cryoanalgesia for pain management for the modified ravitch procedure in children. J Pediatr Surg 2020; 55:1381-1384. [PMID: 31672412 DOI: 10.1016/j.jpedsurg.2019.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 08/31/2019] [Accepted: 09/12/2019] [Indexed: 10/25/2022]
Abstract
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).
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Affiliation(s)
- Mercedes Pilkington
- Pediatric Surgery Section, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Calista M Harbaugh
- Department of Surgery, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Ronald B Hirschl
- Pediatric Surgery Section, University of Michigan, Ann Arbor, MI, 48109, USA
| | - James D Geiger
- Pediatric Surgery Section, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Samir K Gadepalli
- Pediatric Surgery Section, University of Michigan, Ann Arbor, MI, 48109, USA.
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Archer V, Robinson T, Kattail D, Fitzgerald P, Walton JM. Postoperative pain control following minimally invasive correction of pectus excavatum in pediatric patients: A systematic review. J Pediatr Surg 2020; 55:805-810. [PMID: 32081359 DOI: 10.1016/j.jpedsurg.2020.01.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 01/25/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE Surgery for pectus excavatum is associated with significant postoperative pain. The aim of this study was to summarize the current literature regarding postoperative pain control for pediatric patients undergoing minimally invasive repair of pectus excavatum (MIRPE). METHODS A systematic search of Medline, Embase, PubMed, CINAHL, Web of Science, and the Cochrane Library for randomized controlled trials (RCT) comparing methods of pain control in pediatric patients undergoing MIRPE was conducted. Studies were restricted to the English language. RESULTS After screening 1304 references, 9 randomized control trials (RCTs) enrolling 485 patients were included. The average age was 11.9 years (±3.1). Pain scores were decreased with ropivacaine compared to bupivacaine-based epidurals. In studies comparing ketamine to opioid based patient-controlled anesthesia (PCA) pumps, the results were variable. Intercostal and paravertebral nerve blocks had decreased pain scores in 75% of the studies compared to opioid-based PCA. Opioid consumption was decreased in 50% of the trials assessing ketamine-based infusions and 75% of the studies comparing intercostal and paravertebral nerve blocks. Nausea was decreased in several of the ketamine-based infusion and intercostal and paravertebral nerve block studies. CONCLUSION Ketamine-including infusions or paravertebral and intercostal nerve blocks may represent superior methods of postoperative pain control for MIRPE. Further work is needed to confirm results. LEVEL OF EVIDENCE 2A [1].
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Affiliation(s)
- Victoria Archer
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Tessa Robinson
- Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, Hamilton, Ontario, Canada
| | - Deepa Kattail
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada; McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Peter Fitzgerald
- Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, Hamilton, Ontario, Canada; McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - J Mark Walton
- Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, Hamilton, Ontario, Canada; McMaster Children's Hospital, Hamilton, Ontario, Canada.
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Patino M, Chandrakantan A. Midgestational Fetal Procedures. CASE STUDIES IN PEDIATRIC ANESTHESIA 2019:197-201. [DOI: 10.1017/9781108668736.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Aydin G, Sahin AT, Gencay I, Akcabay ZN, Gunal N, Dural K, Ozpolat B, Buyukkocak U. Which Is More Effective for Minimally Invasive Pectus Repair: Epidural or Paravertebral Block? J Laparoendosc Adv Surg Tech A 2019; 30:81-86. [PMID: 31742471 DOI: 10.1089/lap.2019.0403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: The aim of this study was to compare the effectiveness of epidural block (EDB) and paravertebral block (PVB) for minimally invasive pectus repair with the conventional method in terms of pain control during and after pectus operations, patient comfort, and length of stay in hospital. Materials and Methods: A retrospective review was made of patients who underwent minimally invasive pectus repair. The patients were allocated into three groups as follows: PVB group (Pre-emptive ultrasound-guided bilateral thoracic single injection PVB, n = 15); EDB group (Pre-emptive landmark-guided single injection thoracic EDB, n = 8); and Control group (Neither PVB nor EPB, n = 9). The intraoperative analgesic requirement was recorded, and a visual analog scale (VAS) for pain evaluation and the Postoperative Patient Satisfaction Scale were applied to all patients. Results: The intraoperative analgesic requirement, VAS scores, postoperative satisfaction level, and time to first requirement for postoperative analgesia were different between the control and PVB groups (P < .001) and between the control and EDB groups (P < .001), but not different between the PVB and EDB groups. Although the length of stay in hospital was shorter in the PVB and EDB groups compared to the control group, the difference was not statistically significant (P = .422). Conclusion: Epidural and bilateral paravertebral blockades performed in conjunction with general anesthesia decrease the intraoperative and postoperative need for analgesics, and might be beneficial for pain management and contribute to a shorter length of hospital stay for patients undergoing minimally invasive pectus repair operations. Both blockades also significantly improved the patient satisfaction.
