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Trò R, Orecchia A, Disma N, Uva P, Cavanna R, Zanardi N, Torre M, Fato MM. Comparison of Analgesia Methods Through a Web Platform in Patients Undergoing Thoracic Surgery: Pilot Design, Implementation, and Validation Study. JMIR Form Res 2024; 8:e56674. [PMID: 39378419 DOI: 10.2196/56674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 07/05/2024] [Accepted: 07/25/2024] [Indexed: 10/10/2024] Open
Abstract
BACKGROUND Pain management is a vital and essential part of postoperative pectus excavatum (PE) care. Given the lack of an international consensus on guidelines for postoperative handling and evaluation, further research is necessary to compare the efficacy of existing pain management methods regarding pain relief, side effects, and long-term outcomes. In this context, the use of eHealth solutions for data mining can enhance data collection efficiency, reduce errors, and improve patient engagement. However, these digital health care frameworks are currently underused in the context of pain management for PE. OBJECTIVE This research is part of the broader Cryoanalgesia for Pain Management After Pectus Excavatum Repair (COPPER) study conducted by Giannina Gaslini Children's Hospital to address postoperative pain and recovery in PE patients treated with either standard thoracic epidural analgesia or cryoanalgesia, which is considered its innovative alternative approach. Specifically, this work is aimed at introducing a valuable tool for a comprehensive and quantitative comparison of the 2 analgesia strategies. The tool is a web and mobile app designed to facilitate data collection, management, and analysis of clinical data for pain assessment. METHODS The adopted approach involves a careful design based on clinician input, resulting in an intuitive app structure with 3 main screens. Digital surveys are borrowed from paper surveys, including medical history and preoperative, postoperative, and follow-up evaluations. XTENS 2.0 was used to manage the data, and Ionic facilitated cross-platform app development, ensuring secure and adaptable data handling. RESULTS Preliminary analysis on a pilot cohort of 72 patients (36 treated with standard therapy and 36 treated with cryoanalgesia) indicated successful patient enrollment and balanced representation across treatment groups and genders. Notably, hospital stay was significantly shorter with cryoanalgesia than with standard therapy (Mann-Whitney-Wilcoxon 2-sided test with Bonferroni correction; P<.001; U statistic=287.5), validating its treatment efficacy. CONCLUSIONS This work is a step toward modernizing health care through digital transformation and patient-centered models. The app shows promise in streamlined data collection and patient engagement, although improvements in multilingual support, data validation, and incentivization of questionnaire completion are warranted. Overall, this study highlights the potential of digital health solutions in revolutionizing health care practices, fostering patient involvement, and improving care quality.
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Affiliation(s)
- Rosella Trò
- Department of Informatics, Bioengineering, Robotics and System Engineering, University of Genoa, Genoa, Italy
| | - Angelica Orecchia
- Department of Informatics, Bioengineering, Robotics and System Engineering, University of Genoa, Genoa, Italy
| | - Nicola Disma
- Unit for Research in Anaesthesia, Istituto di Ricovero e Cura a Carattere Scientifico Giannina Gaslini, Genoa, Italy
| | - Paolo Uva
- Clinical Bioinformatics, Istituto di Ricovero e Cura a Carattere Scientifico Giannina Gaslini, Genoa, Italy
| | - Roberto Cavanna
- Clinical Bioinformatics, Istituto di Ricovero e Cura a Carattere Scientifico Giannina Gaslini, Genoa, Italy
| | - Nicolò Zanardi
- Clinical Bioinformatics, Istituto di Ricovero e Cura a Carattere Scientifico Giannina Gaslini, Genoa, Italy
| | - Michele Torre
- Pediatric Thoracic and Airway Surgery Unit, Istituto di Ricovero e Cura a Carattere Scientifico Giannina Gaslini, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Marco Massimo Fato
- Department of Informatics, Bioengineering, Robotics and System Engineering, University of Genoa, Genoa, Italy
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Clinker C, Scaife J, Martinez D, Kahan AM, Eldredge RS, Russell KW. Effect of cryoablation in Nuss bar placement on opioid utilization and length of stay. Pediatr Surg Int 2024; 40:260. [PMID: 39363012 DOI: 10.1007/s00383-024-05838-2] [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] [Accepted: 09/18/2024] [Indexed: 10/05/2024]
Abstract
BACKGROUND Our institution recently transitioned from paravertebral nerve blocks (PVBs) to intercostal nerve cryoablation (INC) for pain control following minimally invasive repair of pectus excavatum (MIRPE). This study aimed to determine how INC affected the operative time, length of stay, complication rates, inpatient opioid use, and outpatient prescription of opioids at a single center. METHODS A retrospective review was performed at a single pediatric referral center of all patients who underwent MIRPE between 2018 and 2023. Patient demographics, operative details, and perioperative course were collected. The use of INC versus PVB was recorded. Univariate analyses were performed using Wilcoxon rank sum tests for continuous variables and chi-squared tests for categorical variables. RESULTS 255 patients were included with a median age of 15 years, median BMI of 18.50 kg/m2, and median Haller index of 4.40. INC was utilized in 41% (105/255), and 59% (150/255) received PVB. The two groups did not differ significantly in BMI, Haller index, or complications, though the INC patients were older by 1 year (15.0 vs. 16.0, p = 0.034). INC was associated with an increased operative time (INC: 92 min vs. PVB: 67 min, p < 0.001), decreased length of stay (3 vs. 4 days, p = < 0.001), more than twofold decrease in inpatient opioids per day (INC: 16 MME vs. PVB: 41 MME, p < 0.001), and a fourfold decrease in the amount of opioids prescribed at discharge (INC: 90 MME vs. PVB: 390 MME, p < 0.001). CONCLUSION INC after MIRPE significantly decreased both the inpatient opioid utilization and our outpatient prescribing practices while also decreasing our overall length of stay without increasing complications. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Christopher Clinker
- University of Utah School of Medicine, 100 North Mario Capechi Drive, Salt Lake City, UT, 84103-0000, United States
| | - Jack Scaife
- University of Utah School of Medicine, 100 North Mario Capechi Drive, Salt Lake City, UT, 84103-0000, United States
| | - Davian Martinez
- University of Utah School of Medicine, 100 North Mario Capechi Drive, Salt Lake City, UT, 84103-0000, United States
| | - Anastasia M Kahan
- Department of Surgery, Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, United States
| | | | - Katie W Russell
- University of Utah School of Medicine, 100 North Mario Capechi Drive, Salt Lake City, UT, 84103-0000, United States.
- Department of Surgery, Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, United States.
