1
|
Ka ES, Rim GM, Kang S, Bae S, Jang IT, Park HJ. Serratus Anterior Plane Block: A Better Modality of Pain Control after Pectus Excavatum Repair. J Chest Surg 2024; 57:291-299. [PMID: 38472120 PMCID: PMC11089063 DOI: 10.5090/jcs.23.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 01/03/2024] [Accepted: 01/15/2024] [Indexed: 03/14/2024] Open
Abstract
Background Postoperative pain management following minimally invasive repair of pectus excavatum (MIRPE) remains a critical concern due to severe post-procedural pain. Promising results have been reported for cryoanalgesia following MIRPE; however, its invasiveness, single-lung ventilation, and additional instrumentation requirements remain obstacles. Serratus anterior plane block (SAPB) is a regional block technique capable of covering the anterior chest wall at the T2-9 levels, which are affected by MIRPE. We hypothesized that SAPB would be a superior alternative pain control modality that reduces postoperative pain more effectively than conventional methods. Methods We conducted a retrospective study of patients who underwent MIRPE between March 2022 and August 2023. The efficacy of pain control was compared between group N (conventional pain management, n=24) and group S (SAPB, n=26). Group N received intravenous patient-controlled analgesia (IV-PCA) and subcutaneous local anesthetic infusion. Group S received bilateral continuous SAPB with 0.3% ropivacaine after a bilateral bolus injection of 30 mL of 0.25% ropivacaine with baseline IV-PCA. Pain levels were evaluated using a Visual Analog Scale (VAS) at 1, 3, 6, 12, 24, 48, and 72 hours postoperatively and total intravenous rescue analgesic consumption by morphine milligram equivalents (MME). Results Mean VAS scores were significantly lower in group S than in group N throughout the 72-hour postoperative period (p<0.01). Group S showed significantly lower MME at postoperative 72 hours (group N: 108.53, group S: 16.61; p<0.01). Conclusion SAPB improved immediate postoperative pain control in both the resting and dynamic states and reduced opioid consumption compared to conventional management.
Collapse
Affiliation(s)
- Eun Seok Ka
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Gong Min Rim
- Department of Thoracic and Cardiovascular Surgery, Gangnam Nanoori Hospital, Seoul, Korea
| | - Seungyoun Kang
- Department of Thoracic and Cardiovascular Surgery, Gangnam Nanoori Hospital, Seoul, Korea
| | - Saemi Bae
- Department of Thoracic and Cardiovascular Surgery, Gangnam Nanoori Hospital, Seoul, Korea
| | - Il-Tae Jang
- Department of Thoracic and Cardiovascular Surgery, Gangnam Nanoori Hospital, Seoul, Korea
| | - Hyung Joo Park
- Department of Thoracic and Cardiovascular Surgery, Gangnam Nanoori Hospital, Seoul, Korea
| |
Collapse
|
2
|
Huerta CT, Cobler-Lichter MD, Lynn R, Ramsey WA, Delamater JM, Alligood DM, Parreco JP, Sola JE, Perez EA, Thorson CM. Outcomes After Pectus Excavatum Repair: Center Volume Matters. J Pediatr Surg 2024; 59:935-940. [PMID: 38360451 DOI: 10.1016/j.jpedsurg.2024.01.020] [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: 12/27/2023] [Accepted: 01/18/2024] [Indexed: 02/17/2024]
Abstract
PURPOSE Pectus excavatum (Pectus) repair may be offered for those with significant cardiopulmonary compromise or severe cosmetic defects. The influence of hospital center volume on postoperative outcomes in children is unknown. This study aimed to investigate the outcomes of children undergoing Pectus repair, stratified by hospital surgical volume. METHODS The Nationwide Readmission Database was queried (2016-2020) for patients with Pectus (Q67.6). Patients were stratified into those who received repair at high-volume centers (HVCs; ≥20 repairs annually) versus low-volume centers (LVCs; <20 repairs annually). Demographics and outcomes were analyzed using standard statistical tests. RESULTS A total of 9414 patients with Pectus underwent repair during the study period, with 69% treated at HVCs and 31% at LVCs. Patients at LVCs experienced higher rates of complications during index admission, including pneumothorax (23% vs. 15%), chest tube placement (5% vs. 2%), and overall perioperative complications (28% vs. 24%) compared to those treated at HVCs, all p < 0.001. Patients treated at LVCs had higher readmission rates within 30 days (3.8% vs. 2.8% HVCs) and overall readmission (6.8% vs. 4.7% HVCs), both p < 0.010. Among readmitted patients (n = 547), the most frequent complications during readmission for those initially treated at LVCs included pneumothorax/hemothorax (21% vs. 8%), bar dislodgment (21% vs. 12%), and electrolyte disorders (15% vs. 9%) compared to those treated at HVCs. CONCLUSION Pediatric Pectus repair performed at high-volume centers was associated with fewer index complications and readmissions compared to lower-volume centers. Patients and surgeons should consider this hospital volume-outcome relationship. TYPE OF STUDY Retrospective Comparative. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
| | | | - Royi Lynn
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Walter A Ramsey
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA
| | - Jessica M Delamater
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA
| | - Daniel M Alligood
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA
| | | | - Juan E Sola
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA; Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eduardo A Perez
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA; Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Chad M Thorson
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA; Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| |
Collapse
|
3
|
Zacha S, Biernawska J. Cryoanalgesia as the Essential Element of Enhanced Recovery after Surgery (ERAS) in Children Undergoing Thoracic Surgery-Scoping Review. J Pers Med 2024; 14:411. [PMID: 38673038 PMCID: PMC11051180 DOI: 10.3390/jpm14040411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/06/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
This article aims to present cryoanalgesia as an inventive strategy for pain alleviation among pediatric patients. It underlines the tremendous need to align pain management with the principles of the enhanced recovery after surgery (ERAS) approach. The aim of the study was to review the patient outcomes of nerve cryoanalgesia during surgery reported with regard to ERAS in the literature. The literature search was performed using PubMed and Embase to identify articles on the use of cryoanalgesia in children. It excluded editorials, reviews, meta-analyses, and non-English articles. The analysis focused on the study methods, data analysis, patient selection, and patient follow-up. This review includes a total of 25 articles. Three of the articles report the results of cryoanalgesia implemented in ERAS protocol in children. The research outcome indicates shortened hospital stay, potential reduction in opioid dosage, and significant progress in physical rehabilitation. This paper also describes the first intraoperative utilization of intercostal nerve cryoanalgesia during the Nuss procedure in Poland, highlighting its effectiveness in pain management. Adding the cryoanalgesia procedure to multimodal analgesia protocol may facilitate the implementation of the ERAS protocol in pediatric patients.