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Affiliation(s)
- Gulcin Aydin
- Department of Anesthesiology and Reanimation, Kırıkkale University School of Medicine, Kirikkale, Turkey
| | - Ahmet Tugrul Sahin
- Department of Anesthesiology and Reanimation, Kırıkkale University School of Medicine, Kirikkale, Turkey
| | - Isin Gencay
- Department of Anesthesiology and Reanimation, Kırıkkale University School of Medicine, Kirikkale, Turkey
| | - Zeynep Nur Akcabay
- Department of Anesthesiology and Reanimation, Kırıkkale University School of Medicine, Kirikkale, Turkey
| | - Nesimi Gunal
- Department of Thoracic Surgery, Kırıkkale University School of Medicine, Kirikkale, Turkey
| | - Koray Dural
- Department of Thoracic Surgery, Kırıkkale University School of Medicine, Kirikkale, Turkey
| | - Berkant Ozpolat
- Department of Thoracic Surgery, Kırıkkale University School of Medicine, Kirikkale, Turkey
| | - Unase Buyukkocak
- Department of Anesthesiology and Reanimation, Yüksek İhtisas University School of Medicine, Ankara, Turkey
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20
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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: 100] [Impact Index Per Article: 20.0] [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.
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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)
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21
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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
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22
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Tore Altun G, Arslantas MK, Corman Dincer P, Aykac ZZ. Ultrasound-Guided Serratus Anterior Plane Block for Pain Management Following Minimally Invasive Repair of Pectus Excavatum. J Cardiothorac Vasc Anesth 2019; 33:2487-2491. [PMID: 31097336 DOI: 10.1053/j.jvca.2019.03.063] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/25/2019] [Accepted: 03/29/2019] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Gulbin Tore Altun
- Department of Anesthesiology and Reanimation, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Kemal Arslantas
- Department of Anesthesiology and Reanimation, School of Medicine, Marmara University, Istanbul, Turkey.
| | - Pelin Corman Dincer
- Department of Anesthesiology and Reanimation, School of Medicine, Marmara University, Istanbul, Turkey
| | - Zeynep Zuhal Aykac
- Department of Anesthesiology and Reanimation, School of Medicine, Marmara University, Istanbul, Turkey
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Greaney D, Everett T. Paediatric regional anaesthesia: updates in central neuraxial techniques and thoracic and abdominal blocks. BJA Educ 2019; 19:126-134. [PMID: 33456881 DOI: 10.1016/j.bjae.2018.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2018] [Indexed: 10/27/2022] Open
Affiliation(s)
- D Greaney
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - T Everett
- The Hospital for Sick Children, Toronto, Ontario, Canada
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24
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Schlatter MG, Nguyen LV, Tecos M, Kalbfell EL, Gonzalez-Vega O, Vlahu T. 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. J Pediatr Surg 2019; 54:663-669. [PMID: 30686518 DOI: 10.1016/j.jpedsurg.2018.12.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 12/03/2018] [Accepted: 12/03/2018] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Marc G Schlatter
- Helen DeVos Children's Hospital/Spectrum Health/Michigan State University Department of Surgery, Grand Rapids, Michigan.
