1
|
Boesl MA, Brown N, Bleicher J, Call T, Lambert DH, Lambert LA. Continuous Wound Irrigation and Intraoperative Methadone Decreases Opioid Use and Shortens Length of Stay After CRS/HIPEC. Ann Surg Oncol 2024; 31:3742-3749. [PMID: 38300404 DOI: 10.1245/s10434-024-14900-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 12/29/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND Epidural analgesia is resource and labor intense and may limit postoperative management options and delay discharge. This study compared postoperative outcomes after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) with epidural analgesia versus continuous wound infusion system (CWIS) with/without intraoperative methadone. METHODS A single-institution, retrospective chart review was performed including all patients undergoing open CRS/HIPEC from 2018 to 2021. Patient demographics, surgical characteristics, length of stay, and in-hospital analgesic use were reviewed. In-hospital opioid exposure in morphine milligram equivalents (MME) was calculated. Multivariate analysis (MVA) for mean total and daily opioid exposure was conducted. RESULTS A total of 157 patients were included. Fifty-three (34%) had epidural analgesia, 96 (61%) had CWIS, and 79 (50%) received methadone. Length of stay was significantly shorter with CWIS + methadone versus epidural (7 vs. 8 days, p < 0.01). MVA showed significantly lower mean total and daily opioid exposure with CWIS+methadone versus epidural (total: 252.8 ± 17.7 MME vs. 486.8 ± 86.6 MME; odds ratio [OR] 0.72, 95% confidence interval [CI] 0.52-0.98, p = 0.04; Daily: 32.8 ± 2.0 MME vs. 51.9 ± 5.7 MME, OR 0.72, 95% CI 0.52-0.99, p ≤ 0.05). The CWIS-only group (n = 17) had a significantly lower median oral opioid exposure versus epidural (135 MME vs. 7.5 MME, p < 0.001) and longer length of stay versus CWIS + methadone (9 vs. 7 days, p = 0.04), There were no CWIS or methadone-associated complications and one epidural abscess. CONCLUSIONS CWIS + methadone safely offers better pain control with less in-hospital opioid use, shorter length of stay, and decreased resource utilization compared with epidural analgesia in patients undergoing CRS-HIPEC.
Collapse
Affiliation(s)
- Markus A Boesl
- Department of General Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Noah Brown
- Department of General Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Josh Bleicher
- Department of General Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Tyler Call
- Department of Anesthesiology, University of Utah Health, Salt Lake City, UT, USA
| | - Donald H Lambert
- Department of Anesthesiology, Boston University Medical Center, Boston, MA, USA
| | - Laura A Lambert
- Department of General Surgery, University of Utah Health, Salt Lake City, UT, USA.
- Department of Surgical Oncology, Huntsman Cancer Institute, Salt Lake City, UT, USA.
| |
Collapse
|
2
|
O'Connor LA, Houseman B, Cook T, Quinn CC. Intercostal cryonerve block versus elastomeric infusion pump for postoperative analgesia following surgical stabilization of traumatic rib fractures. Injury 2023; 54:111053. [PMID: 37741705 DOI: 10.1016/j.injury.2023.111053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 09/25/2023]
Abstract
OBJECTIVE Patients with blunt thoracic trauma requiring surgical stabilization of rib fractures (SSRF) frequently experience severe pain. Further, a rising prevalence of opioid-tolerant patients sustain traumatic injuries. The optimal pain management adjunct for concurrent use with SSRF remains uncertain. This study compared outcomes in patients undergoing SSRF with concomitant cryonerve block (CryoNB) or ropivacaine 0.2% elastomeric infusion pump (EIP). METHODS A single-center retrospective comparative analysis was performed at a level II trauma center. A query of our institution's trauma registry of consecutive patients undergoing SSRF from October 2017 to November 2020 with either intercostal CryoNB or ropivacaine 0.2% EIP was conducted. Opioid consumption in oral morphine equivalents (OME), patient-reported pain scores by numerical rating scale, and pulmonary function measured by incentive spirometry effort (mL) were collected at baseline and on postoperative days 1-3. Results were analyzed using a linear-mixed-effects model. Length of stay (LOS), complications, and hospital charges were assessed as secondary outcomes. RESULTS Twenty-six patients meeting inclusion criteria were evaluated. Patient demographics, injury, and surgical variables were similar between groups. The estimated effect for patients treated with CryoNB (n = 14) compared to EIP (n = 12) demonstrated a 25% (estimated -1.37 OME, 95% CI, -2.411 to -0.335, p = 0.01) reduction in hospital opioid requirements, fewer discharge opioids (41.3 mg (37.5-45) versus 175 mg (150- 200), p = 0.03), 22% (estimated -1.506, 95% CI, -2.722 to -0.290, p = 0.02) reduction in pain scores, and shorter postoperative LOS (4 days (4-5) versus 6 days (5-9.5), p = 0.04). Pulmonary function (estimated -48.8 mL, 95% CI, -312.74 to 215.05, p = 0.71), total hospital costs (CryoNB: $90,224 ± 34,633; EIP: $131,498 ± 73,072, p = 0.07), and complications were no different between cohorts. CONCLUSION The addition of intercostal CryoNB as an adjunct to multimodal pain management in trauma patients undergoing surgical fixation of rib fractures may be of benefit. Based on our early data, this technique appears to be promising in reducing opioid requirements and providing an extended duration of pain control without increased costs or complications.
