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

Cryoanalgesia as the Essential Element of Enhanced Recovery after Surgery (ERAS) in Children Undergoing Thoracic Surgery-Scoping Review

This article aims to present cryoanalgesia as an inventive strategy for pain alleviation among pediatric patients. It underlines the tremendous need to align pain management with the principles of the enhanced recovery after surgery (ERAS) approach. The aim of the study was to review the patient outcomes of nerve cryoanalgesia during surgery reported with regard to ERAS in the literature. The literature search was performed using PubMed and Embase to identify articles on the use of cryoanalgesia in children. It excluded editorials, reviews, meta-analyses, and non-English articles. The analysis focused on the study methods, data analysis, patient selection, and patient follow-up. This review includes a total of 25 articles. Three of the articles report the results of cryoanalgesia implemented in ERAS protocol in children. The research outcome indicates shortened hospital stay, potential reduction in opioid dosage, and significant progress in physical rehabilitation. This paper also describes the first intraoperative utilization of intercostal nerve cryoanalgesia during the Nuss procedure in Poland, highlighting its effectiveness in pain management. Adding the cryoanalgesia procedure to multimodal analgesia protocol may facilitate the implementation of the ERAS protocol in pediatric patients.

Intercostal Nerve Cryoablation for Postoperative Pain Control in Pediatric Thoracic Surgery: A Scoping Review

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.

Intercostal nerve cryoablation therapy for the repair of pectus excavatum: a systematic review

Introduction

The minimally invasive repair of pectus excavatum (PE) is a painful procedure that can result in long-term hospitalization and opioid use. To mitigate the length of stay and opioid consumption, many different analgesia strategies have been implemented. The aim of this study is to review the use and patient outcomes of intercostal nerve cryoablation (INC) during PE repair reported in the literature.

Methods

An unfunded literature search using PubMed identifying articles discussing INC during PE repair from 1946 to 1 July 2023 was performed. Articles were included if they discussed patient outcomes with INC use during PE repair. Articles were excluded if they were reviews/meta-analyses, editorials, or not available in English. Each article was reviewed for bias by analyzing the study methods, data analysis, patient selection, and patient follow-up. Articles comparing outcomes of INC were considered significant if p-value was <0.05.

Results

A total of 34 articles were included in this review that described INC use during pectus repair. Most supported a decreased hospital length of stay and opioid use with INC. Overall, INC was associated with fewer short-term and long-term complications. However, the researchers reported varied results of total hospital costs with the use of INC.

Conclusion

The review was limited by a paucity of prospective studies and low number of patients who received INC. Despite this, the present data support INC as a safe and effective analgesic strategy during the repair of PE.

Ultrasound-controlled cryoneurolysis for peripheral mononeuropathies: a retrospective cohort study

Aim: Cryoneurolysis is a potential therapy for peripheral mononeuropathies, but randomized studies of its effects on the duration of pain reduction are lacking. Methods: This retrospective cohort study evaluated the analgesic effects of cryoneurolysis on patients with refractory peripheral mononeuropathy. We included 24 patients who underwent ultrasound-guided cryoneurolysis between June 2018 and July 2022. The daily maximum pain level was recorded using a numerical rating scale before and 1, 3 and 6 months after the procedure. Results: At 1 month, 54.2% of patients reported pain reduction of at least 30%. This percentage was significantly lower at 3 and 6 months (13.8 and 9.1%, respectively). Conclusion: Our results suggest that repeated cryoneurolysis may be a viable treatment for refractory mononeuropathy. Further investigations are needed.

Intravenous Morphine Infusion versus Thoracic Epidural Infusion of Ropivacaine with Fentanyl after the Ravitch Procedure-A Single-Center Cohort Study

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.

Cryoablation is associated with shorter length-of-stay and reduced opioid use after the Ravitch procedure

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.

Percutaneous Cryoanalgesia: A New Strategy for Pain Management in Pectus Excavatum Surgery

INTRODUCTION

 In recent years, pain protocols for pectus excavatum (PE) have incorporated cryoanalgesia through thoracoscopic approach. Since 2019, ultrasound-guided percutaneous cryoanalgesia (PCr) has been applied at our institution, either on the same day as the Nuss procedure or 48 hours before surgery. We carried out a preliminary retrospective review of patients with PE in whom PCr prior to surgery was performed at our institution between 2019 and 2021.