Collapse
Affiliation(s)
- Sławomir Zacha
- Department of Pediatric Orthopedics and Oncology of Musculoskeletal System, Pomeranian Medical University in Szczecin, 70-252 Szczecin, Poland
| | - Jowita Biernawska
- Department of Anesthesiology and Intensive Therapy, Pomeranian Medical University in Szczecin, 70-252 Szczecin, Poland;
| |
Collapse
|
4
|
Linton SC, Tian Y, Zeineddin S, Alayleh A, De Boer C, Goldstein SD, Ghomrawi HMK, Abdullah F. Intercostal Nerve Cryoablation Reduces Opioid Use and Length of Stay Without Increasing Adverse Events: A Retrospective Cohort Study of 5442 Patients Undergoing Surgical Correction of Pectus Excavatum. Ann Surg 2024; 279:699-704. [PMID: 37791468 DOI: 10.1097/sla.0000000000006113] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
OBJECTIVE To examine differences in opioid use, length of stay, and adverse events after minimally invasive correction of pectus excavatum (MIRPE) with and without intercostal nerve cryoablation. BACKGROUND Small studies show that intraoperative intercostal nerve cryoablation provides effective analgesia with no large-scale evaluations of this technique. METHODS The pediatric health information system database was used to perform a retrospective cohort study comparing patients undergoing MIRPE at children's hospitals before and after the initiation of cryoablation. The association of cryoablation use with inpatient opioid use was determined using quantile regression with robust standard errors. Difference in risk-adjusted length of stay between the cohorts was estimated using negative binomial regression. Odds of adverse events between the two cohorts were compared using logistic regression with a generalized estimating equation. RESULTS A total of 5442 patients underwent MIRPE at 44 children's hospitals between 2016 and 2022 with 1592 patients treated after cryoablation was introduced at their hospital. Cryoablation use was associated with a median decrease of 80.8 (95% CI: 68.6-93.0) total oral morphine equivalents as well as a decrease in estimated median length of stay from 3.5 [3.2-3.9] days to 2.5 [2.2-2.9] days ( P value: 0.016). Cryoablation use was not significantly associated with an increase in any studied adverse events. CONCLUSIONS Introduction of cryoablation for perioperative analgesia was associated with decreased inpatient opioid use and length of stay in a large sample with no change in adverse events. This novel modality for perioperative analgesia offers a promising alternative to traditional pain management in thoracic surgery.
Collapse
Affiliation(s)
- Samuel C Linton
- Department of Surgery, Division of Pediatric Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Yao Tian
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Suhail Zeineddin
- Department of Surgery, Division of Pediatric Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Amin Alayleh
- Department of Surgery, Division of Pediatric Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Chris De Boer
- Department of Surgery, Division of Pediatric Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Seth D Goldstein
- Department of Surgery, Division of Pediatric Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Hassan M K Ghomrawi
- Departments of Surgery and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Fizan Abdullah
- Department of Surgery, Division of Pediatric Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| |
Collapse
|
5
|
Perez MN, Ferrantella A, Johnson KN, Goldstein SD. Intercostal spinal nerve cryoablation for analgesia following pectus excavatum repair. Semin Pediatr Surg 2024; 33:151382. [PMID: 38190771 DOI: 10.1016/j.sempedsurg.2024.151382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
Pectus excavatum is a common chest wall deformity, most often treated during adolescence, that presents a significant postoperative pain control challenge for pediatric surgeons following surgical correction. The purpose of this article is to review the technique and outcomes of intercostal spinal nerve cryoablation for postoperative analgesia following surgical correction of pectus excavatum. Contemporary and historic literature were reviewed. Findings are summarized to provide a concise synopsis of the benefits of intercostal spinal nerve cryoablation relative to alternative analgesic modalities, as well as advocate for more widespread inclusion of this technique into multimodal pain regimens.
Collapse
Affiliation(s)
- Mallory N Perez
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Anthony Ferrantella
- Department of Surgery, Phoenix Children's Hospital, Mayo Clinic College of Medicine and Science, Phoenix, AZ, USA
| | - Kevin N Johnson
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Seth D Goldstein
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| |
Collapse
|
6
|
Rim G, Park HJ, Kang S, Jeong JY, Koo J, Jang IT, Bae S. Serratus anterior plane block for acute pain management after pectus excavatum repair. Front Surg 2024; 10:1305326. [PMID: 38259978 PMCID: PMC10800917 DOI: 10.3389/fsurg.2023.1305326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 11/23/2023] [Indexed: 01/24/2024] Open
Abstract
Introduction Conventional postoperative pain management using an intravenous (IV) patient-controlled approach or thoracic epidural analgesia is suboptimal following minimally invasive repair of the pectus excavatum (MIRPE). Recently, cryoanalgesia has gained popularity owing to its superior pain control outcomes compared to those associated with conventional methods. However, because of its invasiveness, additional instrumentation requirement, and limited effect at early postoperative periods, we hypothesized that serratus anterior plane block (SAPB) could be an effective method for post-repair pain management and a possibly superior alternative. Methods We conducted a retrospective cohort study of pediatric patients who had undergone MIRPE between March 2022 and August 2023. We compared the efficacy of pain control in three groups among 74 patients: Group N (conventional pain management, n = 24), Group C (cryoanalgesia, n = 24), and Group S (SAPB, n = 26). Group N received IV patient-controlled analgesia (PCA) and a subcutaneous local anesthetic infusion. Group C received bilateral cryoanalgesia on the fourth and seventh intercostal nerves using a cryoprobe at -80°C for 2 min during the operation and IV-PCA postoperatively. Group S received continuous bilateral SAPB with 0.25% ropivacaine and IV-PCA. The pain levels were measured using the visual analog scale (VAS; resting and dynamic), and the total IV rescue analgesic consumption was determined. Results The three groups had similar baseline characteristics. Group S showed significantly less pain throughout the immediate postoperative course, resting VAS score at 3 h (Group N, 7.21 vs. Group C, 5.75 vs. Group S, 3.81; p < 0.001), and prominent less total IV rescue analgesic consumption (Group N, 116.16 mg vs. Group C, 52.75 mg vs. Group S, 16.61 mg; p < 0.001). Conclusion SAPB resulted in better postoperative pain control than that associated with cryoanalgesia and conventional pain management after pectus excavatum repair, As it was effective in the immediate postoperative period, achieving a VAS score of <4 points (moderate pain) at 3 h postoperatively, it may play an important role and replace invasive cryoanalgesia in the management of pain after pectus surgery.