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DiFiore JW, Robertson JO, Sung W. Sensory Recovery Following Intercostal Nerve Cryoablation for the Nuss Procedure. J Pediatr Surg 2024:161904. [PMID: 39332975 DOI: 10.1016/j.jpedsurg.2024.161904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2024] [Accepted: 09/03/2024] [Indexed: 09/29/2024]
Abstract
BACKGROUND Intercostal nerve cryoablation (CRYO) during the Nuss procedure is effective for postoperative pain control, but little is known about patterns of sensory recovery following its use. METHODS A single institution, prospective study of 121 patients undergoing Nuss bar placement with CRYO for pectus excavatum was conducted to assess sensory recovery. Patients received CRYO from T3-T8 and were followed at scheduled intervals. The primary outcome was time to return of normal chest wall sensation. Secondary outcomes included alterations in sensation, permanent numbness, and chronic neuropathic pain. RESULTS Following CRYO, median time to normal sensation was 6.0 (range 1-12) months. This was achieved postoperatively by 14.9% at 3 months, 62.3% at 6 months, 85.1% at 9 months, and 98.3% at 12 months. 1.7% had a small area of persistent/permanent numbness in the lower central sternum. The most common altered sensation was hypersensitivity which occurred in 20.7%. Hypersensitivity began on average at 3.0 months postoperatively (range 0.25-6 months) and lasted a median of 1.0 (range 0.5-9) months. Only 5.8% described their altered sensation as painful, and all of these were successfully treated with gabapentin and/or capsaicin cream. All others resolved spontaneously. There were no cases of chronic neuropathic pain. CONCLUSIONS Sensory recovery following CRYO is a slow process that ultimately leads to normal sensation in virtually all patients by one year. Hypersensitivity is more common than expected but is rarely described as painful and always resolves. Permanent numbness can occur but is very rare and limited in scope. LEVEL OF EVIDENCE Therapeutic. LEVEL IV
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Affiliation(s)
- John W DiFiore
- Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, Cleveland, OH, USA.
| | - Jason O Robertson
- Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Wai Sung
- Department of Pediatric Anesthesiology, Cleveland Clinic Children's Hospital, Cleveland OH, USA
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Zacha S, Lopez M, Bilas J, Skonieczna-Żydecka K, Miegoń J, Biernawska J. One- versus Two-Minute Intercostal Nerve Cryoanalgesia in Children Undergoing Surgery for Funnel Chest Deformity. J Pers Med 2024; 14:875. [PMID: 39202066 PMCID: PMC11355873 DOI: 10.3390/jpm14080875] [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: 06/28/2024] [Revised: 07/29/2024] [Accepted: 08/16/2024] [Indexed: 09/03/2024] Open
Abstract
An inherent defect of the sternum and ribs results in the formation of a funnel-shaped anterior chest wall. The gold standard of surgical correction is the minimally invasive Nuss procedure, which might cause severe pain and carries the risk of sensory disturbances and chronic discomfort. Integrating cryoanalgesia with standard multimodal analgesia improves the outcomes of this procedure. Based on histological results, it was hypothesised that the time of cryo-application can be reduced from the current standard period of two minutes. The goal of this study was to evaluate the efficacy of a one-minute application compared with the routine two-minute method in the same patient, considering the subjective perception of pain and sensory disturbances. A total of 33 patients were included in this prospective study. The results show that the assessment of pain severity and sensory disturbances did not differ significantly in terms of the time of cryo-application during first 14 days after the surgical procedure. The one-minute cryo-application time for intraoperative intercostal nerve cryoablation prior to the Nuss procedure seems to be as safe and effective as the routinely used two-minute application time in regards to pain severity, sensory disturbances, and the risk of chronic pain development. Intercostal nerve cryoanalgesia is an essential element of multimodal analgesia.
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Affiliation(s)
- Sławomir Zacha
- Department of Paediatric Orthopaedics and Musculoskeletal Oncology, Pomeranian Medical University, 70-252 Szczecin, Poland
| | - Manuel Lopez
- Pediatric Surgery Department, Vall d’Hebron Hospital, 08035 Barcelona, Spain;
| | - Jarosław Bilas
- Department of Paediatric Orthopaedics and Musculoskeletal Oncology, Pomeranian Medical University, 70-252 Szczecin, Poland
| | | | - Jakub Miegoń
- Department of Anaesthesiology and Intensive Therapy, Pomeranian Medical University, 70-252 Szczecin, Poland (J.B.)
| | - Jowita Biernawska
- Department of Anaesthesiology and Intensive Therapy, Pomeranian Medical University, 70-252 Szczecin, Poland (J.B.)
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Eldredge RS, Ochoa B, Orcutt E, Hunteman Z, Rassam K, Lee J, Padilla BE. Prediction Model for Outpatient Opioid Use Following the Minimally Invasive Repair of Pectus Excavatum. J Pediatr Surg 2024:161663. [PMID: 39209686 DOI: 10.1016/j.jpedsurg.2024.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/31/2024] [Accepted: 08/02/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION To minimize unused outpatient opioids while providing adequate pain control, we sought to create a model to predict outpatient opioid use following the minimally invasive repair of pectus excavatum with cryoablation MIRPE-C. METHODS A retrospective review was conducted at a single center from May 2023 to January 2024 among patients <21 years who underwent MIPRE-C. Demographic and clinical data, including inpatient and outpatient opioid use were reviewed. Patients completed opioid use questionnaires at their first postoperative visit. Simple linear regression was employed to create a model for outpatient opioid use. RESULTS Sixty-eight patients underwent MIRPE-C: 84% were male (mean age of 15.2 ± 1.7 years, and median Haller index 4.2[IQR:3.7-5.7]). Daily mean inpatient opioid requirement and daily opioid doses were 0.3 ± 0.2 OME/day/kg and 2 ± 1.2 opioid doses/day. At the first outpatient follow-up visit, patients reported using a median of five 5-mg oxycodone tablets [IQR:1.6-10] for 5 days [IQR:2-7] with 22% of patients needing an opioid refill. On linear regression, inpatient opioid use had a significant relationship with the number of outpatient doses taken, while patient factors were not associated with outpatient opioid use. A simple equation for predicting opioid need based on best fit (R2 = 0.211) was developed: #OUTPATIENT OPIOID TABLETS = 3 TABLETS + (0.82 x #INPATIENT OPIOID RECIEVED). CONCLUSION The proposed outpatient opioid prescription model is simple to calculate and tailors the prescription to individual patient need. This model has the potential to provide effective pain control and avoid prescription refills, while minimizing over-prescription of opioids. LEVEL OF EVIDENCE Treatment study Level III.
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Affiliation(s)
- R Scott Eldredge
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA.
| | - Brielle Ochoa
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Emalee Orcutt
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Zeb Hunteman
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Kristin Rassam
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Justin Lee
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Benjamin E Padilla
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Child Health and Development, University of Arizona, School of Medicine, Phoenix, AZ, USA
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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 2024; 34:338-345. [PMID: 37364610 DOI: 10.1055/a-2117-4628] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [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.