MATERIALS AND METHODS

 Two groups were evaluated: PCr on the same day (PCrSD) and PCr 48 hours before surgery (PCr48). Despite PCr, patients were treated with "patient-controlled analgesia" (PCA) with opioids for at least 24 hours, switching to conventional intravenous analgesia and oral analgesia in the following days. Demographic, clinical-radiological variables, PCA opioid use, pain grade according to the visual analog scale (VAS), and length of stay (LOS) were compared between the groups. A total of 20 patients were included (12 with PCrSD and 8 with PCr48), without significant differences in demographics or clinical-radiological variables. The overall median time of PCr was 65 minutes (55-127), with no differences between the groups.

RESULTS

 PCr48 group presented with significantly lower median number of hours of continuous PCA (24 vs. 32 hours; p = 0.031), lower median number of rescue boluses (11 vs. 18; p = 0.042), lower median VAS in the early postoperative hours (2 vs. 5.5; p = 0.043), and lower median LOS (3.5 vs. 5 days).

CONCLUSION

 PCr performed 48 hours prior to surgery is more effective in terms of PCA requirements, VAS, and LOS when compared with cryoanalgesia on the same day.

Efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain after surgery or trauma: systematic review

Background

There is a critical need for non-narcotic analgesic adjuncts in the treatment of thoracic pain. We evaluated the efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain, specifically addressing the applicability of intercostal cryoneurolysis for pain control after chest wall trauma.

Methods

A systematic review was performed through searches of PubMed, EMBASE, and the Cochrane Library. We included studies involving patients of all ages that evaluated the efficacy of intercostal cryoneurolysis as a pain adjunct for chest wall pathology. Quantitative and qualitative synthesis was performed.

Results

Twenty-three studies including 570 patients undergoing cryoneurolysis met eligibility criteria for quantitative analysis. Five subgroups of patients treated with intercostal cryoneurolysis were identified: pectus excavatum (nine studies); thoracotomy (eight studies); post-thoracotomy pain syndrome (three studies); malignant chest wall pain (two studies); and traumatic rib fractures (one study). There is overall low-quality evidence supporting intercostal cryoneurolysis as an analgesic adjunct for chest wall pain. A majority of studies demonstrated decreased inpatient narcotic use with intercostal cryoneurolysis compared with conventional pain modalities. Intercostal cryoneurolysis may also lead to decreased hospital length of stay. The procedure did not definitively increase operative time, and risk of complications was low.

Conclusions

Given the favorable risk-to-benefit profile, both percutaneous and thoracoscopic intercostal cryoneurolysis may serve as a worthwhile analgesic adjunct in trauma patients with rib fractures who have failed conventional medical management. However, further prospective studies are needed to improve quality of evidence.

Level of evidence

Level IV systematic reviews and meta-analyses.

Use of cryoanalgesia as a postoperative pain management for open pectus carinatum repair

PURPOSE

Cryoanalgesia has shown to have safety and efficacy as an adjunct post-operative pain management for Nuss procedure. One retrospective study reported its efficacy for analgesia with the Ravitch procedure, with improved pain scores and decreased length of stay versus thoracic epidural. We describe our initial experience with the use of cryoanalgesia for an open repair of pectus carinatum.

METHODS

We retrospectively reviewed the medical records of all patients who received cryoanalgesia during an open repair of pectus carinatum from 2016 to 2019 at our institution. We recorded pain scores at immediate post-operative and at 1-week follow up after hospital discharge. Length of stay and mean follow up time were also recorded.

RESULTS

Five pediatric patients underwent open repair of pectus carinatum with cryoanalgesia. The median postoperative length of stay (LOS) was 1 (range 1-2) day. Only one patient reported a non-zero pain score during their hospitalization, and this was a 3 out of 10 in the post-analgesia care unit. At 1-week postoperative visit, all patients had a pain score of 0. Median follow up was 1 (0.5-2) year. No patients developed neuralgia.

CONCLUSION

Cryoanalgesia is a safe and effective pain management strategy for pediatric patients undergoing open pectus carinatum repair.

The impact of an enhanced recovery perioperative pathway for pediatric pectus deformity repair

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.