Collapse
Affiliation(s)
- Gongmin Rim
- Department of Thoracic and Cardiovascular Surgery, Gangnam Nanoori Hospital, Seoul, Republic of Korea
| | - Hyung Joo Park
- Department of Thoracic and Cardiovascular Surgery, Gangnam Nanoori Hospital, Seoul, Republic of Korea
| | - Seungyoun Kang
- Department of Thoracic and Cardiovascular Surgery, Gangnam Nanoori Hospital, Seoul, Republic of Korea
| | - Jin Yong Jeong
- Department of Thoracic and Cardiovascular Surgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Republic of Korea
| | - Jungmin Koo
- Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Il-Tae Jang
- Department of Thoracic and Cardiovascular Surgery, Gangnam Nanoori Hospital, Seoul, Republic of Korea
| | - Saemi Bae
- Department of Thoracic and Cardiovascular Surgery, Gangnam Nanoori Hospital, Seoul, Republic of Korea
| |
Collapse
|
7
|
Carter M, Linton S, Zeineddin S, Pitt JB, Figueroa A, Perez A, Park E, DeTella M, Kwon S, Goldstein SD, Ghomrawi H, Abdullah F. Consumer Wearables Define a Normative Recovery Trajectory Following the Modified Nuss Procedure. J Surg Res 2023; 292:7-13. [PMID: 37567031 DOI: 10.1016/j.jss.2023.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 06/23/2023] [Accepted: 07/05/2023] [Indexed: 08/13/2023]
Abstract
INTRODUCTION The modified Nuss procedure is an elective procedure associated with a lengthy recovery, uncontrolled pain, and risk of infrequent, yet life-threatening complications. The absence of objective measures of normative postoperative recovery creates uncertainty about the postdischarge period, which remains highly dependent on the patients' and their caregivers' expectations and management of recovery. We aimed to describe an objective-normative, physical activity recovery trajectory after the modified Nuss procedure, using step counts from the Fitbit. METHODS This observational study enrolled children ≤18 y with pectus excavatum who underwent the modified Nuss procedure from 2021 to 2022. The Fitbit was worn for 21 postoperative days. Postdischarge outcomes and health-care utilization were evaluated. For patients without postoperative complications, piecewise linear regression analysis was conducted to generate a normative recovery trajectory model of daily step counts. RESULTS Of 80 patients enrolled, 66 (86%) met eligibility criteria (mean age, 15.1 ± 1.3 y; 89.4% male, 62.1% non-Hispanic White). The mean number of telephone and electronic message encounters regarding concerns with the patient's recovery within 30 d postoperatively was 2.1 (standard deviation = 2.7). Ten patients (15.2%) returned to the emergency department (ED) within the 30-d postoperative period. Seven patients (10.6%) presented to the ED one time, and three patients (4.5%) presented to the ED twice. Thirty-day readmission rate was four patients (6.0%). Piecewise regression model showed that patients without complications steadily increased their daily step count on each postoperative day and plateaued on day 18. CONCLUSIONS We have developed a normative recovery trajectory following the modified Nuss procedure using step count data collected by a consumer wearable device. This offers the potential to inform preoperative patient expectations and reduce avoidable health-care utilization through informed preoperative counseling, thus laying the ground work for the use of consumer wearable devices as a postdischarge remote monitoring tool.
Collapse
Affiliation(s)
- Michela Carter
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Samuel Linton
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - J Benjamin Pitt
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Angie Figueroa
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Amparo Perez
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Erica Park
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Mia DeTella
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Soyang Kwon
- The Smith Child Health Research Program, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Hassan Ghomrawi
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Medicine (Rheumatology) and Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| |
Collapse
|
8
|
Lai K, Eldredge RS, Zobel M, Hargis-Villanueva A, Ostlie A, Padilla BE. Intercostal Nerve Cryoablation for Postoperative Pain Control in Pediatric Thoracic Surgery: A Scoping Review. J Laparoendosc Adv Surg Tech A 2023; 33:994-1004. [PMID: 37462727 DOI: 10.1089/lap.2023.0070] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
Background: Cryoanalgesia uses the application of cold temperatures to temporarily disrupt peripheral sensory nerve function for pain control. This review outlines the principles of cryoablation, clinical applications, and clinical data for its use in pediatric thoracic surgery. Methods: A comprehensive PubMed search was performed using the principal terms and combinations of cryoablation, cryoanalgesia, Nuss, Nuss repair, pectus, pectus excavatum, thoracic surgery, thoracotomy, and chest wall. Pediatric articles were reviewed and included if relevant. Adult articles were reviewed for supporting information as needed. Reference lists of included articles were reviewed for possible additional sources. Discussion: The scientific and clinical principles of cryoablation are outlined, followed by a focused review of current clinical application and outcome data. Conclusion: Postoperative pain is a major challenge following thoracic surgery. Cryoanalgesia is emerging as an adjunct in pediatric thoracic surgery, particularly for the Nuss procedure or minimally invasive repair of pectus excavatum. It effectively controls pain, decreasing postoperative opioid use and hospital length of stay with few short-term complications. Although more long-term studies are needed, early evidence suggests there is reliable return of sensation to the chest wall and long-term neuropathic pain is rare.
Collapse
Affiliation(s)
- Krista Lai
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - R Scott Eldredge
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Michael Zobel
- Division of Pediatric Surgery, University of California San Francisco, San Francisco, USA
| | | | - Andrew Ostlie
- Department of Child Health, University of Arizona School of Medicine, Tucson, Arizona, USA
| | - Benjamin E Padilla
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
- Department of Child Health, University of Arizona School of Medicine, Tucson, Arizona, USA
| |
Collapse
|
9
|
Rim GM, Kim HK, Koo JM, Park HJ. A Randomized Controlled Trial of Cryoanalgesia for Pain Management following Pectus Excavatum Repair: A Single-Center, Single-Blind, Parallel Design Study. Eur J Pediatr Surg 2023. [PMID: 37364610 DOI: 10.1055/a-2117-4628] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
INTRODUCTION Conventional postoperative pain management, with an intravenous patient-controlled approach or thoracic epidural analgesia, has proved suboptimal following a minimally invasive repair of pectus excavatum. Considering its postulated mechanism of action, we encouraged cryoanalgesia as an effective method for postrepair pain management and a possibly superior alternative. METHODS A randomized, single-blind clinical trial was tested on patients undergoing pectus excavatum (PE) repair in March and December 2022. Among 101 patients, consenting study participants were randomly assigned to one of two groups: cryoanalgesia (group C, n = 24) or noncryoanalgesia (group N, n = 24). Group N received conventional pain management. Comparing the results, pain levels were measured using the visual analog scale (VAS-R for resting and VAS-D for dynamic) and the total rescue analgesic consumption was determined. Intrathoracic cryoablation was performed bilaterally on the fourth and seventh intercostal nerves using a cryoprobe at -80°C for 2 minutes. RESULTS The two groups had similar baseline-patient characteristics; however, group C had a longer mean operative time (159 vs. 125 minutes, p < 0.01) and experienced significantly less pain throughout the postoperative course, with VAS at 6 hours (5.38 vs. 7.04, p < 0.01) and 48 hours (3.17 vs. 5.67, p < 0.01). CONCLUSION Cryoanalgesia improved postoperative pain control at rest and during movement following PE repair. However, the outcome was less favorable than expected because the VAS was greater than 4 (moderate pain), although after a day or two, it decreased to lower levels (VAS < 4) in the cyro group. Considering its extra invasiveness and instrumentation, a routine cryoanalgesia procedure for pectus surgery is yet to be determined.