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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
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Eldredge RS, Ochoa B, Carmichael J, Ostlie DJ, Lee J, McMahon L, Notrica DM, Padilla BE. Opioid Prescriptions at Discharge After Minimally Invasive Repair of Pectus Excavatum Are Reduced With Cryoablation. J Pediatr Surg 2024; 59:1291-1296. [PMID: 38584007 DOI: 10.1016/j.jpedsurg.2024.03.031] [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: 02/19/2024] [Accepted: 03/04/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND The minimally invasive repair of pectus excavatum (MIRPE) is associated with significant postoperative pain and opioid use. The objective of this study was to determine the effect of intercostal nerve cryoablation (Cryo) on inpatient and post-hospital opioid prescription practices following MIPRE. METHODS A retrospective review at a single pediatric center was conducted of patients ≤21 years old who underwent MIRPE. Oral morphine equivalents (OME) of inpatient and discharge opioids were compared between Cryo and no-Cryo cohorts. RESULTS 579 patients were identified (82.8% male, mean age 15.4 ± 2.0 years). Cryo was performed in 73.5% of patients. The total inpatient OME use was less in the Cryo group (0.89 ± 0.68 vs. 1.6 ± 0.5 OME/kg/day; p < 0.001). Patients who underwent Cryo were prescribed significantly less OME at discharge compared to the no-Cryo group (3.9 ± 1.7 vs. 10.0 ± 4.1 OME mg/kg, p < 0.001). There was no statistically significant difference in the proportion of patients who required an opioid prescription refill (Cryo 12.4% vs. no-Cryo 11.5%, p = 0.884) or were readmitted (Cryo 5.3% vs. no-Cryo 4.6%, p = 0.833). CONCLUSION Patients who underwent cryoablation during MIRPE were prescribed significantly less opioid at the time of discharge without increasing the need for opioid refills or hospital readmissions. LEVEL OF EVIDENCE Treatment study; Level III evidence.
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Affiliation(s)
- R Scott Eldredge
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA
| | - Brielle Ochoa
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Jared Carmichael
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Daniel J Ostlie
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA; Department of Child Health and Development, University of Arizona, School of Medicine, Phoenix, AZ, USA
| | - Justin Lee
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Child Health and Development, University of Arizona, School of Medicine, Phoenix, AZ, USA
| | - Lisa McMahon
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA; Department of Child Health and Development, University of Arizona, School of Medicine, Phoenix, AZ, USA
| | - David M Notrica
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA; Department of Child Health and Development, University of Arizona, School of Medicine, Phoenix, AZ, USA
| | - Benjamin E Padilla
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, AZ, USA; Department of Child Health and Development, University of Arizona, School of Medicine, Phoenix, AZ, USA.
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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.
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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
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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.
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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;
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Janssen N, Daemen JHT, Franssen AJPM, van Polen EJ, van Roozendaal LM, Hulsewé KWE, Vissers Y, de Loos ER. Intercostal nerve cryoablation versus thoracic epidural analgesia for minimal invasive Nuss repair of pectus excavatum: a protocol for a randomised clinical trial (ICE trial). BMJ Open 2024; 14:e081392. [PMID: 38531584 DOI: 10.1136/bmjopen-2023-081392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
INTRODUCTION Epidural analgesia is currently considered the gold standard in postoperative pain management for the minimally invasive Nuss procedure for pectus excavatum. Alternative analgesic strategies (eg, patient-controlled analgesia and paravertebral nerve block) fail in accomplishing adequate prolonged pain management. Furthermore, the continuous use of opioids, often prescribed in addition to all pain management strategies, comes with side effects. Intercostal nerve cryoablation seems a promising novel technique. Hence, the primary objective of this study is to determine the impact of intercostal nerve cryoablation on postoperative length of hospital stay compared with standard pain management of young pectus excavatum patients treated with the minimally invasive Nuss procedure. METHODS AND ANALYSIS This study protocol is designed for a single centre, prospective, unblinded, randomised clinical trial. Intercostal nerve cryoablation will be compared with thoracic epidural analgesia in 50 young pectus excavatum patients (ie, 12-24 years of age) treated with the minimally invasive Nuss procedure. Block randomisation, including stratification based on age (12-16 years and 17-24 years) and sex, with an allocation ratio of 1:1 will be performed.Postoperative length of hospital stay will be recorded as the primary outcome. Secondary outcomes include (1) pain intensity, (2) operative time, (3) opioid usage, (4) complications, including neuropathic pain, (5) creatine kinase activity, (6) intensive care unit admissions, (7) readmissions, (8) postoperative mobility, (9) health-related quality of life, (10) days to return to work/school, (11) number of postoperative outpatient visits and (12) hospital costs. ETHICS AND DISSEMINATION This protocol has been approved by the local Medical Ethics Review Committee, METC Zuyderland and Zuyd University of Applied Sciences. Participation in this study will be voluntary and informed consent will be obtained. Regardless of the outcome, the results will be disseminated through a peer-reviewed international medical journal. TRIAL REGISTRATION NUMBER NCT05731973.
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Affiliation(s)
- Nicky Janssen
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Jean H T Daemen
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Aimée J P M Franssen
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Elise J van Polen
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Lori M van Roozendaal
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Karel W E Hulsewé
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Yvonne Vissers
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Erik R de Loos
- Department of Surgery, Division of General Thoracic Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
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11
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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.
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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
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12
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Massaguer C, Saura-García L, Palazón P, Echaniz G, Roqueta Alcaraz MC, Tarrado X. Bilateral Lung Injury with Delayed Pneumothorax following Preoperative Cryoanalgesia for Pectus Excavatum Repair in a 13-year-old Boy. European J Pediatr Surg Rep 2024; 12:e50-e53. [PMID: 39071096 PMCID: PMC11281861 DOI: 10.1055/a-2349-9668] [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: 05/08/2023] [Accepted: 02/29/2024] [Indexed: 07/30/2024] Open
Abstract
A 13-year-old male patient with marfanoid features and pectus excavatum with Haller index 4 and correction index of 38% underwent the Nuss procedure with cryoanalgesia 9 days prior, which transpired uneventfully. Preoperative spirometry was normal, and echocardiogram showed light aortic valve dilation. A month later, during a routine outpatient checkup, he referred middle abdominal pain, denying respiratory symptoms nor thoracic pain. He presented bilateral apical and right basal hypophonesis. Chest X-ray revealed bilateral pneumothorax and right pleural effusion. Consequently, the patient was admitted to the emergency room, and a chest computed tomography was ordered, reporting right apical blebs. Bilateral thoracoscopy was performed, and apexes were checked for pulmonary blebs to rule out primary pneumothorax. In the right chest, a wedge resection of a distorted area on the apex and pleuroabrasion were done. Four air leaking eschars were found when performing lung expansion under water as leaking test, corresponding to cryoanalgesia intercostal eschars, and subsequently closed by primary suture. In the left chest, there were no blebs. However, another four pleural lesions with intact pleura in the left lower lobe were also found. Postoperative course was uneventful and chest drains were removed 48 hours after surgery. He remains asymptomatic 21 months after discharge. Cryoanalgesia in pectus excavatum is spreading due to the improvement in postoperative pain control. However, some complications may occur.