| | - Long V Nguyen
- Helen DeVos Children's Hospital/Spectrum Health/Michigan State University Department of Surgery, Grand Rapids, Michigan
| | - Maria Tecos
- Helen DeVos Children's Hospital/Spectrum Health/Michigan State University Department of Surgery, Grand Rapids, Michigan
| | - Elle L Kalbfell
- Helen DeVos Children's Hospital/Spectrum Health/Michigan State University Department of Surgery, Grand Rapids, Michigan
| | - Omar Gonzalez-Vega
- Helen DeVos Children's Hospital/Spectrum Health/Michigan State University Department of Surgery, Grand Rapids, Michigan
| | - Tedi Vlahu
- Helen DeVos Children's Hospital/Spectrum Health/Michigan State University Department of Surgery, Grand Rapids, Michigan
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25
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Richardson AM, McCarthy DJ, Sandhu J, Mayrand R, Guerrero C, Rosenberg C, Gernsback JE, Komotar R, Ivan M. Predictors of Successful Discharge of Patients on Postoperative Day 1 After Craniotomy for Brain Tumor. World Neurosurg 2019; 126:e869-e877. [PMID: 30862575 DOI: 10.1016/j.wneu.2019.03.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 02/28/2019] [Accepted: 03/01/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Shorter hospital stays have been associated with decreased complication rates, fewer hospital-acquired infections, and lower costs. We evaluated an optimized treatment paradigm for patients undergoing craniotomy allowing for postoperative day 1 (POD1) discharge if the criteria were met. We compared the complication and readmission rates between the POD1 patients and those with longer stays, and examined the patient and surgical variables for predictors of POD1 discharge. METHODS We performed a retrospective review of craniotomies performed for tumor from 2011 to 2015. Craniotomies for tumors were included, and laser ablations and biopsies were excluded. RESULTS A total 424 of patients were included, 132 (31%) of whom had been discharged on POD1. The mean length of stay was 6 days. The POD1 patients had had significantly better preoperative Karnofsky performance scale scores (P < 0.0001) and modified Rankin scale scores (P < 0.0001). Patient frailty, measured using the modified frailty index, was negatively predictive of POD1 discharge (P = 0.0183). Surgical factors predictive of early discharge were awake surgery (P < 0.0001) and supratentorial location (P < 0.0001). No POD1 patients experienced deep venous thrombosis (DVT), pulmonary embolus (PE), or urinary tract infections. However, of the patients with a length of stay >1 day, 4.4% and 2.7% developed DVT or PE (P = 0.0119) and urinary tract infections (P = 0.0202), respectively. Multivariate regression identified patient factors (male gender, low preoperative modified Rankin scale score), tumor factors (right-sided, supratentorial, smaller size), lower modified frailty index score, and operative factors (lack of a cerebrospinal fluid drain, awake surgery) as independent predictors of successful early discharge. CONCLUSIONS Patients with good functional status can be safely discharged on POD1 after tumor craniotomy if the appropriate postoperative criteria have been met. Patients with early discharge had lower 30-day readmission and DVT/PE rates, likely owing to better baseline health status.
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Affiliation(s)
- Angela M Richardson
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - David J McCarthy
- Miller School of Medicine, University of Miami, Miami, Florida, USA.
| | | | - Roxanne Mayrand
- Department of Neuroscience, University of Miami, Miami, Florida, USA
| | | | - Cathy Rosenberg
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Joanna E Gernsback
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Ricardo Komotar
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Michael Ivan
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
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26
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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]
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27
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Nardiello MA, Herlitz M. Bilateral single shot erector spinae plane block for pectus excavatum and pectus carinatum surgery in 2 pediatric patients. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2018; 65:530-533. [PMID: 29866441 DOI: 10.1016/j.redar.2018.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/08/2018] [Accepted: 04/11/2018] [Indexed: 06/08/2023]
Abstract
Numerous publications have emerged on the application of erector spinae plane block in adult population. There are few reports of the use of this block in pediatric patients. The objective is to report 2 cases of adolescents, one diagnosed with pectus excavatum and the other one with pectus carinatum undergoing reconstructive surgery in which a bilateral single-shot erector spinae plane block was performed as an analgesic technique. The block was performed before surgery under general anesthesia in lateral decubitus position, guided by ultrasound using 20ml of 0.25% bupivacaine per side. After the surgery they were extubated and transferred to the Intensive Care Unit. During their postoperative period they had visual analogic scale values less than 4 and no long term narcotics were used during the intraoperative and postoperative period. Bilateral single shot erector spinae plane block was effective as an analgesic technique for the intraoperative and postoperative period in pectus excavatum and pectus carinatum surgery in adolescents.