Collapse
Affiliation(s)
- Gong Min Rim
- Department of Cardiothoracic Surgery, Nanoori Hospitals, Seoul, Republic of Korea
| | - Hee Kyung Kim
- Department of Thoracic and Cardiovascular Surgery-Cardiothoracic Surgery, Seoul St. Mary's Hospital, Seoul, Republic of Korea
| | - Jung Min Koo
- Department of Anesthesiology, College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Republic of Korea
| | - Hyung Joo Park
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, Seoul, Republic of Korea
| |
Collapse
|
10
|
Eldredge RS, McMahon L. Intercostal nerve cryoablation therapy for the repair of pectus excavatum: a systematic review. Front Surg 2023; 10:1235120. [PMID: 37693640 PMCID: PMC10484532 DOI: 10.3389/fsurg.2023.1235120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
Introduction The minimally invasive repair of pectus excavatum (PE) is a painful procedure that can result in long-term hospitalization and opioid use. To mitigate the length of stay and opioid consumption, many different analgesia strategies have been implemented. The aim of this study is to review the use and patient outcomes of intercostal nerve cryoablation (INC) during PE repair reported in the literature. Methods An unfunded literature search using PubMed identifying articles discussing INC during PE repair from 1946 to 1 July 2023 was performed. Articles were included if they discussed patient outcomes with INC use during PE repair. Articles were excluded if they were reviews/meta-analyses, editorials, or not available in English. Each article was reviewed for bias by analyzing the study methods, data analysis, patient selection, and patient follow-up. Articles comparing outcomes of INC were considered significant if p-value was <0.05. Results A total of 34 articles were included in this review that described INC use during pectus repair. Most supported a decreased hospital length of stay and opioid use with INC. Overall, INC was associated with fewer short-term and long-term complications. However, the researchers reported varied results of total hospital costs with the use of INC. Conclusion The review was limited by a paucity of prospective studies and low number of patients who received INC. Despite this, the present data support INC as a safe and effective analgesic strategy during the repair of PE.
Collapse
Affiliation(s)
| | - Lisa McMahon
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children’s Hospital, Phoenix, AZ, United States
| |
Collapse
|
11
|
Arshad SA, Garcia EI, Bell C, Avritscher EBC, Kumar M, Brahmamdam P, Fraser JA, St Peter SD, Aranda A, Hill M, Marquart J, Van Arendonk K, Plumblee L, Streck CJ, Zamora IJ, Ghani MOA, Reichard KW, Sacks K, Kallis M, Hong A, Richards H, Lin S, Gross ER, Kabeer MH, Reyna T, Paton EA, Camp LB, Stephenson K, Dassinger M, Vali K, Filipescu R, DeUgarte DA, Krishna V, Slater B, Islam S, Thompson G, Moore JT, Englum BR, Scholz S, Sharbaugh E, Gander JW, Tsao K. Multicenter Assessment of Cryoanalgesia Use in Minimally Invasive Repair of Pectus Excavatum: A 20-center Retrospective Cohort Study. Ann Surg 2023; 277:e1373-e1379. [PMID: 35797475 DOI: 10.1097/sla.0000000000005440] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the clinical implications of cryoanalgesia for pain management in children undergoing minimally invasive repair of pectus excavatum (MIRPE). BACKGROUND MIRPE entails significant pain management challenges, often requiring high postoperative opioid use. Cryoanalgesia, which blocks pain signals by temporarily ablating intercostal nerves, has been recently utilized as an analgesic adjunct. We hypothesized that the use of cryoanalgesia during MIRPE would decrease postoperative opioid use and length of stay (LOS). MATERIALS AND METHODS A multicenter retrospective cohort study of 20 US children's hospitals was conducted of children (age below 18 years) undergoing MIRPE from January 1, 2014, to August 1, 2019. Differences in total postoperative, inpatient, oral morphine equivalents per kilogram, and 30-day LOS between patients who received cryoanalgesia versus those who did not were assessed using bivariate and multivariable analysis. P value <0.05 is considered significant. RESULTS Of 898 patients, 136 (15%) received cryoanalgesia. Groups were similar by age, sex, body mass index, comorbidities, and Haller index. Receipt of cryoanalgesia was associated with lower oral morphine equivalents per kilogram (risk ratio=0.43, 95% confidence interval: 0.33-0.57) and a shorter LOS (risk ratio=0.66, 95% confidence interval: 0.50-0.87). Complications were similar between groups (29.8% vs 22.1, P =0.07), including a similar rate of emergency department visit, readmission, and/or reoperation. CONCLUSIONS Use of cryoanalgesia during MIRPE appears to be effective in lowering postoperative opioid requirements and LOS without increasing complication rates. With the exception of preoperative gabapentin, other adjuncts appear to increase and/or be ineffective at reducing opioid utilization. Cryoanalgesia should be considered for patients undergoing this surgery.