Collapse
Affiliation(s)
- Lizabeth A O'Connor
- Elliot Health System, Division of Thoracic Surgery, 1 Elliot Way, Manchester, NH 03103, United States.
| | - Bryan Houseman
- Elliot Health System, Division of Orthopedic Trauma, 1 Elliot Way, Manchester, NH 03103, United States
| | - Thomas Cook
- University of Massachusetts Amherst, Department of Mathematics and Statistics, Lederle Graduate Research Tower, 1623D, University of Massachusetts Amherst, 710N. Pleasant Street, Amherst, MA 01003, United States
| | - Curtis C Quinn
- Elliot Health System, Division of Thoracic Surgery, 1 Elliot Way, Manchester, NH 03103, United States
| |
Collapse
|
3
|
Monitored Anesthesia Care with Dexmedetomidine Supplemented by Midazolam/Fentanyl versus Midazolam/Fentanyl Alone in Patients Undergoing Pleuroscopy: Effect on Oxygenation and Respiratory Function. J Clin Med 2021; 10:jcm10163510. [PMID: 34441805 PMCID: PMC8396832 DOI: 10.3390/jcm10163510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/30/2021] [Accepted: 08/06/2021] [Indexed: 12/19/2022] Open
Abstract
Although pleuroscopy is considered a safe and well tolerated procedure with a low complication rate, it requires the administration of procedural sedation and analgesia. The purpose of this study was to assess the effects of dexmedetomidine administration on oxygenation and respiratory function in patients undergoing diagnostic or therapeutic pleuroscopy. Through a prospective, single center, cohort study, we studied 55 patients receiving either a dexmedetomidine intravenous infusion supplemented by midazolam/fentanyl (Group DEX + MZ/F) or a conventional sedation protocol with midazolam/fentanyl (Group MZ/F). Our primary outcome was the changes in lung gas exchange (PaO2/FiO2 ratio) obtained at baseline and at predetermined end points, while changes in respiratory mechanics (FEV1, FVC and the ratio FEV1/FVC) and PaCO2 levels, drug consumption, time to recover from sedation and adverse events were our secondary endpoints (NCT03597828). We found a lower postoperative decrease in FEV1 volumes in Group DEX + MZ/F compared to Group MZ/F (p = 0.039), while FVC, FEV1/FVC and gas exchange values did not differ between groups. We also found a significant reduction in midazolam (p < 0.001) and fentanyl consumption (p < 0.001), along with a more rapid recovery of alertness postprocedure in Group DEX + MZ/F compared to Group MZ/F (p = 0.003), while pain scores during the postoperative period, favored the Group DEX + MZ/F (p = 0.020). In conclusion, the use of intravenous dexmedetomidine during pleuroscopy is associated with a smaller decrease in FEV1, reduction of the consumption of supplementary sedatives and analgesics and quicker awakening of patients postoperatively, when compared to midazolam/fentanyl. Therefore, dexmedetomidine administration may provide clinically significant benefits in terms of lung mechanics and faster recovery of patients undergoing pleuroscopy.
