A review of anesthetic considerations and postoperative pain control after the Nuss procedure

Intercostal Nerve Cryoablation as an Effective Pain Management Strategy in the Nuss Procedure: Reducing Opioid Use and Hospital Stay

INTRODUCTION

 Erector spinae plane (ESP) blocks, thoracic epidural, and patient-controlled analgesia (PCA) have all been used for perioperative pain management in the Nuss procedure without a consensus on what modality produces the best outcomes. Intercostal nerve cryoablation (INC) is a relatively new modality that involves freezing the nerves to prevent pain during recovery. Our hypothesis is that using INC for the Nuss procedure will decrease opioid use, pain scores, and length of stay (LOS) but will increase cost compared with ESP block, thoracic epidural, and PCA.

MATERIALS AND METHODS

 This retrospective, observational study compared 108 patients who underwent the Nuss procedure at a pediatric acute care children's hospital in the southeast US. Patient charts were evaluated for significant differences in LOS, opioid use, and reported pain ratings based on type of analgesia administered: INC (n = 30), ESP block (n = 19), thoracic epidural (n = 41), and PCA (n = 18). Secondary variables included emergency department visits, readmissions, opioid refills, and various anesthetic and operative costs. Analysis of variance was performed on all outcome measures.

RESULTS

 Average LOS was significantly decreased in the INC group (2.9 days) compared with the thoracic epidural (4.7 days, p < 0.05) and the PCA groups (3.7 days, p < 0.05). Average cumulative opioid use was significantly decreased in the INC group (50.4 morphine milligram equivalents [MME]) compared with the thoracic epidural (117 MME, p < 0.05) and PCA groups (172.1 MME, p < 0.05).

CONCLUSIONS

 This study suggests that INC can be a viable and cost-effective option for reducing postoperative opioid consumption and LOS in Nuss procedure patients. Pain perception was lower in the INC group compared with the rest of the groups, except the epidurals, which were similar. However, the opioid consumption of the INC group was significantly lower than any other group. Despite the INC group having higher initial costs, it did not result in the highest total hospital charges, indicating its potential cost-effectiveness. There is a need for larger prospective randomized controlled trials to guide future research efforts.

Perioperative considerations in anesthesia for minimally invasive repair of pectus excavatum, Nuss procedure

Pectus excavatum (PE) is a common anterior chest wall deformity that affects the heart and lungs depending on the severity of compression. The Nuss procedure, a minimally invasive repair of pectus excavatum, has evolved over the years with thoracoscopic assistance and minimal incision. Despite improved surgical techniques, pain and nausea are often the most common factors determining hospital length of stay. This review will explore the preoperative, intraoperative, and postoperative anesthetic considerations necessary for improving patient outcomes, reducing surgical stress, and shortening hospital stays for patients undergoing the Nuss procedure.

Ultrasound-guided erector spinae plane block versus thoracic epidural block for postoperative analgesia in pediatric Nuss surgery: a randomized noninferiority trial

PURPOSE

Thoracic epidural anesthesia (TEA) is often used for analgesia after thoracic surgery. Erector spinae plane block (ESPB) has been proposed to provide adequate analgesia. We hypothesized that ESPB would be noninferior to TEA as a part of multimodal analgesia in pediatric patients undergoing the Nuss procedure.

METHODS

Patients aged 7-18 years and scheduled for the Nuss procedure were randomly allocated to receive bilateral single-shot ESPB or TEA and a multimodal analgesic regimen including parent-controlled intravenous analgesia (PCIA). At 6 h, 12 h, 18 h, and 24 h postoperatively, pain was evaluated using the numeric rating scale (NRS) and opioid consumption was assessed by counting the number of PCIA boluses. The joint primary outcomes were the average pain score and opioid consumption at 24 h after surgery. The secondary outcomes were the NRS scores and the number of opioid boluses administered at different postoperative time points, adverse events, and recovery quality.