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Affiliation(s)
- Clara Massaguer
- Department of Pediatric Surgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Laura Saura-García
- Department of Pediatric Surgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Pedro Palazón
- Department of Pediatric Surgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Gastón Echaniz
- Department of Anesthesiology, Hospital Sant Joan de Déu Barcelona, Catalunya, Spain
| | | | - Xavier Tarrado
- Department of Pediatric Surgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Catalunya, Spain
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13
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Carter M, Inge M, Zeineddin S, Linton SC, Pitt JB, Robson P, Abdullah F, Goldstein SD. Measurement and Thermodynamic Modeling of Energy Flux During Intercostal Nerve Cryoablation. J Surg Res 2024; 293:231-238. [PMID: 37797391 DOI: 10.1016/j.jss.2023.08.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/27/2023] [Accepted: 08/27/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION Intercostal nerve cryoablation is an increasingly adopted technique to decrease postoperative pain in patients undergoing surgical correction of pectus excavatum (SCOPE). Concerns regarding cryo-induced systemic hypothermia have been raised in pediatric patients; however, assessment of a cooled cryoprobe on body temperature has not been performed. We aimed to determine the energy flux from a maximally cooled cryoprobe and model the possible effects on a whole-body system. METHODS To directly measure energy flux, a maximally cooled cryoSPHERE probe (AtriCure, Inc, Mason, OH) was isolated in a well-mixed water bath at 37°C. Real-time temperatures were recorded. Three models were created to estimate intraoperative flux. Perioperative temperatures of 50 patients who received cryoablation during SCOPE were compared to 50 patients who did not receive cryoablation. RESULTS Direct calorimetry measured average energy flux of the maximally cooled cryoprobe to be 28 J/s. Thermodynamic modeling demonstrated the following: 1) The highest possible cryoprobe flux is less than estimated basal metabolic rate (BMR) of the average teenager undergoing SCOPE and 2) Flux in a best model of human tissue energy transfer using available literature is far less than the effects of BMR and insensible losses. Clinically, there were no significant differences in the minimum intraoperative, end procedure or first postoperative body temperatures for patients who received cryoablation and those who did not. CONCLUSIONS Cryoprobe flux is significantly fewer joules per second than BMR. Furthermore, in a clinical series there were no empiric differences in body temperature due to cryoablation employment, contradicting concerns regarding hypothermia secondary to cryoablation.
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Affiliation(s)
- Michela Carter
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Madeline Inge
- Division of Pediatric Surgery, Department of Surgery, Northwestern University 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, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Samuel C Linton
- Division of Pediatric Surgery, Department of Surgery, Northwestern University 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, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Philip Robson
- Biomedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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14
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Lee WG, Evans LL, Harrison MR. Beyond the gut: spectrum of magnetic surgery devices. Front Surg 2023; 10:1253728. [PMID: 37942002 PMCID: PMC10628496 DOI: 10.3389/fsurg.2023.1253728] [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: 07/06/2023] [Accepted: 10/06/2023] [Indexed: 11/10/2023] Open
Abstract
Since the 1970s, magnetic force has been used to augment modern surgical techniques with the aims of minimizing surgical trauma and optimizing minimally-invasive systems. The majority of current clinical applications for magnetic surgery are largely centered around gastrointestinal uses-such as gastrointestinal or bilioenteric anastomosis creation, stricturoplasty, sphincter augmentation, and the guidance of nasoenteric feeding tubes. However, as the field of magnetic surgery continues to advance, the development and clinical implementation of magnetic devices has expanded to treat a variety of non-gastrointestinal disorders including musculoskeletal (pectus excavatum, scoliosis), respiratory (obstructive sleep apnea), cardiovascular (coronary artery stenosis, end-stage renal disease), and genitourinary (stricture, nephrolithiasis) conditions. The purpose of this review is to discuss the current state of innovative magnetic surgical devices under clinical investigation or commercially available for the treatment of non-gastrointestinal disorders.
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Affiliation(s)
- William G. Lee
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Lauren L. Evans
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Michael R. Harrison
- Department of Surgery, University of California San Francisco, San Francisco, CA, United States
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15
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Lai K, Eldredge RS, Zobel M, Hargis-Villanueva A, Ostlie A, Padilla BE. Intercostal Nerve Cryoablation for Postoperative Pain Control in Pediatric Thoracic Surgery: A Scoping Review. J Laparoendosc Adv Surg Tech A 2023; 33:994-1004. [PMID: 37462727 DOI: 10.1089/lap.2023.0070] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
Background: Cryoanalgesia uses the application of cold temperatures to temporarily disrupt peripheral sensory nerve function for pain control. This review outlines the principles of cryoablation, clinical applications, and clinical data for its use in pediatric thoracic surgery. Methods: A comprehensive PubMed search was performed using the principal terms and combinations of cryoablation, cryoanalgesia, Nuss, Nuss repair, pectus, pectus excavatum, thoracic surgery, thoracotomy, and chest wall. Pediatric articles were reviewed and included if relevant. Adult articles were reviewed for supporting information as needed. Reference lists of included articles were reviewed for possible additional sources. Discussion: The scientific and clinical principles of cryoablation are outlined, followed by a focused review of current clinical application and outcome data. Conclusion: Postoperative pain is a major challenge following thoracic surgery. Cryoanalgesia is emerging as an adjunct in pediatric thoracic surgery, particularly for the Nuss procedure or minimally invasive repair of pectus excavatum. It effectively controls pain, decreasing postoperative opioid use and hospital length of stay with few short-term complications. Although more long-term studies are needed, early evidence suggests there is reliable return of sensation to the chest wall and long-term neuropathic pain is rare.
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Affiliation(s)
- Krista Lai
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - R Scott Eldredge
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Michael Zobel
- Division of Pediatric Surgery, University of California San Francisco, San Francisco, USA
| | | | - Andrew Ostlie
- Department of Child Health, University of Arizona School of Medicine, Tucson, Arizona, USA
| | - Benjamin E Padilla
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona, USA
- Department of Child Health, University of Arizona School of Medicine, Tucson, Arizona, USA
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16
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Marturano MN, Thakkar V, Wang H, Cunningham KW, Lauer C, Sachdev G, Ross SW, Jordan MM, Dieffenbaugher ST, Sing RF, Thomas BW. Intercostal nerve cryoablation during surgical stabilization of rib fractures decreases post-operative opioid use, ventilation days, and intensive care days. Injury 2023; 54:110803. [PMID: 37193637 DOI: 10.1016/j.injury.2023.05.034] [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: 08/15/2022] [Revised: 04/16/2023] [Accepted: 05/08/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Intercostal nerve cryoablation is an adjunctive measure that has demonstrated pain control, decrease in opioid consumption, and decrease in hospital length of stay (LOS) in patients who undergo surgical stabilization of rib fractures (SSRF). METHODS SSRF patients from January 2015 to September 2021 were retrospectively compared. All patients received multimodal pain regimens post-operatively and the independent variable was intraoperative cryoablation. RESULTS 241 patients met inclusion criteria. 51 (21%) underwent intra-operative cryoablation during SSRF and 191 (79%) did not. Patients with standard treatment consumed 9.4 more daily MME (p = 0.035), consumed 73 percent more post-operative total MME (p = 0.001), spent 1.55 times as many days in the intensive care unit (p = 0.013), and spent 3.8 times as many days on the ventilator than patients treated with cryoablation, respectively. Overall hospital LOS, operative case time, pulmonary complications, MME at discharge, and numeric pain scores at discharge were no different (all p>0.05). CONCLUSION Intercostal nerve cryoablation during SSRF is associated with fewer ventilator days, ICU LOS, total post-operative, and daily opioid use without increasing time in the operating room or perioperative pulmonary complications.