Collapse
|
4
|
Tan JW, Mohamed JS, Tam JKC. Incorporation of an intercostal catheter into a multimodal analgesic strategy for uniportal video-assisted thoracoscopic surgery: a feasibility study. J Cardiothorac Surg 2021; 16:210. [PMID: 34332605 PMCID: PMC8325303 DOI: 10.1186/s13019-021-01590-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/21/2021] [Indexed: 02/05/2023] Open
Abstract
Background Well-controlled postoperative pain is essential for early recovery after uniportal video-assisted thoracoscopic surgery (UVATS). Conventional analgesia like opioids and thoracic epidural anaesthesia have been associated with hypotension and urinary retention. Intercostal catheters are a regional analgesic alternative that can be inserted during UVATS to avoid these adverse effects.
This feasibility study aims to evaluate the postoperative pain scores and analgesic requirements with incorporation of an intercostal catheter into a multimodal analgesic strategy for UVATS. Methods In this observational study, 26 consecutive patients who underwent UVATS were administered a multilevel intercostal block and oral paracetamol. All of these patients received 0.2% ropivacaine continuously at 4 ml/h via an intercostal catheter at the level of the incision. Rescue analgesia including etoricoxib, gabapentin and opioids were prescribed using a pain ladder approach. Postoperative pain scores and analgesic usage were assessed. The secondary outcomes were postoperative complications, days to ambulation and length of stay. Results No technical difficulties were encountered during placement of the intercostal catheter. There was only one case of peri-catheter leakage. Mean pain score was 0.31 (range 0–2) on post-operative day 1 and was 0.00 by post-operative day 5. 16 patients (61.6%) required only oral rescue analgesia. The number of patients who required rescue non-opioids only increased from 1 in the first 7 months to 8 in the next 7 months. There were no cases of hypotension or urinary retention. Median time to ambulation was 1 day (range 1–2). Mean post-operative length of stay was 4.17 ± 2.50 days. Conclusions Incorporation of an intercostal catheter into a multimodal analgesia strategy for UVATS is feasible and may provide adequate pain control with decreased opioid usage.
Collapse
Affiliation(s)
- Jian Wei Tan
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health Systems, Singapore, Singapore
| | - Jameelah Sheik Mohamed
- Department of Surgery, Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Singapore, 119228, Singapore
| | - John Kit Chung Tam
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health Systems, Singapore, Singapore. .,Department of Surgery, Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, NUHS Tower Block, Singapore, 119228, Singapore.
| |
Collapse
|
5
|
Uhlich R, Kerby JD, Bosarge P, Hu P. Use of continuous intercostal nerve blockade is associated with improved outcomes in patients with multiple rib fractures. Trauma Surg Acute Care Open 2021; 6:e000600. [PMID: 33981859 PMCID: PMC8076940 DOI: 10.1136/tsaco-2020-000600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 12/04/2020] [Accepted: 04/05/2021] [Indexed: 11/03/2022] Open
Abstract
Background Rib fractures are common among trauma patients and may result in significant morbidity and mortality. There are numerous treatment options, but ideal management is unclear. Delivery of local anesthetic via an analgesia catheter for continuous intercostal nerve blockade offers an attractive potential option for management of patients with rib fractures. Methods We performed a single-center, retrospective case-control analysis of trauma patients with multiple rib fractures from 2016 to 2018, comparing patients managed with continuous intercostal nerve blockade with standard care. Matching was performed in a 2:1 ratio by Injury Severity Score, age, and gender. Respiratory morbidity potentially secondary to rib fractures, including unplanned intubation, failure of extubation, need for tracheostomy, pneumonia, or mortality, were all identified and included. Potential complications due to catheter insertion were identified to be recorded. The primary outcome of interest was 30-day hospital-free days. Results Nine hundred and thirty-three patients were eligible for analysis, with 48 managed using intercostal blockade compared with 96 matching controls. No complications of intercostal blockade were identified during the study period. Controls demonstrated fewer rib fractures (6.60±4.11 vs. 9.3±3.73, p=0.001) and fewer flail segments (0.8±1.76 vs. 2.0±2.94, p=0.02). Those managed with intercostal blockade demonstrated significantly more 30-day hospital-free days (15.9±6.43 vs. 13.2±9.94, p=0.048), less incidence of pneumonia (4.2% vs. 16.7%, p=0.03), and lower hospital mortality (2.1% vs. 13.5%, p=0.03). When adjusting for number of rib fractures and number of flail segments, use of continuous intercostal nerve blockade was significantly associated with lower hospital mortality (OR 0.10; 95% CI 0.01 to 0.91), pneumonia (OR 0.15; 95% CI 0.03 to 0.76), or need for tracheostomy (OR 0.23; 95% CI 0.06 to 0.83). Discussion The addition of continuous intercostal nerve blockade may help to improve outcomes in patients with multiple rib fractures compared with standard care alone. Level of evidence Therapeutic/care management; level IV.