RESULTS

Three hundred patients underwent randomization, and 286 received ESPB (147 patients) or TEA (139 patients). At 24 h postoperatively, ESPB was noninferior to TEA in terms of the average NRS score (mean difference, - 0.1, 95% confidence interval [CI], - 0.3-0.1, margin = 1, P for noninferiority < 0.001) and the number of opioid boluses administered (mean difference, - 1.1, 95% CI, - 2.8-0.6, margin = 7, P for noninferiority < 0.001). Adverse events and patient recovery were comparable between groups.

CONCLUSIONS

The results demonstrate that combined with a multimodal analgesia, ESPB provides noninferior analgesia compared to TEA with respect to pain score and opioid consumption among pediatric patients undergoing the Nuss procedure.

Analgesic Effectiveness of Truncal Plane Blocks in Patients Undergoing the Nuss Procedure: A Randomized Controlled Trial

INTRODUCTION

Most patients undergoing the Nuss procedure reported moderate to severe pain after surgery. This study aimed to investigate the efficacy and safety of ultrasound-guided serratus anterior plane block (SAPB) combined with transversus thoracic muscle plane (TTMP) block for relieving acute pain in patients undergoing the Nuss procedure.

METHODS

The enrolled patients in our study were allocated to either receive combined nerve blocks with ropivacaine (NB group) or saline (CON group). The primary outcome of this study was postoperative pain at 2, 4, 8, 16, 24, 36, and 48 h during rest and movement (coughing). Secondary outcomes included intraoperative dosage of remifentanil, the time to extubation and the length of stay in the post-anesthesia care unit (PACU), the total acetaminophen and codeine tablet consumption, time to first bowel movement, time to first flatus, opioid-related adverse events, and the length of hospital stay.

RESULTS

Patients in the NB group had significantly lower Numerical Rating Scale (NRS) pain scores compared with the CON group. The NB group required significantly less postoperative acetaminophen consumption and lower dosages of perioperative sufentanyl and remifentanil compared with the CON group. The length of stay in the PACU and time to extubation were significantly increased in the CON group compared with the NE group. Time to first bowel movement and time to first flatus were earlier in the NB group. But there were no significant differences between the groups in terms of the length of hospital stay and codeine tablet consumption.

CONCLUSION

Ultrasound-guided SAPB and TTMP blocks in patients undergoing the Nuss procedure could provide effective analgesia.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Registry (ChiCTR2000038506).

Serratus Anterior Plane Block: A Better Modality of Pain Control after Pectus Excavatum Repair

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.

Benefits of the Erector Spinae Plane Block before Cryoanalgesia in Children Undergoing Surgery for Funnel Chest Deformity

Thoracic surgery causes significant pain despite standard multimodal analgesia. Intraoperative cryoanalgesia may be a solution. The onset of the clinical effect of cryoanalgesia can take 12-36 h. The addition of a regional anaesthesia before the cryoanalgesia procedure can enable analgesic protection for the patient during this period. The main aim of the study was to evaluate the benefits of the erector spinae plane (ESP) block prior to Nuss surgery. The 'control' group consisted of 10 teenagers who underwent cryoablation together with intravenous multimodal analgesia according to the standard protocol. The 'intervention' group included 26 teenage patients who additionally received an erector spinae plane block before operation. Pain relief (p = 0.015), opioid use (p = 0.009), independent physical activity and rehabilitation (p = 0.020) were faster in the intervention group. No features of local anaesthetic drug toxicity or complications of the ESP block were observed. The bilateral ESP block together with intraoperative intercostal nerve cryoablation performed prior to Nuss correction of funnel chest were more effective in terms of pain control.

Raising the Bar: Multimodal Analgesia with Transdermal Lidocaine for Nuss Repair of Pectus Excavatum Decreases Length of Stay and Opioid Use

INTRO

Pain management for minimally invasive (Nuss) repair of pectus excavatum (PE) is challenging, particularly as the judicious use of opioids has become a patient safety priority. Multi-modal pain management protocols are increasingly used, but there is limited experience using transdermal lidocaine patches (TLP) in this patient population.