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Affiliation(s)
- M A Nardiello
- Departamento de Cirugía, Hospital Regional Guillermo Grant Benavente, Universidad de Concepción, Concepción, Chile.
| | - M Herlitz
- Departamento de Cirugía, Hospital Regional Guillermo Grant Benavente, Universidad de Concepción, Concepción, Chile
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28
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Wildemeersch D, D'Hondt M, Bernaerts L, Mertens P, Saldien V, Hendriks JM, Walcarius AS, Sterkens L, Hans GH. Implementation of an Enhanced Recovery Pathway for Minimally Invasive Pectus Surgery: A Population-Based Cohort Study Evaluating Short- and Long-Term Outcomes Using eHealth Technology. JMIR Perioper Med 2018; 1:e10996. [PMID: 33401363 PMCID: PMC7709887 DOI: 10.2196/10996] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/20/2018] [Accepted: 08/10/2018] [Indexed: 01/26/2023] Open
Abstract
Background Pectus excavatum and pectus carinatum are the most common chest wall deformities. Although minimally invasive correction (minimally invasive repair of pectus, MIRP) has become common practice, it remains associated with severe postoperative pain. Preoperative psychosocial factors such as anxiety and low self-esteem can increase postsurgical pain. Early detection of psychological symptoms, effective biopsychosocial perioperative management of patients, and prevention of pain chronification using an enhanced recovery pathway (ERP) may improve outcomes. However, the incidence of the latter is poorly described in adolescents undergoing MIRP. Objective The objective of our study was to evaluate the implementation of an ERP containing early recovery goals and to assess persistent postsurgical pain 3 months postoperatively in pediatric patients undergoing MIRP. The ERP consists of a Web-based platform containing psychological screening questionnaires and extensive telemonitoring for follow-up of patients at home. Methods A population-based cohort study was conducted with prospectively collected data from patients undergoing pectus surgery between June 2017 and December 2017. An ERP was initiated preoperatively; it included patient education, electronic health-based psychological screening, multimodal pre-emptive analgesia, nausea prophylaxis as well as early Foley catheter removal and respiratory exercises. After hospital discharge, patients were followed up to 10 weeks using a Web-based diary evaluating pain and sleep quality, while their rehabilitation progress was monitored via Bluetooth-connected telemonitoring devices. Results We enrolled 29 adolescents using the developed ERP. Pre-emptive multimodal analgesia pain rating scores were low at hospital admission. Optimal epidural placement, defined by T8-9 or T9-10, occurred in 90% (26/29) of the participants; thus, no motor block or Horner syndrome occurred. Mean bladder catheterization duration was 3.41 (SD 1.50) days in ERP patients. Numeric rating scale (NRS) scores for pain and the incidence of nausea were low, contributing to a fluent rehabilitation. Mean NRS scores were 2.58 (SD 1.77) on postoperative day (POD) 1, 2.48 (SD 1.66) on POD 2, and 3.14 (SD 1.98) on POD 3 in ERP-treated patients. Telemonitoring at home was feasible in adolescents after hospital discharge despite adherence difficulties. Although the pain scores at the final interview were low (0.81 [SD 1.33]), 33% (9/27) long-term follow-up ERP patients still experienced frequent disturbing thoracic pain, requiring analgesic administration, school absenteeism, and multiple doctor (re)visits. Conclusions Allocating patients to the appropriate level of care preoperatively and immediately postoperatively may improve long-term outcome variables. Internet-based technologies and feasible, objective monitoring tools can help clinicians screen surgical patients for risk factors and initiate early treatment when indicated. Future research should focus on improving risk stratification and include a psychological assessment and evaluation of the effect of perioperative care pathways in children undergoing major surgery. Trial Registration ClinicalTrials.gov NCT03100669; https://clinicaltrials.gov/ct2/show/NCT03100669 (Archived by WebCite at http://www.webcitation.org/72qLB1ADX)