Collapse
Affiliation(s)
- Rindi Uhlich
- Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Patrick Bosarge
- Surgery, University of Arizona College of Medicine - Phoenix, Phoenix, Arizona, USA
| | - Parker Hu
- Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| |
Collapse
|
6
|
Zhou J, Pu Q, Lin L, Chong W, Chen B, Hai Y, Liu F, Liu L. Effect of patient-controlled intravenous analgesia combined with flurbiprofen axetil and dezocine on postoperative analgesia for lobectomy (EPIC-FAD): a trial protocol. Trials 2021; 22:175. [PMID: 33648558 PMCID: PMC7923454 DOI: 10.1186/s13063-021-05108-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 02/07/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The optimal analgesic strategy for surgical pain after lobectomy remains undefined. To compare the combination of flurbiprofen axetil and dezocine with flurbiprofen axetil alone and dezocine alone, in post-lobectomy patients. METHODS A single-center, parallel-design double-blind superiority trial, with 5 groups (1:1:1:1:1 ratio) with different combinations of flurbiprofen and dezocine. Patients scheduled for lobectomy will be recruited. The primary outcome is total sufentanil use in patient-controlled intravenous analgesia within the first 24 postoperative hours. Secondary outcomes include pain numeric rating scales at 6th, 12th, 24th, 48th, and 72th postoperative hours, and on the 1st, 3rd, and 6th postoperative months at rest and during coughing, adverse effects from experimental drug treatment, sufentanil use at other time points, analgesia cost, time to chest tube removal, length of hospital stay, time to pass first flatus, and serum level of cytokines. Doctors, patients, and nurses are blinded, and only the manager is unblinded. Analysis is intention-to-treat. Statistical analysis is pre-specified. Statistical comparison of the treatment groups includes one-way analysis of variance followed by Tukey's post hoc test. DISCUSSION Trial did not begin to recruit. Participant recruitment start date is planned to be June 1, 2020. Approximate recruitment end date is May 31, 2021. If successful, the trial may shed light on the use of certain analgesic combinations in post-lobectomy pain control. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR1800018563 . Registered on September 25, 2018.
Collapse
Affiliation(s)
- Jian Zhou
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Qiang Pu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Lin Lin
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Weelic Chong
- Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Boran Chen
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Yang Hai
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China.,Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Fei Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lunxu Liu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China. .,West China School of Medicine, Sichuan University, Chengdu, China. .,Western China Collaborative Innovation Center for Early Diagnosis and Multidisciplinary Therapy of Lung Cancer, Sichuan University, Chengdu, China.
| |
Collapse
|
7
|
Özden Omaygenç D, Çıtak N, İşgörücü Ö, Ulukol A, Büyükkale S, Obuz Ç, Doğru MV, Sayar A. Comparison of Thoracic Epidural and Intravenous Analgesia from the Perspective of Recovery of Respiratory Function in the Early Post-Thoracotomy Period in Lung Cancer Surgery. Turk Thorac J 2021; 22:31-36. [PMID: 33646101 DOI: 10.5152/turkthoracj.2021.19114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 02/28/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Thoracic epidural analgesia (TEA) reduces pulmonary complications after thoracotomy. Hypothetically, this advantage is partially because of the preserved pulmonary function, which is achieved by the reduction of postoperative pain and immobility. This study aimed to compare the principal methods of analgesia through early postoperative spirometric performance and gas exchange parameters after elective lung cancer surgery. TEA or intravenous analgesia (IVA) involving pethidine was used as the principal method in our sample population. MATERIAL AND METHODS A total of 62 patients operated via the posterolateral thoracotomy approach were enrolled. Postoperative analgesia was secured using multimodal analgesia with either TEA with 0.1% bupivacaine or IVA. Pain perception was assessed with the visual analog scale (VAS) while at rest and on coughing. Arterial blood samples were collected at 1, 24, and 72 hours postoperatively. Preoperative and third postoperative day spirometric measurements were recorded. RESULTS There were no significant differences among the groups in terms of demographic characteristics, properties of surgical technique, and disease-associated conditions. VAS scores of the TEA group were lower at the 72-hour follow-up, but a considerable fraction of these differences did not reach statistical significance. Reduction in the forced expiratory volume in the first second and forced vital capacities was more prominent in the IVA group on the third postoperative day, but these were not statistically significant either. Oxygenation parameters favored TEA but remained comparable. Finally, the pH values were significantly lower in the IVA group at 1 and 72 hours postoperatively (p=0.008 and p=0.02, respectively). CONCLUSION We believe that TEA is advantageous over IVA with alteration of respiratory volumes during the early postoperative period.