METHODS

Pediatric anesthesiologists and surgeons in a children's hospital within a hospital designed a multi-modal perioperative pain management protocol for patients undergoing Nuss repair of PE (IRB00068901). The protocol included use of TLP in addition to other adjuncts such as methadone, gabapentin, and NSAIDS. Following initiation of the protocol charts were reviewed retrospectively, comparing outcomes before and after implementation of the protocol.

RESULTS

Forty-nine patients underwent a Nuss procedure between 2013 and 2022, 15 prior to initiation of the protocol and 34 after. Patient demographics and operative length were similar between the two groups. Average length of stay decreased from 4.7 to 3.3 days and reported opioid use at the time of the first outpatient post-op visit dropped from 60% to 24% (p < 0.05). Morphine milligram equivalents (MME) usage was decreased following implementation during hospital admission, at discharge, and at first post-operative visit (464 vs. 169, 1288 vs. 218, and 214 vs. 56, respectfully, p < 0.05). There were no ED visits or readmissions <30 days related to post-operative pain.

CONCLUSION

Post-operative opioid usage and hospital length of stay were decreased after initiation of the protocol. Transdermal lidocaine patches may be a helpful adjunct to minimize narcotic requirements after repair of pectus excavatum.

LEVEL OF EVIDENCE

Level II.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Comparing postoperative analgesia of bilateral serratus anterior plane block and thoracic paravertebral block for children following the Nuss procedure: protocol for a randomised, double-blind, non-inferiority clinical trial

INTRODUCTION

The Nuss procedure, despite being a minimally invasive surgery, is regarded as one of the most painful surgical procedures in children, and postoperative pain control remains a major clinical issue in this population. Thoracic paravertebral nerve block (TPVB) is reported as excellent pain relief for the Nuss procedure despite its challenging performance and associated adverse effects. Serratus anterior plane block (SAPB) is a simplified and effective method for managing thoracic pain as an alternative to TPVB. However, whether SAPB can provide analgesia comparable with that provided by the TPVB approach in children undergoing the Nuss procedure is unknown.

METHODS AND ANALYSIS

This will be a prospective, randomised, double-blind, single-centre, non-inferiority trial that will enrol children aged 7-16 years subjected to the Nuss operation for pectus excavatum. In total, 74 paediatric patients will be randomly assigned to either the SAPB or TPVB group after general anaesthesia to receive ultrasound-guided regional nerve blocks (0.25% ropivacaine 2.5 mg/kg). The primary outcome will be the assessment of postoperative pain intensity at predetermined time points. The secondary outcomes will include assessing intraoperative opioid intake, consumption of analgesics within 24 hours postoperatively, time of first use of rescue analgesics, extubation time, perioperative adverse events and plasma ropivacaine concentrations across the block groups. Demographic and clinical characteristics (eg, pectus severity and the number of bars used) of the patients will be recorded. All data will be collected by investigators who are blinded to the treatment.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Ethics Committee on Biomedical Research of the West China Hospital of Sichuan University (2021-1275). During the period of the study, all procedures will be conducted following the principles of the Declaration of Helsinki. The results of the trial will be published in a peer-reviewed scientific journal.

TRIAL REGISTRATION NUMBER

ChiCTR2200056596.

A pilot study of multi-modal pain management for same-day discharge after minimally invasive repair of pectus excavatum (Nuss procedure) in children

BACKGROUND

Despite advancements in minimally invasive repair of pectus excavatum (MIRPE), Nuss procedure, postoperative pain control remains challenging. This report covers a multimodal regimen using bilateral single-shot paravertebral block (PVB) and bilateral thoracoscopic intercostal nerve (T3-T7) cryoablation, leading to significant reduction in length of stay (LOS) and high rate of same-day discharge.