Collapse
Affiliation(s)
- Seyed A Arshad
- McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Children's Memorial Hermann Hospital, Houston, TX
| | - Elisa I Garcia
- McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Children's Memorial Hermann Hospital, Houston, TX
| | - Cynthia Bell
- McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Children's Memorial Hermann Hospital, Houston, TX
| | - Elenir B C Avritscher
- McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Children's Memorial Hermann Hospital, Houston, TX
| | | | | | | | | | | | | | - John Marquart
- Medical College of Wisconsin/Children's Hospital of Wisconsin
| | | | - Leah Plumblee
- Medical University of South Carolina Shawn Jenkins Children's Hospital
| | | | - Irving J Zamora
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt
| | - Muhammad O A Ghani
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt
| | | | | | | | - Andrew Hong
- Northwell Health/Cohen Children's Medical Center
| | - Holden Richards
- Oregon Health and Science University/Doernbecher Children's Hospital
| | - Saunders Lin
- Oregon Health and Science University/Doernbecher Children's Hospital
| | - Erica R Gross
- Stony Brook Medicine/Stony Brook Children's Hospital
| | | | - Troy Reyna
- The University of California Irvine/CHOC Children's Hospital
| | - Elizabeth A Paton
- The University of Tennessee Health Science Center/Le Bonheur Children's Hospital
| | - Lauren B Camp
- The University of Tennessee Health Science Center/Le Bonheur Children's Hospital
| | - Krista Stephenson
- University of Arkansas for Medical Sciences/Arkansas Children's Hospital
| | - Melvin Dassinger
- University of Arkansas for Medical Sciences/Arkansas Children's Hospital
| | - Kaveh Vali
- University at Buffalo/Oishei Children's Hospital
| | | | | | - Vikram Krishna
- University of California-Los Angeles/Mattel Children's Hospital
| | | | - Saleem Islam
- University of Florida/Shands Children's Hospital
| | | | - James T Moore
- University of Maryland School of Medicine/University of Maryland Children's Hospital
| | - Brian R Englum
- University of Maryland School of Medicine/University of Maryland Children's Hospital
| | - Stefan Scholz
- University of Pittsburgh/UPMC Children's Hospital of Pittsburgh
| | | | - Jeffrey W Gander
- University of Virginia/University of Virginia Children's Hospital. Excluding those from the lead site, authors are listed by alphabetical order of their institution's name
| | - KuoJen Tsao
- McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
- Children's Memorial Hermann Hospital, Houston, TX
| |
Collapse
|
12
|
Walter CM, Lee CS, Moore DL, Abbasian N, Clay SJ, Mecoli MD, Olbrecht VA, Batra M, Ding L, Yang F, Nair M, Huq A, Simpson BE, Brown RL, Garcia VF, Chidambaran V. Retrospective study comparing outcomes of multimodal epidural and erector spinae catheter pain protocols after pectus surgery. J Pediatr Surg 2023; 58:397-404. [PMID: 35907711 DOI: 10.1016/j.jpedsurg.2022.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/10/2022] [Accepted: 06/28/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION There are no optimal postoperative analgesia regimens for Nuss procedures. We compared the effectiveness of thoracic epidurals (EPI) and novel ambulatory erector spinae plane (ESP) catheters as part of multimodal pain protocols after Nuss surgery. METHODS Data on demographics, comorbidities, perioperative details, length of stay (LOS), in hospital and post discharge pain/opioid use, side effects, and emergency department (ED) visits were collected retrospectively in children who underwent Nuss repair with EPI (N = 114) and ESP protocols (N = 97). Association of the group with length of stay (LOS), in hospital opioid use (intravenous morphine equivalents (MEq)/kg over postoperative day (POD) 0-2), and oral opioid use beyond POD7 was analyzed using inverse probability of treatment weighting (IPTW) with propensity scores, followed by multivariable regression. RESULTS Groups had similar demographics. Compared to EPI, ESP had longer block time and higher rate of ketamine and dexmedetomidine use. LOS for ESP was 2 days IQR (2, 2) compared to 3 days IQR (3, 4) for EPI (p < 0.01). Compared to EPI, ESP group had higher opioid use (in MEq/kg) intraoperatively (0.32 (IQR 0.27, 0.36) vs. 0.28 (0.24, 0.32); p < 0.01) but lower opioid use on POD 0 (0.09 (IQR 0.04, 0.17) vs. 0.11 (0.08, 0.17); p = 0.03) and POD2 (0.00 (IQR 0.00, 0.00) vs. 0.04 (0.00, 0.06) ; p < 0.01). ESP group also had lower total in hospital opioid use (0.57 (IQR 0.42, 0.73) vs.0.82 (0.71, 0.91); p < 0.01), and shorter duration of post discharge opioid use (6 days (IQR 5,8) vs. 9 days (IQR 7,12) (p < 0.01). After IPTW adjustment, ESP continued to be associated with shorter LOS (difference -1.20, 95% CI: -1.38, -1.01, p < 0.01) and decreased odds for opioid use beyond POD7 (OR 0.11, 95% CI: 0.05, 0.24); p < 0.01). However, total in hospital opioid use in MEq/kg (POD0-2) was now similar between groups (difference -0.02 (95% CI: -0.09, -0.04); p = 0.50). The EPI group had higher incidence of emesis (29% v 4%, p < 0.01), while ESP had higher catheter malfunction rates (23% v 0%; p < 0.01) but both groups had comparable ED visits/readmissions. DISCUSSION/CONCLUSION Compared to EPI, multimodal ambulatory ESP protocol decreased LOS and postoperative opioid use, with comparable ED visits/readmissions. Disadvantages included higher postoperative pain scores, longer block times and higher catheter leakage/malfunction. LEVELS OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Charlotte M Walter
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Christopher S Lee
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - David L Moore
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Niekoo Abbasian
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Smokey J Clay
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States.
| | - Marc D Mecoli
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Vanessa A Olbrecht
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Meenu Batra
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Lili Ding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, MLC 5041, 3333 Burnet Ave, Cincinnati, OH 45229, United States; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Fang Yang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, MLC 5041, 3333 Burnet Ave, Cincinnati, OH 45229, United States; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Manu Nair
- Summer Undergraduate Research Fellow, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States
| | - Abraar Huq
- Summer Undergraduate Research Fellow, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States
| | - Blair E Simpson
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, MLC 3024, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Rebeccah L Brown
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States; Division of Pediatric, General and Thoracic Surgery Department, Cincinnati Children's Hospital Medical Center, MLC 2023, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Victor F Garcia
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States; Division of Pediatric, General and Thoracic Surgery Department, Cincinnati Children's Hospital Medical Center, MLC 2023, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States.
| |
Collapse
|
13
|
Chen SY, Mack SJ, Stein JE, Kelley-Quon LI, Kim ES. Intercostal Nerve Cryoablation is Associated with Reduced Opioid Use in Pediatric Oncology Patients. J Surg Res 2023; 283:377-384. [PMID: 36427448 PMCID: PMC10756229 DOI: 10.1016/j.jss.2022.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/24/2022] [Accepted: 11/02/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Intercostal nerve cryoablation reduces postoperative pain in adults undergoing thoracotomy and children undergoing pectus excavatum repair. We hypothesize that cryoablation is associated with decreased post-thoracotomy pain and opioid use in pediatric oncology patients. METHODS A single-center retrospective cohort study was performed for oncology patients who underwent thoracotomy from January 1, 2017 to May 31, 2021. Outcomes included postoperative opioid use measured in morphine milligram equivalents per kilogram (MME/kg), pain scores (scale 0-10), and opioid prescription at discharge. Univariable analysis compared patients who received cryoablation to patients who did not receive cryoablation. Multivariable regression analysis controlling for age and prior thoracotomy evaluated associations between cryoablation and postoperative pain. RESULTS Overall, 32 patients (19 males:13 females) underwent thoracotomy with 16 who underwent >1 thoracotomy resulting in 53 thoracotomies included for analysis. Cryoablation was used in 14 of 53 (26.4%) thoracotomies. Throughout the postoperative hospitalization, patients receiving cryoablation during thoracotomy consumed less opioids compared to patients who did not receive cryoablation (median 0.38 MME/kg, interquartile range [IQR] 0.20-1.15 versus median 1.47 MME/kg, IQR 0.71-4.02, P < 0.01). Maximum pain scores were lower in cryoablation patients (median 6, IQR 5-8) than noncryoablation patients (median 8, IQR 6-10), with a significant difference observed on postoperative day 4 (P = 0.01). Cryoablation patients were also less frequently prescribed opioids at discharge (21.4% versus 58.97%, P = 0.02). Multivariable regression demonstrated that cryoablation was associated with 2.59 MME/kg less opioid use (95% confidence interval -4.56 to -0.63) and decreased likelihood of opioid prescription at discharge (adjusted odds ratio 0.14, 95% confidence interval 0.03-0.67). CONCLUSIONS Cryoablation is significantly associated with decreased post-thoracotomy pain and opioid use in pediatric cancer patients and should be considered in postoperative pain regimens.