Collapse
Affiliation(s)
- Derya Özden Omaygenç
- Department of Anesthesiology and Reanimation, Kanuni Sultan Süleyman Training and Research Hospital, İstanbul, Turkey
| | - Necati Çıtak
- Department of Thoracic Surgery, University of Zurich, Zurich, Switzerland
| | - Özgür İşgörücü
- Department of Thoracic Surgery, Bakırköy Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Ayşe Ulukol
- Department of Anesthesiology and Reanimation, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, İstanbul, Turkey
| | - Songül Büyükkale
- Department of Thoracic Surgery, Şişli Memorial Hospital, İstanbul, Turkey
| | - Çiğdem Obuz
- Department of Thoracic Surgery, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, İstanbul, Turkey
| | - Mustafa Vedat Doğru
- Department of Thoracic Surgery, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, İstanbul, Turkey
| | - Adnan Sayar
- Department of Thoracic Surgery, Şişli Memorial Hospital, İstanbul, Turkey
| |
Collapse
|
8
|
Bousema JE, Dias EM, Hagen SM, Govaert B, Meijer P, van den Broek FJC. Subpleural multilevel intercostal continuous analgesia after thoracoscopic pulmonary resection: a pilot study. J Cardiothorac Surg 2019; 14:179. [PMID: 31640750 PMCID: PMC6806578 DOI: 10.1186/s13019-019-1003-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 09/20/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sufficient pain control and rapid mobilisation after VATS are important to enhance recovery and prevent complications. Thoracic epidural analgesia (TEA) is the gold standard, but failure rates of 9-30% have been described. In addition, TEA reduces patient mobilisation and bladder function. Subpleural continuous analgesia (SCA) is a regional analgesic technique that is placed under direct thoracoscopic vision and is not associated with the mentioned disadvantages of TEA. The objective of this study was to assess surgical feasibility, pain control and patient satisfaction of SCA. METHODS Observational pilot study in patients who underwent VATS pulmonary resection and received SCA (n = 23). Pain scores (numeric rating scale 0-10) and patient satisfaction (5-point Likert scale) were collected on postoperative day (POD) 0-3. Secondary outcomes were the period of urinary catheter use and period to full mobilisation. RESULTS Placement of the subpleural catheter took an average of 11 min (SD 5) and was successful in all patients. Pain scores on POD 0-3 were 1.2 (SD 1.2), 2.0 (SD 1.9), 1.7 (SD 1.5) and 1.2 (SD 1.1) respectively. On POD 0-3 at least 79% of patients were satisfied or very satisfied on pain relief and mobilisation. The duration of subpleural continuous analgesia was 4 days (IQR 3-5, range 2-11). Urinary catheters were used zero days (IQR 0-1, range 0-6) and full mobilisation was achieved on POD 2 (IQR 1-2, range 1-6). CONCLUSION Subpleural continuous analgesia in VATS pulmonary resection is feasible and provides adequate pain control and good patient satisfaction. TRIAL REGISTRATION This pilot study was not registered in a trial register.