METHODS

This is a comparative study of pain management protocols for patients undergoing the Nuss procedure at a single center from 2016 through 2020. All patients underwent the the same surgical technique for the treatment of pectus excavatum at a single center. Patients received bilateral PVB with continuous infusion (Group 1, n = 12), bilateral PVB with infusion and right-side cryoablation (Group 2, n = 9), or bilateral single-shot PVB and bilateral cryoablation (Group 3, n = 17). The primary outcome was LOS with focus on same-day discharge, and the secondary outcome was decreased opioid usage.

RESULTS

Eleven of 17 patients in Group 3 (65%) (bilateral single-shot PVB and bilateral cryoablation) were discharged the same day as surgery. The remaining Group 3 patients were discharged the following day with no complications or interventions. Compared to Group 1 (no cryoablation), Group 3 had shorter LOS (median 4.4 days vs. 0.7 days, respectively, p < 0.001) and significantly decreased median opioid use on the day of surgery (0.92 mg/kg vs. 0.47 mg/kg, p = 0.006).

CONCLUSION

Findings demonstrate the feasibility of multimodal pain management for same-day discharge after the Nuss procedure. Future multisite studies are needed to investigate the superiority of this approach to established methods.

LEVEL OF EVIDENCE

III.

Intercostal Nerve Cryoablation in Minimally Invasive Repair of Pectus Excavatum: Effect on Pulmonary Function

Introduction: Cryoablation of intercostal nerves is performed for pain control after minimally invasive repair of pectus excavatum (MIRPE). Cryoablation affects both sensory and motor neurons, resulting in temporary anesthesia to the chest wall and loss of intercostal motor function. The study objective is to determine the effect of cryoablation on incentive spirometry (IS) volumes, as a measure of pulmonary function, after MIRPE. Materials and Methods: A single-institution retrospective review of pediatric patients undergoing MIRPE was performed. All patients received a multimodal regimen (MMR) of analgesics postoperatively. Three groups were compared-cryoablation (CRYO), elastomeric pain pump (EPP), and MMR alone. The primary outcomes were postoperative IS volumes and IS volumes as a ratio of preoperative forced vital capacity (FVC). Secondary outcomes included pain scores, opioid use, length of stay (LOS), and infectious complications. Results: MIRPE was performed in 115 patients: 50 CRYO, 50 EPP, and 15 MMR alone. Groups were similar for demographics and pectus excavatum severity. Postoperative spirometry measurements were similar across groups: IS (CRYO 750 mL [500,961] versus EPP 750 mL [590,1019] versus MMR 696 mL [500,1037], P = .77); IS/FVC (CRYO 0.19 [0.14,0.26] versus EPP 0.20 [0.16,0.26] versus MMR 0.16 [0.15,0.24], P = .69). Although pain scores were also similar across groups, CRYO patients used less opioid (P < .05) and had shorter LOS (P < .05). Postoperative pneumonia was rare and similar across groups (P = 1.00). Conclusion: Intercostal nerve cryoablation during MIRPE does not adversely affect postoperative IS volumes or increase pneumonia rate, despite the temporary loss of motor innervation to intercostal muscles. Cryoablation provides effective pain control with less opioid use.

Cryoablation in 350 Nuss procedures: Evolution of hospital length of stay and opioid use

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.

Infectious complications of intercostal nerve cryoablation mediated by perioperative hypothermia during pediatric Nuss procedure

BACKGROUND

Intercostal nerve cryoablation (cryoanalgesia) is increasingly used for pain control in minimally invasive repair of pectus excavatum (MIRPE) by Nuss procedure. Cryoanalgesia may lower core body temperature and increase the risk of postoperative infectious complications. We investigated cryoanalgesia effects on infectious complications following MIRPE.