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Affiliation(s)
- Matthew N Marturano
- Department of Trauma and Acute Care Surgery, Atrium Health-Carolinas Medical Center, Charlotte NC, USA
| | - Vandan Thakkar
- Campbell University School of Osteopathic Medicine, Lillington NC, USA
| | - Huaping Wang
- Department of Trauma and Acute Care Surgery, Atrium Health-Carolinas Medical Center, Charlotte NC, USA
| | - Kyle W Cunningham
- Department of Trauma and Acute Care Surgery, Atrium Health-Carolinas Medical Center, Charlotte NC, USA
| | - Cynthia Lauer
- Department of Trauma and Acute Care Surgery, Atrium Health-Carolinas Medical Center, Charlotte NC, USA
| | - Gaurav Sachdev
- Department of Trauma and Acute Care Surgery, Atrium Health-Carolinas Medical Center, Charlotte NC, USA
| | - Samuel W Ross
- Department of Trauma and Acute Care Surgery, Atrium Health-Carolinas Medical Center, Charlotte NC, USA
| | - Mary M Jordan
- Department of Trauma and Acute Care Surgery, Atrium Health Cabarrus, Concord NC, USA
| | - Sean T Dieffenbaugher
- Department of Trauma and Acute Care Surgery, Atrium Health-Carolinas Medical Center, Charlotte NC, USA
| | - Ronald F Sing
- Department of Trauma and Acute Care Surgery, Atrium Health-Carolinas Medical Center, Charlotte NC, USA
| | - Bradley W Thomas
- Department of Trauma and Acute Care Surgery, Atrium Health-Carolinas Medical Center, Charlotte NC, USA.
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17
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Azem K, Mangoubi E, Zribi B, Fein S. Regional analgesia for lung transplantation: A narrative review. Eur J Anaesthesiol 2023; 40:643-651. [PMID: 37232676 DOI: 10.1097/eja.0000000000001858] [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: 05/27/2023]
Abstract
Lung transplantation (LTx) is the definitive treatment for end-stage pulmonary disease. About 4500 LTxs are performed annually worldwide. It is considered challenging and complex surgery regarding anaesthesia and pain management. While providing adequate analgesia is crucial for patient comfort, early mobilisation and prevention of postoperative pulmonary complications, standardising an analgesic protocol is challenging due to the diversity of aetiologies, surgical approaches and the potential use of extracorporeal life support (ECLS). Although thoracic epidural analgesia is commonly considered the gold standard, concerns regarding procedural safety and its potential for devastating consequences have led physicians to seek safer analgesic modalities such as thoracic nerve blocks. The advantages of thoracic nerve blocks for general thoracic surgery are well established. However, their utility in LTx remains unclear. Considering paucity of relevant literature, this review aims to raise awareness about the literature gap in the field and highlight the need for further high-quality studies determining the effectiveness of available techniques.
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Affiliation(s)
- Karam Azem
- From the Department of Anaesthesia, Rabin Medical Centre, Beilinson Hospital, Petah Tikva (KA, EM. BZ, SF) and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (KA, EM. BZ, SF)
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18
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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.
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Affiliation(s)
| | - Lisa McMahon
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children’s Hospital, Phoenix, AZ, United States
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19
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Akinboro S, John R, Reyna T, Davis R, Ayoub C, Sangster R, Kim J, Nguyen H, Moreno C, Guner Y, Goodman L, Yu PT, Morphew T, Kabeer M. A pilot study of multi-modal pain management for same-day discharge after minimally invasive repair of pectus excavatum (Nuss procedure) in children. Pediatr Surg Int 2023; 39:159. [PMID: 36967421 PMCID: PMC10040230 DOI: 10.1007/s00383-023-05429-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2023] [Indexed: 03/28/2023]
Abstract
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.
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Affiliation(s)
| | - Rebecca John
- Children's Hospital of Orange County, Orange, USA.
| | - Troy Reyna
- Children's Hospital of Orange County, Orange, USA
| | - Rachel Davis
- Children's Hospital of Orange County, Orange, USA
| | | | | | - Joseph Kim
- Children's Hospital of Orange County, Orange, USA
| | - Hai Nguyen
- Children's Hospital of Orange County, Orange, USA
| | | | - Yigit Guner
- Children's Hospital of Orange County, Orange, USA
| | | | - Peter T Yu
- Children's Hospital of Orange County, Orange, USA
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20
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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: 18] [Impact Index Per Article: 18.0] [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.
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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.
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21
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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.
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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.
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22
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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.
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23
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Song SH, Moon DH, Shim YH, Jung H, Lee S. Limited cryoablation reduces hospital stay and opioid consumption compared to thoracic epidural analgesia after minimally invasive repair of pectus excavatum. Medicine (Baltimore) 2022; 101:e29773. [PMID: 35945758 PMCID: PMC9351910 DOI: 10.1097/md.0000000000029773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
pain following minimally invasive repair of pectus excavatum (MIRPE) is a critical concern that leads to a prolonged hospital stay and high doses of opiates administered to the patients. This study aimed to evaluate the efficacy of intraoperative cryoanalgesia (cryoablation of the intercostal nerves) during MIRPE. We retrospectively analyzed the data of 64 patients who underwent MIRPE and received cryoanalgesia or epidural analgesia between January 2019 and January 2021. The oral morphine milligram equivalent (MME) was used to calculate the dosage of opioid agents. The median age was 15 years (range, 4-33 years). The median postoperative hospital stay was 4 days (range, 2-6 days), with a median oral MME consumption of 45 mg (ranging from 0 to 1360 mg). Cryoanalgesia was performed in 38 patients, and epidural analgesia was administered to the remaining 26 patients. The cryoanalgesia group had a significantly lesser pain score, shorter postoperative hospital stay and lower oral MME consumption than the epidural analgesia group (5 vs 2; P < .001, 3 days vs 5 days; P < .001, 19 mg vs 634 mg; P < .001). Cryoanalgesia appears to reduce postoperative hospital stay and opioid consumption compared with epidural analgesia. The outcomes of this study indicate that cryoanalgesia might be a safe and effective method for pain control following MIRPE.