Collapse
Affiliation(s)
- Stephanie Y Chen
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Shale J Mack
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - James E Stein
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Eugene S Kim
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.
| |
Collapse
|
14
|
Impact of Cryoanalgesia Use During Minimally Invasive Pectus Excavatum Repair on Hospital Days and Total Hospital Costs Among Pediatric Patients. J Pediatr Surg 2023:S0022-3468(23)00157-4. [PMID: 36922280 DOI: 10.1016/j.jpedsurg.2023.02.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/14/2023] [Indexed: 02/19/2023]
Abstract
INTRODUCTION Surgical repair of pectus excavatum is a painful procedure requiring multimodal pain control with historically prolonged hospital stay. This study aimed to evaluate the impact of cryoanalgesia during minimally invasive repair of pectus excavatum (MIRPE) on hospital days (HDs), total hospital costs (HCs), and complications. We hypothesized that cryoanalgesia would be associated with reduced HDs and total HCs with no increase in post-operative complications. METHODS We conducted a retrospective review of pediatric patients who underwent MIRPE from 2011 to 2021. MIRPE details and post-operative outcomes within 90 days were abstracted. Total HDs included the index MIRPE admission and readmissions within 90 days. HCs were obtained from the hospital accounting system, retroactively adjusting for medical inflation. Bayesian generalized linear models with neutral prior assuming no effect were used. Differences between treatment groups were assessed using gamma distribution (HDs and HCs) and poisson (post-operative complications). All models used log link and controlled for age, gender, race, and Haller index. RESULTS Forty-four patients underwent MIRPE during the study period. Cryoanalgesia was utilized in 29 (66%) patients. The probability of a reduction with cryoanalgesia vs. no cryoanalgesia was 99% for HDs (3.0 vs. 5.4 days; Bayesian RR: 0.6, 95% CrI: 0.5-0.8), 89% for HCs ($18,787 vs. $19,667; RR: 0.9, 95% CrI: 0.8-1.1), and 70% for postoperative complications (17% vs 33%; RR: 0.8, 95% CrI: 0.3-1.9). CONCLUSION Cryoanalgesia use in MIRPE likely reduced HDs, HCs, and post-operative complications. Further research is warranted to confirm these findings in large prospective studies. LEVEL OF EVIDENCE Level III.
Collapse
|
15
|
Velayos M, Alonso M, Estefanía K, Jesus Muñoz A, Torres R, Hernández F, Reinoso F, Torre CDL. Ultrasound-Guided Percutaneous Cryoanalgesia for Pectus Excavatum: When Should It be Applied? Eur J Pediatr Surg 2023; 33:61-67. [PMID: 36257335 DOI: 10.1055/s-0042-1757361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION The addition of ultrasound-guided percutaneous cryoanalgesia (PCr) for pain management after pectus excavatum (PE) surgery offers a new and advantageous approach. Our aim is to describe our experience with PCr applied on the same day, 24 hours, and 48 hours prior to PE surgery. MATERIAL AND METHODS Prospective pilot study in patients undergoing ultrasound-guided PCr (2019-2022) was divided into three groups: PCr on the same day of surgery (PCrSD), PCr 24 hours before (PCr24), and PCr 48 hours before (PCr48). We describe the application of technique and data obtained by comparing the three groups. RESULTS We present 42 patients (25 PCrSD, 11 PCr24, 6 PCr48). PCr24 had a shorter procedure duration than PCrSD (65.8 vs. 91.2 minute; p = 0.048). Related to analgesia, PCr24 and PCr48 showed lower opioid consumption than PCrSD in PCA volume (48.5 and 49.6 vs. 75.1 mL; p = 0.015) and PCA time (23.3 and 23.8 vs. 34.3 hours; p = 0.01). Degree of pain (VAS scale) on the day of surgery and on the second postoperative day was lower in PCr24 and PCr48 than in PCrSD (4 and 2 vs. 5; p = 0.012; 0 and 1 vs. 2; p = 0.01, respectively) as well as shorter hospital stay (3 and 3.5 vs. 5 days; p = 0.021). In addition, PCr24 showed lower opioid consumption and hospital stay than PCr48 (p > 0.05). The greatest savings in hospital costs were obtained in the PCr24 group. CONCLUSION PCr48 and PCr24 prior to PE surgery offers lower opioid consumption, less pain and shorter hospital stay than PCrSD. PCr24 is comparable to PCr48, but seems to show advantages and simpler logistics for the patient and the hospital.
Collapse
Affiliation(s)
- María Velayos
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Mercedes Alonso
- Departament of Anesthesia, La Paz University Hospital, Madrid, Spain
| | - Karla Estefanía
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Antonio Jesus Muñoz
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Raquel Torres
- Pain Unit Nursery, La Paz University Hospital, Madrid, Spain
| | - Francisco Hernández
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Francisco Reinoso
- Departament of Anesthesia, La Paz University Hospital, Madrid, Spain
| | - Carlos De la Torre
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
| |
Collapse
|
16
|
Zeineddin S, Goldstein SD, Linton S, DeBoer C, Alayleh A, Ortiz I, Sands L, Kujawa S, Suresh S, Ghomrawi H, Abdullah F. Effectiveness of one minute per level intercostal nerve cryoablation for postoperative analgesia after surgical correction of pectus excavatum. J Pediatr Surg 2023; 58:34-40. [PMID: 36283847 DOI: 10.1016/j.jpedsurg.2022.09.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/16/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Intraoperative intercostal nerve cryoablation has emerged as a promising modality for postoperative analgesia following Surgical Correction of Pectus Excavatum (SCOPE). Most centers use two-minute cryoablation per level, although data from histologic and adult studies suggest the effectiveness of one-minute freezes. We aimed to describe our center's experience with one minute per level cryoablation. METHODS A retrospective single institution review of patients undergoing SCOPE was performed to compare patients pre- and post-intercostal nerve cryoablation implementation. Cryoablation was performed as one minute for each of the thoracic intercostal nerves T3-T7. Multivariable regression analyses were conducted to compare the outcomes and cost between pre- and post-implementation groups. RESULTS During the study period, 198 patients underwent SCOPE with one Nuss bar, receiving either intraoperative intercostal nerve cryoablation (Cryo, n = 100) or preoperative thoracic paravertebral catheters (NoCryo, n = 98). Surgical time was on average 9 min longer for the Cryo group (p<0.01). Median length of stay for the Cryo group was 3 days shorter compared to the NoCryo group (p<0.01). The Cryo group had a 19-fold and 5.6-fold reduction in average inpatient and total postoperative opioid usage, respectively (p<0.01). Total hospital costs were significantly lower in the Cryo group (p<0.01). Overall complication rate was not statistically significant different between the two groups. CONCLUSIONS Intraoperative one minute per level cryoablation is a potent approach to postoperative analgesia for SCOPE patients that led to a shorter hospital length of stay, lower hospital costs, and decreased opioid use compared to conventional analgesia at our institution. Pediatric surgeons performing correction of chest wall deformities should consider offering this technique.