METHOD

We performed a retrospective review of patients undergoing MIRPE at our institution. Patients treated via multimodal analgesia with cryoanalgesia (Cryo) were compared to patients treated via multimodal analgesia +/- elastomeric pain pumps (Non-cryo). Core body and intraoperative minimum/maximum temperatures were recorded. Primary outcomes were wound infection and pneumonia; secondary outcome was length of stay (LOS). Fisher's Exact and Mann-Whitney U tests compared proportions and medians respectively, p-value ≤ 0.05 being significant.

RESULTS

80 patients were included, 35(43.7%) Cryo and 45(56.3%) Non-cryo. There were no significant differences in median [IQR] for age(15[13.3,16.0];p =0.86), number of bars inserted (2[1,2];p = 0.57), or operative time(123.5[98.3, 148.8]; p = 0.11) between the two groups. We found no significant differences in median [IQR] minimum temperature (35.4°C [35.0,35.8];p = 0.76), median change in intraoperative temperature (-0.13°C [-0.44,0.00];p = 0.94) or median recovery temperature (-1.10°C [-1.56,-0.65]; p = 0.59) between Cryo and Non-cryo. PACU temperature was significantly lower in the Cryo group, 36.4°C [36.2,36.6] p = 0.04. There were no postoperative wound infections in either group and no significant difference in incidence of postoperative pneumonia (8.57% versus 2.22%,p =  0.31) or median[IQR] for LOS (4[3,4];p = 0.57), between Cryo and Non-cryo patients.

CONCLUSION

Although cryoanalgesia for MIRPE resulted in lower core body temperature, there appears to be no significant difference between Cryo and Non-Cryo patients for LOS or infectious complications.

Postoperative pain following minimally invasive repair of pectus excavatum: A descriptive study

BACKGROUND

Minimally Invasive Repair of Pectus Excavatum (MIRPE) is associated with significant postoperative pain. The objective of our study was to characterize the severity and duration of this pain, and to investigate possible associations with pectus severity.

METHODS

We conducted a retrospective cohort study of pediatric patients who underwent MIRPE from January 2014 to April 2018. Pectus excavatum (PE) severity was determined with 3 indices measured from computed tomography: Depression Index (DI), Correction Index (CI), and Haller index (HI). Mean pain scores for every 6-hour period and the presence of pain and intake of analgesics during follow-up were extracted from the medical record.

RESULTS

The cohort included 57 patients with a mean age of 15.9 ± 1.3 years. All 3 severity indices were positively correlated, with a correlation coefficient of 0.8 between the DI and CI. The requirement for 2 bars was significantly associated with higher indices (95% CI:0.18-0.63, p = 0.01). Pain was managed with thoracic epidural analgesia for all but one patient. Growth linear modeling identified five different pain trajectory subgroups of patients up to post-operative day 5. None of the tested predictors (age, gender, body image, physical activity level, DI, CI, HI, difference deformity-epidural level) were significantly associated with class membership. Persistent pain at one-year follow-up was present in 18% of patients, all with severe deformity (DI≥0.8).

CONCLUSION

Pain trajectory and intensity after MIRPE can be classified into discrete patterns but are not influenced by PE severity. Severe deformity seems to predict persistent pain at one year.

A multimodal protocol utilizing liposomal bupivacaine rib blocks leads to opioid reduction in patients undergoing the Nuss procedure

Background

A major challenge associated with the Nuss procedure for pectus excavatum repair is postoperative pain control. Early Recovery Program (ERP) protocols for the Nuss procedure are becoming common, but there is a paucity of experience using liposomal bupivacaine (LB), a long-acting local anesthetic, for rib blocks in this setting. We investigated whether a protocol utilizing LB rib blocks decreased opioid use after the Nuss procedure while achieving equivalent pain control.