Collapse
Affiliation(s)
- Jelle E. Bousema
- Department of Surgery, Máxima Medical Centre, PO BOX 7777, Veldhoven, MB 5500 the Netherlands
| | - Esther M. Dias
- Department of Anaesthesiology, Máxima Medical Centre, Veldhoven, the Netherlands
| | - Sander M. Hagen
- Department of Surgery, Máxima Medical Centre, PO BOX 7777, Veldhoven, MB 5500 the Netherlands
| | - Bastiaan Govaert
- Department of Surgery, Máxima Medical Centre, PO BOX 7777, Veldhoven, MB 5500 the Netherlands
| | - Patrick Meijer
- Department of Anaesthesiology, Máxima Medical Centre, Veldhoven, the Netherlands
| | | |
Collapse
|
9
|
Comparison of cost and outcomes in patients receiving thoracic epidural versus liposomal bupivacaine for video-assisted thoracoscopic pulmonary resection. Am J Surg 2019; 217:520-524. [DOI: 10.1016/j.amjsurg.2018.10.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/12/2018] [Accepted: 10/13/2018] [Indexed: 11/21/2022]
|
10
|
Velazco CS, Arsanjani R, Jaroszewski DE. Nuss procedure in the adult population for correction of pectus excavatum. Semin Pediatr Surg 2018; 27:161-169. [PMID: 30078487 DOI: 10.1053/j.sempedsurg.2018.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Minimally invasive repair of pectus excavatum has been successfully modified for use in adult patients. Many patients present in adulthood with progression of symptoms as the chest wall becomes less compliant with age. A thorough workup is completed including echocardiogram and chest CT to evaluate for anatomic abnormalities. Cardiopulmonary exercise testing is done to quantify the physiologic impact. Modifications of the original Nuss procedure required to allow for successful adult repair include the use of forced sternal elevation, the use of multiple bars, medial bar fixation, and interspace support to prevent bar rotation and migration. Occasionally, fractures may occur that require an open procedure and osteotomy or cartilage resection and hybrid approach incorporating the principals of intrathoracic support and osteotomy with bar stabilization.
Collapse
Affiliation(s)
- Cristine S Velazco
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States.
| |
Collapse
|
11
|
Mercieri M, D'Andrilli A, Arcioni R. Improving postoperative pain management after video-assisted thoracic surgery lung resection contributes to enhanced recovery, but guidelines are still lacking. J Thorac Dis 2018; 10:S983-S987. [PMID: 29849227 DOI: 10.21037/jtd.2018.03.152] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Marco Mercieri
- Department of Medical and Surgical Science and Translational Medicine, Sapienza University of Rome, Pain Unit, Sant'Andrea Hospital, Rome, Italy
| | - Antonio D'Andrilli
- Department of Medical and Surgical Science and Translational Medicine, Sapienza University of Rome, Thoracic Surgery Unit, Sant'Andrea Hospital, Rome, Italy
| | - Roberto Arcioni
- Department of Medical and Surgical Science and Translational Medicine, Sapienza University of Rome, Pain Unit, Sant'Andrea Hospital, Rome, Italy
| |
Collapse
|
12
|
Ewais MM, Chaparala S, Uhl R, Jaroszewski DE. Outcomes in adult pectus excavatum patients undergoing Nuss repair. PATIENT-RELATED OUTCOME MEASURES 2018; 9:65-90. [PMID: 29430201 PMCID: PMC5796466 DOI: 10.2147/prom.s117771] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Pectus excavatum (PEx) is one of the most common congenital chest wall deformities. Depending on the severity, presentation of PEx may range from minor cosmetic issues to disabling cardiopulmonary symptoms. The effect of PEx on adult patients has not been extensively studied. Symptoms may not occur until the patient ages, and they may worsen over the years. More recent publications have implied that PEx may have significant cardiopulmonary implications and repair is of medical benefit. Adults presenting for PEx repair can undergo a successful repair with a minimally invasive "Nuss" approach. Resolution of symptoms, improved quality of life, and satisfying results are reported.