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Affiliation(s)
- Seung Hwan Song
- Department of Thoracic and Cardiovascular Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Duk Hwan Moon
- Department of Thoracic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yon Hee Shim
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyunjoo Jung
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sungsoo Lee
- Department of Thoracic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- *Correspondence: Sungsoo Lee, Department of Thoracic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonju-ro, Gangnam-gu, Seoul, Republic of Korea, 06273 (e-mail: )
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24
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DiFiore JW, Robertson JO, Chhabada S, DeRoss AL, Hossain MS, Rincon-Cruz L, Sung W. Next day discharge after the Nuss procedure using intercostal nerve cryoablation, intercostal nerve blocks, and a perioperative ERAS pain protocol. J Pediatr Surg 2022; 57:213-218. [PMID: 34823843 DOI: 10.1016/j.jpedsurg.2021.10.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/23/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Nuss procedure for pectus excavatum has historically been associated with significant postoperative pain, which has been the major factor contributing to hospital length of stay (LOS). METHODS A single-institution, prospective study of 40 consecutive patients undergoing Nuss bar placement for pectus excavatum between November 2019 and January 2021 was conducted to assess the effectiveness of a multimodality pain management protocol. All patients received T3-T8 intercostal nerve cryoablation (INC), T3-T8 bupivacaine intercostal nerve blocks, Exparel at the skin incisions, and management with a perioperative analgesia regimen that minimized narcotic usage. The primary outcome was LOS. Secondary outcomes included opioid use, pain scores, and time to sensory recovery. RESULTS 37/40 patients (92.5%) were discharged home on postoperative day (POD) 1, and 3/40 (7.5%) were discharged on POD 2 (mean LOS = 1.1 days). The median average postoperative pain score was 2/10. After eliminating IVPCA from our protocol, total oral morphine equivalent (OME) decreased by 73% (55.5 mg to 15 mg) with no change in pain scores or discharge timing. CONCLUSIONS INC combined with bupivacaine intercostal nerve blocks and a pre- and post-hospital analgesia protocol facilitated discharge one day after the Nuss procedure, achieved excellent pain control, and eliminated the need for intravenous opioids.
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Affiliation(s)
- John W DiFiore
- Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, 9500 Euclid Avenue / A12-329, Cleveland, OH 44195, USA.
| | - Jason O Robertson
- Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, 9500 Euclid Avenue / A12-329, Cleveland, OH 44195, USA
| | | | - Anthony L DeRoss
- Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, 9500 Euclid Avenue / A12-329, Cleveland, OH 44195, USA
| | - Mir S Hossain
- Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, 9500 Euclid Avenue / A12-329, Cleveland, OH 44195, USA
| | - Lorena Rincon-Cruz
- Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, 9500 Euclid Avenue / A12-329, Cleveland, OH 44195, USA
| | - Wai Sung
- Department of Pediatric Anesthesiology, Cleveland Clinic Children's, Cleveland, OH, USA
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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.
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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
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26
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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.
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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
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27
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Arshad SA, Ferguson DM, Garcia EI, Hebballi NB, Buchanan AC, Tsao K. Cryoanalgesia is Associated With Decreased Postoperative Opioid Use in Minimally Invasive Repair of Pectus Excavatum. J Surg Res 2021; 271:1-6. [PMID: 34814047 DOI: 10.1016/j.jss.2021.10.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 09/24/2021] [Accepted: 10/10/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Postoperative pain control is challenging after pectus excavatum repair. We aimed to understand the impact that cryoanalgesia had on opioid utilization and outcomes of pediatric patients undergoing minimally invasive repair of pectus excavatum (MIRPE). METHODS A single-center retrospective cohort study was conducted of all patients (< 18 y) who underwent MIRPE (2011-2019). Patients receiving cryoanalgesia were compared to those who did not. The primary outcome was total postoperative, inpatient, opioid use, measured as milligrams of oral morphine equivalents per kilogram (OME/kg). Univariate and multivariable analyses were performed. RESULTS Of 35 patients, 20 received cryoanalgesia (57%). Baseline characteristics were similar. Patients who received cryoanalgesia had a lower opioid requirement: median 2.3 mg OME/kg (IQR 1.2-3.1), versus 4.9 mg OME/kg (IQR 2.9-5.8), P < 0.001. Accounting for receipt of cryoanalgesia, epidural, and/or patient-controlled analgesia, cryoanalgesia was associated with a 3.3 mg OME/kg reduction in opioid use (P < 0.001). Median length of stay (LOS) was shorter in cryoanalgesia patients: 3.1 d (IQR 2.3-3.4), versus 5.1 d (IQR 4.3-5.4), P < 0.001. Complications within 90 d were similar between groups. CONCLUSIONS Cryoanalgesia is an effective adjunctive pain control modality for patients undergoing MIRPE. Use of cryoanalgesia was associated with lower postoperative opioid requirements and shorter LOS, without increased short-term complications, and should be considered for enhanced recovery after MIRPE.
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Affiliation(s)
- Seyed A Arshad
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas.
| | - Dalya M Ferguson
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas.
| | - Elisa I Garcia
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas.
| | - Nutan B Hebballi
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas.
| | - Allison C Buchanan
- Department of Anesthesiology, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas.
| | - KuoJen Tsao
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas.
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28
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Arshad SA, Hatton GE, Ferguson DM, Li LT, Austin MT, Tsao K. Cryoanalgesia enhances recovery from minimally invasive repair of pectus excavatum resulting in reduced length of stay: A case-matched analysis of NSQIP-Pediatric patients. J Pediatr Surg 2021; 56:1099-1102. [PMID: 33853733 DOI: 10.1016/j.jpedsurg.2021.03.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/12/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Pain control is challenging after minimally invasive repair of pectus excavatum (MIRPE). Cryoanalgesia, which temporarily ablates peripheral nerves, improves pain control and may accelerate post-operative recovery. We hypothesized that cryoanalgesia would be associated with shorter length of stay (LOS) in children undergoing MIRPE. METHODS A matched cohort study was conducted of children (<18 years) who underwent MIRPE 2016-2018, using the National Surgical Quality Improvement Program-Pediatric database. Each patient who received cryoanalgesia during MIRPE was matched to four controls (no cryoanalgesia). Univariate and multilevel regression analyses were performed. RESULTS Thirty-five patients who received cryoanalgesia during MIRPE were matched to 140 controls. Patients who received cryoanalgesia had a LOS reduction with similar secondary outcomes (operative time, rates of complication, reoperation, and readmission). On multilevel regression adjusted for matched groups, cryoanalgesia was associated with a 1.3-day reduction in LOS (95% CI -1.8 to -0.8, p < 0.001). On sensitivity analysis excluding patients with complications, cryoanalgesia remained associated with a LOS reduction. CONCLUSIONS Cryoanalgesia is a promising adjunct in the care of pediatric patients undergoing MIRPE. Utilization is associated with a shorter LOS without an increase in operative time or complications. Cryoanalgesia should be considered for inclusion in enhanced recovery strategies for patients undergoing MIRPE.
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Affiliation(s)
- Seyed A Arshad
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston 77030, TX, United States
| | - Gabrielle E Hatton
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston 77030, TX, United States
| | - Dalya M Ferguson
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston 77030, TX, United States
| | - Linda T Li
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston 77030, TX, United States
| | - Mary T Austin
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston 77030, TX, United States
| | - KuoJen Tsao
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston 77030, TX, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston 77030, TX, United States.