Methods

All adolescent patients undergoing the Nuss procedure at our institution between January 2013 and January 2021 were included. Patients were divided into a pre-intervention cohort (n=15), a transition cohort (n=4), and a post-intervention cohort (n=13). Patients in all groups received scheduled acetaminophen and non-steroidals postoperatively. The pre-intervention cohort received an opioid patient-controlled analgesia (PCA) pump postoperatively, with a transition to oral opiates. The transition and post-intervention cohorts received scheduled gabapentin in addition to intraoperative bilateral rib blocks with longer-acting local anesthetic. Rib blocks were performed using 0.25% Bupivacaine in the pre-intervention group. In the transition group, epinephrine (1 mg/kg) was added to 0.25% bupivacaine for the rib block. Following approval in patients aged 13–18 years, 1.3% LB (2.25 mg/kg) was given for a rib block in the post-intervention cohort.

Results

Demographic and clinical variables were equivalent in all groups. Post-intervention patients received 90% fewer opioids [median morphine equivalent (MME) mg/kg] compared to the pre-intervention cohort (0.8 vs. 8.2 MME mg/kg, P<0.0001), with no significant difference in pain scores between groups. Hospital length of stay was decreased among the intervention cohort (3 vs. 4 days, P=0.002).

Conclusions

Significant decreases in opioid use and length of stay after the Nuss procedure were achieved by the implementation of a multimodal ERP for pain management, without increase in patient-reported pain scores.

Intraoperative Methadone Reduces Postoperative Opioid Requirements in Nuss Procedure for Pectus Excavatum

INTRODUCTION

Surgical correction of pectus excavatum by Nuss procedure, commonly referred to as minimally invasive repair of pectus excavatum (MIRPE), often results in significant postoperative pain. This study investigated whether adding intraoperative methadone would reduce the postoperative opioid requirement during admission for patients undergoing MIRPE.

METHODS

A retrospective cohort chart review was conducted for 40 MIRPE patients between 2018 and 2020. Patients were stratified into 2 groups: those who received multimodal anesthesia (MM, n = 20) and those who received multimodal anesthesia with the addition of intraoperative methadone (MM + M, n = 20). Data collected included total opioid consumption during hospital stay (morphine milligram equivalents [MMEs]), hospital length of stay (LOS), pain scores, time to ambulation, and time to tolerating solid food.

RESULTS

Addition of intraoperative methadone for patients undergoing MIRPE significantly reduced postoperative opioid requirements (MME/kg) during admission (P = .007). On average, patients in the MM group received 1.61 ± .55 MME/kg while patients in the MM + M group received 1.16 ± .44 MME/kg. Hospital opioid (non-methadone) total was also significantly reduced between the MM (1.87 ± .54) and MM + M group (1.37 ± .46), P = .003. There was no significant difference in hospital opioid total MME/kg administered between the groups. There were no significant differences observed in hospital LOS, pain scores, time to ambulation, or time to toleration of solid food.

DISCUSSION

Incorporating intraoperative methadone for patients undergoing MIRPE reduced postoperative opioid requirements and hospital opioid (non-methadone) totals without a significant change in pain scores. Patients undergoing the Nuss procedure may benefit from the administration of intraoperative methadone.

Anesthesia for Innovative Pediatric Surgical Procedures

Over the past few decades, there have been many advances in pediatric surgery, some using new devices (eg, VEPTR, MAGEC rods) and others using less invasive approaches (eg, Nuss procedure, endoscopic cranial suture release, minimally invasive tethered cord release). Although many of these procedures were initially met with caution or skepticism, continued experience over the past few decades has shown that these procedures are safe and effective. This article reviews the anesthetic considerations for these conditions and procedures.

Intercostal nerve cryoablation versus thoracic epidural for postoperative analgesia following pectus excavatum repair: a systematic review and meta-analysis

OBJECTIVES

Minimally invasive pectus excavatum repair via the Nuss procedure is associated with significant postoperative pain that is considered as the dominant factor affecting the duration of hospitalization. Postoperative pain after the Nuss procedures is commonly controlled by thoracic epidural analgesia. Recently, intercostal nerve cryoablation has been proposed as an alternative method with long-acting pain control and shortened hospitalization. The subsequent objective was to systematically review the outcomes of intercostal nerve cryoablation in comparison to thoracic epidural after the Nuss procedure.