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Affiliation(s)
- Davina Wildemeersch
- Department of Anesthesiology, Antwerp University Hospital, Edegem, Belgium.,Multidisciplinary Pain Center, Antwerp University Hospital, Edegem, Belgium.,Laboratory for Pain Research, University of Antwerp, Wilrijk, Belgium
| | - Michiel D'Hondt
- Department of Anesthesiology, Antwerp University Hospital, Edegem, Belgium
| | - Lisa Bernaerts
- Division of Psychology, Multidisciplinary Pain Center, Antwerp University Hospital, Edegem, Belgium
| | - Pieter Mertens
- Department of Anesthesiology, Antwerp University Hospital, Edegem, Belgium
| | - Vera Saldien
- Department of Anesthesiology, Antwerp University Hospital, Edegem, Belgium
| | - Jeroen Mh Hendriks
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Anne-Sophie Walcarius
- Department of Physical Medicine and Rehabilitation, Antwerp University Hospital, Edegem, Belgium
| | - Lutgard Sterkens
- Department of Physical Medicine and Rehabilitation, Antwerp University Hospital, Edegem, Belgium
| | - Guy H Hans
- Multidisciplinary Pain Center, Antwerp University Hospital, Edegem, Belgium.,Laboratory for Pain Research, University of Antwerp, Wilrijk, Belgium
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29
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Author's Reply: Early Consequences of Pectus Excavatum Surgery on Self-Esteem and General Quality of Life. World J Surg 2018; 43:965. [PMID: 30155639 DOI: 10.1007/s00268-018-4779-3] [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]
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30
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Harbaugh CM, Johnson KN, Kein CE, Jarboe MD, Hirschl RB, Geiger JD, Gadepalli SK. Comparing outcomes with thoracic epidural and intercostal nerve cryoablation after Nuss procedure. J Surg Res 2018; 231:217-223. [PMID: 30278932 DOI: 10.1016/j.jss.2018.05.048] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/18/2018] [Accepted: 05/24/2018] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Calista M Harbaugh
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Kevin N Johnson
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan
| | - Courtney E Kein
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Marcus D Jarboe
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ronald B Hirschl
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan
| | - James D Geiger
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan
| | - Samir K Gadepalli
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan
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31
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Darling C, Chao S, Ramamurthi R, Tsui B. Letter to the Editor: Early Consequences of Pectus Excavatum Surgery on Self-Esteem and General Quality of Life. World J Surg 2018; 43:963-964. [PMID: 29882100 DOI: 10.1007/s00268-018-4704-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Curtis Darling
- Pediatric Anesthesia, Lucile Packard Children's Hospital Stanford, Palo Alto, USA
| | - Stephanie Chao
- Pediatric Surgery, Lucile Salter Packard Children's Hospital at Stanford, Palo Alto, USA
| | | | - Ban Tsui
- Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, USA.
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32
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Singhal NR, Jerman JD. A review of anesthetic considerations and postoperative pain control after the Nuss procedure. Semin Pediatr Surg 2018; 27:156-160. [PMID: 30078486 DOI: 10.1053/j.sempedsurg.2018.05.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Neil Raj Singhal
- Department of Anesthesia and Division of Pain Management, Phoenix Children's Hospital, 1919 East Thomas Road 4th Floor, Perioperative, Phoenix, AZ 85016, United States .