Collapse
Affiliation(s)
- Suhail Zeineddin
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA; Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Seth D Goldstein
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA; Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Samuel Linton
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA; Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Christopher DeBoer
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA; Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Amin Alayleh
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA
| | - Irma Ortiz
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA
| | - Laurie Sands
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA
| | - Suzanne Kujawa
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA
| | - Santhanam Suresh
- Department of Pediatric Anesthesia, Children's Hospital of Chicago, Chicago, IL, USA
| | - Hassan Ghomrawi
- Department of Surgery, Northwestern University, Chicago, IL, USA; Department of Pediatrics, Northwestern University, Chicago, IL, USA
| | - Fizan Abdullah
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA; Department of Surgery, Northwestern University, Chicago, IL, USA.
| |
Collapse
|
17
|
Lai K, Notrica DM, McMahon LE, Kang P, Molitor MS, Egan JC, Bae JO, Hunteman ZM, Ostlie DJ, Lee JH, Padilla BE. Cryoablation in 350 Nuss procedures: Evolution of hospital length of stay and opioid use. J Pediatr Surg 2022:S0022-3468(22)00717-5. [PMID: 36494205 DOI: 10.1016/j.jpedsurg.2022.10.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 10/10/2022] [Accepted: 10/30/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Current studies show cryoablation decreases opioid requirements and lengths of stay (LOS) in patients undergoing the Nuss procedure for pectus excavatum. This study evaluated the relationship between cryoablation and clinical outcomes for the Nuss procedure. METHODS A retrospective single-center chart review was performed on patients undergoing the Nuss procedure with intercostal cryoablation from December 2017-August 2021. Demographics, hospital course, and postoperative complications were abstracted. To evaluate the evolution of outcomes over time, the earliest quarter (Q1) of cryoablation patients was compared to the last quarter (Q4). RESULTS Over 45 months, 350 Nuss procedures with cryoablation were performed. The mean age at operation was 15.7 ± 2.3 years with an average Haller Index of 5.4 ± 4.2. The mean operative time was 136 ± 40.5 minutes. On average, patients used 2.8 ± 2.5 OME/kg of opioid in hospital with a LOS of 2.7 ± 1.1 days. The Q4 patients were discharged 1.3 days earlier (p<0.05) than Q1 patients, with 80% of Q4 discharged by postoperative day #2 vs. 23% in Q1 (p<0.05). Q4 patients received 74% (p<0.05) less opioid in hospital and 21% (p<0.05) less on discharge. Within 90 days postoperatively, complication rates (chest tube placement, wound infection, readmission, neuropathic pain) were similar. Only two patients (0.6%) required reoperation for bar migration/slippage. CONCLUSION With increased experience, cryoablation for the Nuss procedure decreased opioid use by 74% and was associated with 80% of patients achieving early discharge. Major complication rates were not increased. Cryoablation can be successfully implemented as an effective method of postoperative analgesia. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Krista Lai
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - David M Notrica
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Lisa E McMahon
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Paul Kang
- Mel and Enid Zuckerman College of Public Heath, University of Arizona, Tucson, AZ, United States
| | - Mark S Molitor
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - J Craig Egan
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Jae-O Bae
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Zebediah M Hunteman
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Daniel J Ostlie
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Justin H Lee
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Benjamin E Padilla
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, United States.
| |
Collapse
|
18
|
Neurolysis for analgesia following pectus repair in a national cohort. J Pediatr Surg 2022; 57:315-318. [PMID: 35339278 DOI: 10.1016/j.jpedsurg.2022.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Pectus excavatum and pectus carinatum are the most common chest wall deformities of childhood. Surgical repair can be complicated by post-operative analgesic challenges. Thoracic epidural analgesia, patient-controlled analgesia, and multimodal pain control are among the most common strategies. We sought to define the current utilization of intraoperative thoracic neurolysis, hypothesizing that this would minimize length of stay (LOS) and post-operative narcotic use with relatively higher proportion of non-narcotic post-operative analgesia. METHODS We performed a retrospective review of the Pediatric Health Information System (PHIS) database between 2017 and 2020. We first identified patients who underwent a pectus repair via ICD-10-PCS codes. We used ICD-10-PCS codes 01580ZZ and 01584ZZ to identify those patients who underwent concomitant thoracic neurolysis. Statistical analyses were performed using R; p value less than 0.05 was considered significant. RESULTS We identified 2979 patients who underwent a pectus repair. 184 underwent a concomitant thoracic nerve destruction procedure (6.7%); 13 were performed in 2017 (2.01%), 76 in 2018 (10.7%), and 84 in 2019 (9.6%). LOS was shorter in those patients who underwent neurolysis (mean=2.55 vs 3.73 days, SD=1.33 vs 1.78 days, p<0.001). There were fewer post-operative ICU admissions in neurolysis patients (3/184 vs. 193/2795, p = 0.003). The cost of procedures that included a neurolysis were higher, though not significantly so (mean=$24,885.64 vs $22,200.59). CONCLUSION Thoracic neurolysis may be a useful analgesic strategy, expediating post-operative discharge and potentially obviating the need for intensive care. Further larger-scale prospective trials should be considered to further elucidate the role of this analgesia method. LEVEL OF EVIDENCE Level III.
Collapse
|
19
|
Abstract
BACKGROUND Minimally invasive repair of pectus excavatum (MIRPE) involves placement of a transthoracic, retrosternal support bar under thoracoscopic guidance. Despite its minimally invasive technical approach, postoperative pain is a significant morbidity that often results in increased length of stay. Multi-modal pain control strategies have been used in the past with limited success. Recently, the use of intraoperative intercostal nerve cryoablation (CA) has been added. In the present study, we aim to evaluate the effects of CA on postoperative pain control, opioid requirements, and perioperative outcomes. STUDY DESIGN A single-center, retrospective chart review of all patients (less than 18 years old) who underwent MIRPE from 2009 to 2020 was performed. CA was started in June 2018. Data collection included demographics, preoperative characteristics, intraoperative findings, and postoperative outcomes. We hypothesized that CA would be associated with improved pain scores, lower doses of total inpatient opioid requirement, and shorter length of stay (LOS). RESULTS One hundred sixty-one patients met inclusion criteria: 75 underwent intraoperative CA and 86 underwent MIRPE without CA (NCA group). CA significantly decreased median LOS from 4 days in NCA to 2 days; the use of CA was the only significant predictor of LOS on linear regression. CA was also associated with decreased total PCA, intravenous opioid, and oral opioid dosages. There was no difference in inpatient pain scores and a slight increase in mean procedure time. However, CA was associated with significantly decreased postoperative complications. CONCLUSIONS The use of cryoablation during MIRPE significantly decreases LOS, perioperative opioid requirements, and postoperative complications, with a minimal increase in operative time. Cryoablation is an effective pain control modality in the surgical management of chest wall deformities in children.