Collapse
Affiliation(s)
- MennatAllah M Ewais
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Shivani Chaparala
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Rebecca Uhl
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Dawn E Jaroszewski
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| |
Collapse
|
13
|
Ghee CD, Fortes DL, Liu C, Khandhar SJ. A Randomized Controlled Trial of Continuous Subpleural Bupivacaine After Thoracoscopic Surgery. Semin Thorac Cardiovasc Surg 2017; 30:240-249. [PMID: 29024718 DOI: 10.1053/j.semtcvs.2017.09.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2017] [Indexed: 12/26/2022]
Abstract
We sought to evaluate the merit of routine placement of a subpleural tunneled pain catheter delivering local anesthetic as measured by narcotic medication usage and subjective pain score analysis. Eighty-six patients were randomized into the subpleural catheter or intraoperative incision site injection groups in a 1:1 fashion, and underwent thoracoscopic surgery using 2 incisions. All patients had standardized anesthetic delivery and postoperative pain control. Patients' use of pain medication and pain scores was tracked for 7 days postoperatively. There was no significant difference in the 2 groups' usage of narcotics (P = 0.23), acetaminophen (P = 0.23), or nonsteroidal antiinflammatory drugs (P = 0.57) over time from linear mixed model analysis. The subpleural catheter group had significantly higher nonsteroidal antiinflammatory drug self-reported usage on postoperative day 4 (P = 0.04), postoperative day 5 (P = 0.05), postoperative day 6 (P = 0.01), and postoperative day 7 (P <0.01). There were no significant differences in average daily pain scores (all P ≥ 0.06). Length of hospital stay and results from 30-day postoperative surveys were not significantly different between the subpleural catheter and the intraoperative incision site injection groups. Our results did not show any objective differences between the subpleural catheter and the intraoperative incision site injection groups to justify routine use of tunneled subpleural catheters. The main limitation of this study is missing self-reported data. The differences noted in daily nonsteroidal antiinflammatory drug use in the pain catheter arm may actually suggest slightly worse pain control in those patients, although the clinical significance seems to be minimal.
Collapse
Affiliation(s)
- Charles D Ghee
- Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia.
| | | | - Chang Liu
- Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Sandeep J Khandhar
- Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia
| |
Collapse
|
14
|
|
15
|
Jaroszewski DE, Temkit M, Ewais MM, Luckritz TC, Stearns JD, Craner RC, Gaitan BD, Ramakrishna H, Thunberg CA, Weis RA, Myers KM, Merritt MV, Rosenfeld DM. Randomized trial of epidural vs. subcutaneous catheters for managing pain after modified Nuss in adults. J Thorac Dis 2016; 8:2102-10. [PMID: 27621865 DOI: 10.21037/jtd.2016.06.62] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Minimally invasive repair of pectus excavatum (MIRPE) is now performed in adults. Managing adult patients' pain postoperatively has been challenging due to increased chest wall rigidity and the pressure required for supporting the elevated sternum. The optimal pain management regimen has not been determined. We designed this prospective, randomized trial to compare postoperative pain management and outcomes between thoracic epidural analgesia (TEA) and bilateral subcutaneous infusion pump catheters (On-Q). METHODS Patients undergoing MIRPE (modified Nuss) underwent random assignment to TEA or On-Q group. Both groups received intravenous, patient-controlled opioid analgesia, with concomitant delivery of local anesthetic. Primary outcomes were length of stay (LOS), opioid use, and pain scores. RESULTS Of 85 randomly assigned patients, 68 completed the study [52 men, 76.5%; mean (range) age, 32.2 (20.0-58.0) years; Haller index, 5.9 (range, 3.0-26.7)]. The groups were equally matched for preoperative variables; however, the On-Q arm had more patients (60.3%). No significant differences were found between groups in mean daily pain scores (P=0.52), morphine-equivalent opioid usage (P=0.28), or hospital stay 3.5 vs. 3.3 days (TEA vs. On-Q; P=0.55). Thirteen patients randomized to TEA refused the epidural and withdrew from the study because they perceived greater benefit of the On-Q system. CONCLUSIONS Postoperative pain management in adults after MIRPE can be difficult. Both continuous local anesthetic delivery by TEA and On-Q catheters with concomitant, intravenous, patient-controlled anesthesia maintained acceptable analgesia with a reasonable LOS. In our cohort, there was preference for the On-Q system for pain management.