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Cha PI, Min JG, Patil A, Choi J, Kothary NN, Forrester JD. Efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain after surgery or trauma: systematic review. Trauma Surg Acute Care Open 2021; 6:e000690. [PMID: 34079913 PMCID: PMC8137159 DOI: 10.1136/tsaco-2021-000690] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/04/2021] [Accepted: 04/24/2021] [Indexed: 11/03/2022] Open
Abstract
Background There is a critical need for non-narcotic analgesic adjuncts in the treatment of thoracic pain. We evaluated the efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain, specifically addressing the applicability of intercostal cryoneurolysis for pain control after chest wall trauma. Methods A systematic review was performed through searches of PubMed, EMBASE, and the Cochrane Library. We included studies involving patients of all ages that evaluated the efficacy of intercostal cryoneurolysis as a pain adjunct for chest wall pathology. Quantitative and qualitative synthesis was performed. Results Twenty-three studies including 570 patients undergoing cryoneurolysis met eligibility criteria for quantitative analysis. Five subgroups of patients treated with intercostal cryoneurolysis were identified: pectus excavatum (nine studies); thoracotomy (eight studies); post-thoracotomy pain syndrome (three studies); malignant chest wall pain (two studies); and traumatic rib fractures (one study). There is overall low-quality evidence supporting intercostal cryoneurolysis as an analgesic adjunct for chest wall pain. A majority of studies demonstrated decreased inpatient narcotic use with intercostal cryoneurolysis compared with conventional pain modalities. Intercostal cryoneurolysis may also lead to decreased hospital length of stay. The procedure did not definitively increase operative time, and risk of complications was low. Conclusions Given the favorable risk-to-benefit profile, both percutaneous and thoracoscopic intercostal cryoneurolysis may serve as a worthwhile analgesic adjunct in trauma patients with rib fractures who have failed conventional medical management. However, further prospective studies are needed to improve quality of evidence. Level of evidence Level IV systematic reviews and meta-analyses.
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Affiliation(s)
- Peter I Cha
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Jung Gi Min
- Stanford University School of Medicine, Stanford, California, USA
| | | | - Jeff Choi
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Nishita N Kothary
- Section of Interventional Radiology, Department of Radiology, School of Medicine, Stanford University, Stanford, California, USA
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30
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Pechetov AA, Lednev AN, Makov MA, Chlan TN. [Intercostal nerve cryoablation in correction of pectus excavatum in adults]. Khirurgiia (Mosk) 2021:14-19. [PMID: 33977693 DOI: 10.17116/hirurgia202105114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate an effectiveness of cryoanalgesia in older patients with pectus excavatum and to determine feasibility of further research. MATERIAL AND METHODS We have developed an original technique of intercostal nerve cryoablation for correction of pectus excavatum in adults. The results of intercostal nerve cryoablation during correction of pectus excavatum in 10 older patients were analyzed. RESULTS Postoperative outcomes were followed-up over a period of 4 - 12 months. There were no perioperative surgical complications. In 1 case, moderate pain syndrome persisted for 3 months after surgery (mean VAS score 2±1.3). In 9 months, mean VAS score was 0.6±0.6 in a month after surgery. CONCLUSION Intercostal nerve cryoablation in correction of pectus excavatum in adults may be an alternative to the current methods of regional analgesia. Further research is requried to achieve objective information.
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Affiliation(s)
- A A Pechetov
- A.V. Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - A N Lednev
- A.V. Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - M A Makov
- A.V. Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - T N Chlan
- A.V. Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
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Small A, Fisher AD, Lee C, Colditz I. Analgesia for Sheep in Commercial Production: Where to Next? Animals (Basel) 2021; 11:ani11041127. [PMID: 33920025 PMCID: PMC8070992 DOI: 10.3390/ani11041127] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/08/2021] [Accepted: 04/12/2021] [Indexed: 12/11/2022] Open
Abstract
Simple Summary Increasing societal and customer pressure to provide animals with ‘a life worth living’ continues to apply pressure on industry to alleviate pain associated with husbandry practices, injury and illness. Although a number of analgesic solutions are now available for sheep, providing some amelioration of the acute pain responses, this review has highlighted a number of potential areas for further research. Abstract Increasing societal and customer pressure to provide animals with ‘a life worth living’ continues to apply pressure on livestock production industries to alleviate pain associated with husbandry practices, injury and illness. Over the past 15–20 years, there has been considerable research effort to understand and develop mitigation strategies for painful husbandry procedures in sheep, leading to the successful launch of analgesic approaches specific to sheep in a number of countries. However, even with multi-modal approaches to analgesia, using both local anaesthetic and non-steroidal anti-inflammatory drugs (NSAID), pain is not obliterated, and the challenge of pain mitigation and phasing out of painful husbandry practices remains. It is timely to review and reflect on progress to date in order to strategically focus on the most important challenges, and the avenues which offer the greatest potential to be incorporated into industry practice in a process of continuous improvement. A structured, systematic literature search was carried out, incorporating peer-reviewed scientific literature in the period 2000–2019. An enormous volume of research is underway, testament to the fact that we have not solved the pain and analgesia challenge for any species, including our own. This review has highlighted a number of potential areas for further research.
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Affiliation(s)
- Alison Small
- CSIRO Agriculture & Food, Locked Bag 1, Armidale, NSW 2350, Australia; (C.L.); (I.C.)
- Correspondence: ; Tel.: +61-2-6776-1435
| | - Andrew David Fisher
- Animal Welfare Science Centre, University of Melbourne, Parkville, VIC 3052, Australia;
| | - Caroline Lee
- CSIRO Agriculture & Food, Locked Bag 1, Armidale, NSW 2350, Australia; (C.L.); (I.C.)
| | - Ian Colditz
- CSIRO Agriculture & Food, Locked Bag 1, Armidale, NSW 2350, Australia; (C.L.); (I.C.)
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Dekonenko C, Dorman RM, Duran Y, Juang D, Aguayo P, Fraser JD, Oyetunji TA, Snyder CL, Holcomb GW, Millspaugh DL, St Peter SD. Postoperative pain control modalities for pectus excavatum repair: A prospective observational study of cryoablation compared to results of a randomized trial of epidural vs patient-controlled analgesia. J Pediatr Surg 2020; 55:1444-1447. [PMID: 31699436 DOI: 10.1016/j.jpedsurg.2019.09.021] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 08/30/2019] [Accepted: 09/05/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pain following bar placement for pectus excavatum is the dominant factor post-operatively and determines length of stay (LOS). We recently adopted intercostal cryoablation as our preferred method of pain control following minimally invasive pectus excavatum repair. We compared the outcomes of cryoablation to results of a recently concluded trial of epidural (EPI) and patient-controlled analgesia (PCA) protocols. METHODS We conducted a prospective observational study of patients undergoing bar placement for pectus excavatum using intercostal cryoablation. Results are reported and compared with those of a randomized trial comparing EPI with PCA. Comparisons of medians were performed using Kruskal-Wallis H tests with alpha 0.05. RESULTS Thirty-five patients were treated with cryoablation compared to 32 epidural and 33 PCA patients from the trial. Cryoablation was associated with longer operating time (101 min, versus 58 and 57 min for epidural and PCA groups, p < 0.01), resulted in less time to pain control with oral medication (21 h, versus 72 and 67 h, p < 0.01), and decreased LOS (1 day, versus 4.3 and 4.2 days, p < 0.01). CONCLUSION Intercostal cryoablation during minimally invasive pectus excavatum repair reduces LOS and perioperative opioid consumption compared with both EPI and PCA. LEVEL OF EVIDENCE II.