METHODS

Six scientific databases were searched. Data concerning the length of hospital stay, operative time and postoperative opioid usage were extracted. If possible, data were submitted to meta-analysis using the mean of differences, random-effects model with inverse variance method and I2 test for heterogeneity.

RESULTS

Four observational and 1 randomized study were included, enrolling a total of 196 patients. Meta-analyses demonstrated a significantly shortened length of hospital stay [mean difference -2.91 days; 95% confidence interval (CI) -3.68 to -2.15; P < 0.001] and increased operative time (mean difference 40.91 min; 95% CI 14.42-67.40; P < 0.001) for cryoablation. Both analyses demonstrated significant heterogeneity (both I2 = 91%; P < 0.001). Qualitative analysis demonstrated the amount of postoperative opioid usage to be significantly lower for cryoablation in 3 out of 4 reporting studies.

CONCLUSIONS

Intercostal nerve cryoablation during the Nuss procedure may be an attractive alternative to thoracic epidural analgesia, resulting in shortened hospitalization. However, given the low quality and heterogeneity of studies, more randomized controlled trials are needed.

A New Device for Thoracoscopic Cryoanalgesia in Pectus Excavatum Repair: Preliminary Single Center Experience

Introduction: Cryoanalgesia has been recently described as alternative technique for immediate and persistent pain treatment after pectus excavatum repair. Cryoanalgesia has the potentiality to reduce analgesic consumption and length of hospitalization. However, cryoanalgesia has not been standardized yet: the previous reports describe different techniques and systems and include only small series. In Europe, no reports on cryoanalgesia for pectus repair have been published so far. Materials and Methods: This is a prospective single center pilot study performed in adolescents undergoing minimally invasive pectus excavatum repair with a new cryoanalgesia system, using a probe designed specifically for thoracoscopy. This new double lumen probe has the theoretical advantage of freezing only in its tip, so reducing the risk of complications. Results: Seven patients undergoing pectus excavatum repair were treated with cryoanalgesia performed with the new probe. No complications of cryoanalgesia were reported. Total consumption of morphine during hospital stay was between 0.1 and 0.35 mg/kg, with no side effects reported. Mean time to discharge was 2.4 days. All patients reported a good pain control with a fair need of rescue medications for pain relief during the first week after discharge, and a very good pain control without need of rescue medications during following weeks. Conclusions: Our pilot study showed that the new cryoanalgesia device is efficacious in terms of pain control, hospital stay and resumption of post-operative activities. The cryoprobe designed allowed an easy and safe maneuver. A prospective trial is needed to better define the risks and benefits of this technique.

The Nuss procedure for repair of pectus excavatum: 20 error traps and a culture of safety

In 1998, Donald Nuss changed the way the world thought about the surgical repair of pectus excavatum. The new operation adheres to sound orthopedic fundaments, but has a significantly higher learning curve than other operations in pediatric surgery. Variations in pectus excavatum type, severity, symmetry and chest wall pliability bring challenges. This article will detail common error traps and ways to avoid them when performing the Nuss procedure. As recent publications have shown, an operation done more than 50,000 times across the world may bring to light infrequent but devastating outcomes that may be preventable. The critical view of safety for pectus repair is discussed, as are areas where a culture of safety could optimize results on a larger scale. We will review potential opportunities to improve outcomes by identifying error traps in the preoperative, intraoperative, and postoperative care of patients undergoing the Nuss procedure.

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

OBJECTIVE

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

DESIGN

A retrospective cohort study.

SETTING

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

PARTICIPANTS

All participants were scheduled for MIRPE.

INTERVENTIONS

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

MEASUREMENT AND MAIN RESULTS

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

CONCLUSIONS

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