Collapse
|
20
|
Velayos M, Alonso M, Delgado-Miguel C, Estefanía-Fernández K, Muñoz-Serrano AJ, Santamaría MVL, Reinoso-Barbero F, De La Torre CA. Percutaneous Cryoanalgesia: A New Strategy for Pain Management in Pectus Excavatum Surgery. Eur J Pediatr Surg 2022; 32:73-79. [PMID: 34942673 DOI: 10.1055/s-0041-1740555] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION In recent years, pain protocols for pectus excavatum (PE) have incorporated cryoanalgesia through thoracoscopic approach. Since 2019, ultrasound-guided percutaneous cryoanalgesia (PCr) has been applied at our institution, either on the same day as the Nuss procedure or 48 hours before surgery. We carried out a preliminary retrospective review of patients with PE in whom PCr prior to surgery was performed at our institution between 2019 and 2021. MATERIALS AND METHODS Two groups were evaluated: PCr on the same day (PCrSD) and PCr 48 hours before surgery (PCr48). Despite PCr, patients were treated with "patient-controlled analgesia" (PCA) with opioids for at least 24 hours, switching to conventional intravenous analgesia and oral analgesia in the following days. Demographic, clinical-radiological variables, PCA opioid use, pain grade according to the visual analog scale (VAS), and length of stay (LOS) were compared between the groups. A total of 20 patients were included (12 with PCrSD and 8 with PCr48), without significant differences in demographics or clinical-radiological variables. The overall median time of PCr was 65 minutes (55-127), with no differences between the groups. RESULTS PCr48 group presented with significantly lower median number of hours of continuous PCA (24 vs. 32 hours; p = 0.031), lower median number of rescue boluses (11 vs. 18; p = 0.042), lower median VAS in the early postoperative hours (2 vs. 5.5; p = 0.043), and lower median LOS (3.5 vs. 5 days). CONCLUSION PCr performed 48 hours prior to surgery is more effective in terms of PCA requirements, VAS, and LOS when compared with cryoanalgesia on the same day.
Collapse
Affiliation(s)
- María Velayos
- Pediatric Surgery Department, La Paz University Hospital, Madrid, Spain
| | - Mercedes Alonso
- Children's Anesthesia and Resuscitation Department, La Paz University Hospital, Madrid, Spain
| | | | | | | | | | | | | |
Collapse
|
21
|
Zacha S, Andrzejewska A, Jastrzębska-Ligocka B, Szwed A, Modrzejewska E, Zacha W, Skonieczna-Żydecka K, Miegoń J, Jarosz K, Biernawska J. Intercostal nerve cryoanalgesia in the treatment of pain in patients operated on by the modified Nuss method with the BackOnFeet application-a new strategy to improve outcomes. Front Pediatr 2022; 10:1069805. [PMID: 36714658 PMCID: PMC9878586 DOI: 10.3389/fped.2022.1069805] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/19/2022] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION The surgical Nuss correction of the funnel chest deformity is a painful procedure without an established consensus of pain relief methods. High doses and long duration of opioids requirements impedes the ERAS protocol introduction. The aim of this study was to evaluate the effectiveness of intraoperative intercostal nerve cryolysis in terms of pain management in relation to the routinely used multimodal analgesia in Poland. We also assessed the impact of using the proprietary "BackOnFeet" application on the quality of life of patients after surgery in relation to the ERAS protocol. METHODS The prospective, single-centre, non-randomised, before-after pilot study was conducted. Inclusion criteria were: funnel-shaped chest deformity, age range 11-18 years, first chest wall operation, agreement for the cryolysis and regional analgesia, no history of chronic painkillers use. The results of the "control group" (multimodal analgesia with regional analgesia commonly performed in Poland) were assessed. The interdisciplinary perioperative protocol with the "BackOnFeet" application and intraoperative intercostal nerve cryoanalgesia were introduced to the "intervention group". RESULTS Eighteen children were treated with standard protocol typical for Polish management and matched to eighteen patients who received cryoanalgesia and the "BackOnFeet" application access "intervention group". We noticed lower NRS points in first 24 h (p = 0.0048), shortening of time of opioid use (p = 0.0002), hospitalisation time (p = 0,01), improved quality of postoperative rehabilitation (p < 0.0001) and quality of life (p < 0.0001) among the "intervention group". CONCLUSIONS Intraoperative intercostal nerves cryolysis performed during the minimally invasive Nuss correction of funnel deformation in combination with bilateral is more effective in terms of acute pain management in relation to the routinely used multimodal analgesia in Poland, allowing for the shortening of time of opioid use, hospitalisation time, improved quality of postoperative rehabilitation and enabled ERAS protocol introduction. The use of the proprietary "BackOnFeet" application has a positive effect on the quality of life of patients after surgery.
Collapse
Affiliation(s)
- Sławomir Zacha
- Department of Pediatric Orthopedics and Oncology of the Musculoskeletal System, Pomeranian Medical University, Szczecin, Poland
| | - Agata Andrzejewska
- Department of Anesthesiology and Intensive Care, Pomeranian Medical University, Szczecin, Poland
| | | | - Aleksander Szwed
- Department of Pediatric Orthopedics and Oncology of the Musculoskeletal System, Pomeranian Medical University, Szczecin, Poland
| | - Elżbieta Modrzejewska
- Department of Pediatric Orthopedics and Oncology of the Musculoskeletal System, Pomeranian Medical University, Szczecin, Poland
| | - Wojciech Zacha
- Department of Orthopedics, Traumatology and Oncology of the Musculoskeletal System, Pomeranian Medical University, Szczecin, Poland
| | | | - Jakub Miegoń
- Department of Anesthesiology and Intensive Care, Pomeranian Medical University, Szczecin, Poland
| | - Konrad Jarosz
- Department of Clinical Nursing, Pomeranian Medical University, Szczecin, Poland
| | - Jowita Biernawska
- Department of Anesthesiology and Intensive Care, Pomeranian Medical University, Szczecin, Poland
| |
Collapse
|
22
|
McCoy N, Hollinger L. Cryoanalgesia and Lung Isolation: A New Challenge for the Nuss Procedure Made Easier With the EZ-Blocker™. Front Pediatr 2021; 9:791607. [PMID: 34912765 PMCID: PMC8667069 DOI: 10.3389/fped.2021.791607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 10/28/2021] [Indexed: 12/02/2022] Open
Affiliation(s)
- Nicole McCoy
- Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Laura Hollinger
- Department of Surgery, Division of Pediatric Surgery, Medical University of South Carolina, Charleston, SC, United States
| |
Collapse
|