| | - Jonathan D Jerman
- Department of Anesthesia and Division of Pain Management, Phoenix Children's Hospital, 1919 East Thomas Road 4th Floor, Perioperative, Phoenix, AZ 85016, United States
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Kabagambe SK, Goodman LF, Chen YJ, Keller BA, Becker JC, Raff GW, Stark RA, Stephenson JT, Rahm A, Farmer DL, Hirose S. Subcutaneous local anesthetic infusion could eliminate use of epidural analgesia after the Nuss procedure. Pain Manag 2017; 8:9-13. [PMID: 29210330 DOI: 10.2217/pmt-2017-0042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Sandra K Kabagambe
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA
| | - Laura F Goodman
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA
| | - Y Julia Chen
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA
| | - Benjamin A Keller
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA
| | - James C Becker
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA
| | - Gary W Raff
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA.,Department of Surgery, Shriners Hospitals for Children, Northern California, Sacramento, CA 95817, USA
| | - Rebecca A Stark
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA.,Department of Surgery, Shriners Hospitals for Children, Northern California, Sacramento, CA 95817, USA
| | - Jacob T Stephenson
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA.,Department of Surgery, Shriners Hospitals for Children, Northern California, Sacramento, CA 95817, USA
| | - Amy Rahm
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA.,Department of Surgery, Shriners Hospitals for Children, Northern California, Sacramento, CA 95817, USA
| | - Diana L Farmer
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA.,Department of Surgery, Shriners Hospitals for Children, Northern California, Sacramento, CA 95817, USA
| | - Shinjiro Hirose
- Department of Surgery, University of California Davis, Sacramento, CA 95817, USA.,Department of Surgery, Shriners Hospitals for Children, Northern California, Sacramento, CA 95817, USA
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Man JY, Gurnaney HG, Dubow SR, DiMaggio TJ, Kroeplin GR, Adzick NS, Muhly WT. A retrospective comparison of thoracic epidural infusion and multimodal analgesia protocol for pain management following the minimally invasive repair of pectus excavatum. Paediatr Anaesth 2017; 27:1227-1234. [PMID: 29063665 DOI: 10.1111/pan.13264] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/10/2017] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Janice Y Man
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pediatric Anesthesiology, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, CA, USA.,Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Harshad G Gurnaney
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Scott R Dubow
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Theresa J DiMaggio
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Gina R Kroeplin
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Scott Adzick
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Wallis T Muhly
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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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.
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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.
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Keller BA, Kabagambe SK, Becker JC, Chen YJ, Goodman LF, Clark-Wronski JM, Furukawa K, Stark RA, Rahm AL, Hirose S, Raff GW. Intercostal nerve cryoablation versus thoracic epidural catheters for postoperative analgesia following pectus excavatum repair: Preliminary outcomes in twenty-six cryoablation patients. J Pediatr Surg 2016; 51:2033-2038. [PMID: 27745867 DOI: 10.1016/j.jpedsurg.2016.09.034] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 09/12/2016] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Benjamin A Keller
- Davis Health System, Department of Surgery, University of California, Sacramento, CA.
| | - Sandra K Kabagambe
- Davis Health System, Department of Surgery, University of California, Sacramento, CA
| | - James C Becker
- Davis Health System, Department of Surgery, University of California, Sacramento, CA
| | - Y Julia Chen
- Davis Health System, Department of Surgery, University of California, Sacramento, CA
| | - Laura F Goodman
- Davis Health System, Department of Surgery, University of California, Sacramento, CA
| | | | - Kenneth Furukawa
- Davis Health System, Department of Anesthesia, University of California, Sacramento, CA
| | - Rebecca A Stark
- Davis Health System, Department of Surgery, University of California, Sacramento, CA; Department of Surgery, Shriners Hospital for Children - Northern California, Sacramento, CA
| | - Amy L Rahm
- Davis Health System, Department of Surgery, University of California, Sacramento, CA; Department of Surgery, Shriners Hospital for Children - Northern California, Sacramento, CA
| | - Shinjiro Hirose
- Davis Health System, Department of Surgery, University of California, Sacramento, CA; Department of Surgery, Shriners Hospital for Children - Northern California, Sacramento, CA
| | - Gary W Raff
- Davis Health System, Department of Surgery, University of California, Sacramento, CA; Department of Surgery, Shriners Hospital for Children - Northern California, Sacramento, CA
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