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Affiliation(s)
| | - Robert M Dorman
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO
| | - Yara Duran
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO
| | - David Juang
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO
| | | | - Charles L Snyder
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO
| | - George W Holcomb
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO
| | | | - Shawn D St Peter
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO.
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Torre M, Mameli L, Bonfiglio R, Guerriero V, Derosas L, Palomba L, Disma N. A New Device for Thoracoscopic Cryoanalgesia in Pectus Excavatum Repair: Preliminary Single Center Experience. Front Pediatr 2020; 8:614097. [PMID: 33585365 PMCID: PMC7874221 DOI: 10.3389/fped.2020.614097] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/14/2020] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Michele Torre
- Pediatric Thoracic and Airway Surgery Unit, IRCCS Giannina Gaslini, Genoa, Italy.,Pediatric Surgery Department, IRCCS Giannina Gaslini, Genoa, Italy
| | - Leila Mameli
- Anesthesiology and Pain Management Department, IRCCS Giannina Gaslini, Genoa, Italy
| | - Rachele Bonfiglio
- Anesthesiology and Pain Management Department, IRCCS Giannina Gaslini, Genoa, Italy
| | | | - Lucia Derosas
- Anesthesiology and Pain Management Department, IRCCS Giannina Gaslini, Genoa, Italy
| | - Loredana Palomba
- Anesthesiology and Pain Management Department, IRCCS Giannina Gaslini, Genoa, Italy
| | - Nicola Disma
- Anesthesiology and Pain Management Department, IRCCS Giannina Gaslini, Genoa, Italy
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Graves CE, Moyer J, Zobel MJ, Mora R, Smith D, O'Day M, Padilla BE. Intraoperative intercostal nerve cryoablation During the Nuss procedure reduces length of stay and opioid requirement: A randomized clinical trial. J Pediatr Surg 2019; 54:2250-2256. [PMID: 30935731 PMCID: PMC6920013 DOI: 10.1016/j.jpedsurg.2019.02.057] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/29/2019] [Accepted: 02/22/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Minimally-invasive repair of pectus excavatum by the Nuss procedure is associated with significant postoperative pain, prolonged hospital stay, and high opiate requirement. We hypothesized that intercostal nerve cryoablation during the Nuss procedure reduces hospital length of stay (LOS) compared to thoracic epidural analgesia. DESIGN This randomized clinical trial evaluated 20 consecutive patients undergoing the Nuss procedure for pectus excavatum between May 2016 and March 2018. Patients were randomized evenly via closed-envelope method to receive either cryoanalgesia or thoracic epidural analgesia. Patients and physicians were blinded to study arm until immediately preoperatively. SETTING Single institution, UCSF-Benioff Children's Hospital. PARTICIPANTS 20 consecutive patients were recruited from those scheduled for the Nuss procedure. Exclusion criteria were age < 13 years, chest wall anomaly other than pectus excavatum, previous repair or other thoracic surgery, and chronic use of pain medications. MAIN OUTCOMES AND MEASURES Primary outcome was postoperative LOS. Secondary outcomes included total operative time, total/daily opioid requirement, inpatient/outpatient pain score, and complications. Primary outcome data were analyzed by the Mann-Whitney U-test for nonparametric continuous variables. Other continuous variables were analyzed by two-tailed t-test, while categorical data were compared via Chi-squared test, with alpha = 0.05 for significance. RESULTS 20 patients were randomized to receive either cryoablation (n = 10) or thoracic epidural (n = 10). Mean operating room time was 46.5 min longer in the cryoanalgesia group (p = 0.0001). Median LOS decreased by 2 days in patients undergoing cryoablation, to 3 days from 5 days (Mann-Whitney U, p = 0.0001). Cryoablation patients required significantly less inpatient opioid analgesia with a mean decrease of 416 mg oral morphine equivalent per patient (p = 0.0001), requiring 52%-82% fewer milligrams on postoperative days 1-3 (p < 0.01 each day). There was no difference in mean pain score between the groups at any point postoperatively, up to one year, and no increased incidence of neuropathic pain in the cryoablation group. No complications were noted in the cryoablation group; among patients with epidurals, one patient experienced a symptomatic pneumothorax and another had urinary retention. CONCLUSIONS AND RELEVANCE Intercostal nerve cryoablation during the Nuss procedure decreases hospital length of stay and opiate requirement versus thoracic epidural analgesia, while offering equivalent pain control. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
| | | | | | | | | | | | - Benjamin E. Padilla
- Corresponding author at: University of California, San Francisco Department of Surgery Division of Pediatric Surgery 550 16th St, Fifth Floor San Francisco, CA 94158-0570 United States. (B.E. Padilla)
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Parrado R, Lee J, McMahon LE, Clay C, Powell J, Kang P, Notrica DM, Ostlie DJ, Bae JO. The Use of Cryoanalgesia in Minimally Invasive Repair of Pectus Excavatum: Lessons Learned. J Laparoendosc Adv Surg Tech A 2019; 29:1244-1251. [DOI: 10.1089/lap.2019.0203] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Raphael Parrado
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
- Department of Child Health, University of Arizona College of Medicine, Phoenix, Arizona
- Department of Surgery, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | - Justin Lee
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
- Department of Child Health, University of Arizona College of Medicine, Phoenix, Arizona
- Department of Surgery, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | - Lisa E. McMahon
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
- Department of Child Health, University of Arizona College of Medicine, Phoenix, Arizona
- Department of Surgery, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | - Conner Clay
- University of Arizona College of Medicine, Phoenix, Arizona
| | - Jordan Powell
- University of Arizona College of Medicine, Phoenix, Arizona
| | - Paul Kang
- Department of Epidemiology and Biostatistics, University of Arizona College of Public Health, Phoenix, Arizona
| | - David M. Notrica
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
- Department of Child Health, University of Arizona College of Medicine, Phoenix, Arizona
- Department of Surgery, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | - Daniel J. Ostlie
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
- Department of Child Health, University of Arizona College of Medicine, Phoenix, Arizona
- Department of Surgery, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
| | - Jae-O Bae
- Department of Surgery, Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
- Department of Child Health, University of Arizona College of Medicine, Phoenix, Arizona
- Department of Surgery, Mayo Clinic College of Medicine and Science, Phoenix, Arizona
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Notrica DM. The Nuss procedure for repair of pectus excavatum: 20 error traps and a culture of safety. Semin Pediatr Surg 2019; 28:172-177. [PMID: 31171153 DOI: 10.1053/j.sempedsurg.2019.04.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- David M Notrica
- Department of Surgery, Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016, United States; Department of Surgery, Mayo Clinic College of Medicine and Science, 5757 East Mayo Boulevard, Phoenix AZ 85054, United States; Department of Child Health, University of Arizona College of Medicine Phoenix, 1919 East Thomas Road, Phoenix, AZ 85016, United States.
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Zhao F, Vossler J, Kaye A. A multi-institution case series of intercostal nerve cryoablation for pain control when used in conjunction with surgical stabilization of rib fractures. ACTA ACUST UNITED AC 2019. [DOI: 10.4103/jctt.jctt_12_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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