Collapse
Affiliation(s)
- Dawn E Jaroszewski
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - M'hamed Temkit
- Department of Biostatistics, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - MennatAllah M Ewais
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Todd C Luckritz
- Department of Pharmacy, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Joshua D Stearns
- Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Ryan C Craner
- Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Brantley D Gaitan
- Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Harish Ramakrishna
- Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | | | - Ricardo A Weis
- Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Kelly M Myers
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Marianne V Merritt
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - David M Rosenfeld
- Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| |
Collapse
|
16
|
Jung J, Park SY, Haam S. Efficacy of subpleural continuous infusion of local anesthetics after thoracoscopic pulmonary resection for primary lung cancer compared to intravenous patient-controlled analgesia. J Thorac Dis 2016; 8:1814-9. [PMID: 27499973 DOI: 10.21037/jtd.2016.06.16] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND This study compared the efficacy and side effects of intravenous patient-controlled analgesia (IV-PCA) with those of a subpleural continuous infusion of local anesthetic (ON-Q system) in patients undergoing thoracoscopic pulmonary resection for primary lung cancer. METHODS We retrospectively reviewed 66 patients who underwent thoracoscopic pulmonary resection for primary lung cancer from January 2014 to August 2015 (36 in the IV-PCA group and 30 in the ON-Q group). The numeric pain intensity scale (NPIS), additional IV injections for pain control, side effects, and early discontinuation of the pain control device were compared. RESULTS There were no differences in the general characteristics of the two groups. The NPIS scores gradually decreased with time (P<0.001), but the two groups had differences in pattern of NPIS scores (P=0.111). There were no differences in the highest NPIS score during admission (4.75±2.35 vs. 5.27±1.87, P=0.334) or the number of additional IV injections for pain control in the same period (0.72±0.94 for IV-PCA vs. 0.83±0.65 for ON-Q; P=0.575). Side effects such as nausea, dizziness, and drowsiness were significantly more frequent with IV-PCA (36.1% vs. 10.0%, P=0.014), and early discontinuation of the pain control device was more frequent in the IV-PCA group (33.3% vs. 6.7%, P=0.008). CONCLUSIONS The ON-Q system was equivalent to the IV-PCA for postoperative pain control after thoracoscopic pulmonary resection for primary lung cancer, and it also had fewer effects and early discontinuations.
Collapse
Affiliation(s)
- Joonho Jung
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Seong Yong Park
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Seokjin Haam
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| |
Collapse
|
17
|
Lee SH, Lee CY, Lee JG, Kim N, Lee HM, Oh YJ. Intraoperative Dexmedetomidine Improves the Quality of Recovery and Postoperative Pulmonary Function in Patients Undergoing Video-assisted Thoracoscopic Surgery: A CONSORT-Prospective, Randomized, Controlled Trial. Medicine (Baltimore) 2016; 95:e2854. [PMID: 26886651 PMCID: PMC4998651 DOI: 10.1097/md.0000000000002854] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Video-assisted thoracoscopic surgery (VATS) has been known to be a stressful event for patients, and dexmedetomidine is known to attenuate surgery-induced sympathetic responses and potentiate analgesia in perioperative periods. The present was designed to evaluate the effects of intraoperative dexmedetomidine administration on the quality of recovery (QoR) and pulmonary function after VATS. Patients with lung cancer undergoing VATS were randomized to Dex group (loading of 1.0 μg/kg for 20 minutes before the termination of surgery, n = 50) or Control group (comparable volume of normal saline, n = 50). The QoR-40 questionnaire assesses postoperative recovery and validates the overall surgical and general anesthesia outcomes. The QoR-40 scores, forced expiratory volume for 1 second (FEV1) on postoperative day (POD) 1 and 2, and emergence agitation were evaluated. The global QoR-40 score (162.3 ± 17.8 vs 153.3 ± 18.7, P = 0.016 on POD 1; 174.3 ± 16.0 vs 166.8 ± 16.7, P = 0.028 on POD 2) and FEV1 (2.1 ± 0.4 vs 1.9 ± 0.5 L, P = 0.034 on POD 1; 2.2 ± 0.5 vs 2.0 ± 0.4 L, P = 0.030 on POD 2) were significantly higher in the Dex group compared with the Control group on POD1 and POD 2. The score of emergence agitation was lower in the Dex group compared with the Control group (3 [2-5] vs 5 [3-7], P < 0.001). The number of patients indicating severe emergence agitation was shorter in the Dex group than Control group (0 [0%] vs 7 [14%], P = 0.048). The length of hospital stay was significantly shorter (6.7 [3-9] vs 8.4 [4-9] days, P = 0.045) in the Dex group compared with the Control group. Intraoperative dexmedetomidine administration improved QoR, postoperative pulmonary function, and emergence agitation in patients undergoing VATS. Consequently, intraoperative dexmedetomidine administration could improve postoperative outcomes and reduced the length of hospital stay in patients undergoing VATS.
Collapse
Affiliation(s)
- Su Hyun Lee
- From the Department of Anesthesiology and Pain Medicine (SHL, NK, HML, YJO); Anesthesia and Pain Research Institute (SHL, NK, YJO); Department of Thoracic and Cardiovascular Surgery (CYL, JGL), Yonsei University College of Medicine, Seoul, Korea
| | | | | | | | | | | |
Collapse
|