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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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Wojtyś ME, Kordykiewicz D, Wójcik J, Tomos P, Kostopanagiotou K. Consultations for Poland Syndrome: The Essentials for a Thoracic Surgeon. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1178. [PMID: 39064607 PMCID: PMC11278914 DOI: 10.3390/medicina60071178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Revised: 07/16/2024] [Accepted: 07/18/2024] [Indexed: 07/28/2024]
Abstract
Poland syndrome (PS) is a rare congenital musculoskeletal entity occurring in approximately 1 in 30,000 newborns that manifests with variable symbrachydactyly, ipsilateral costochondral deformities, an absence of pectoral muscles, and breast underdevelopment. These have potential impacts on social, somatic, and psychological functionality, often leading affected individuals to seek expert opinions on corrective surgery. Due to phenotypic variability, strict management guidelines are lacking, with treatment decisions often based on the specialist's personal experience rather than published evidence. Comprehensive imaging with CT and MRI with 3D reconstruction is crucial for providing a descriptive assessment of musculoskeletal defects. Management is multidisciplinary, involving thoracic, plastic, and pediatric surgeons and hand surgery specialists, as well as psychologists and developmental growth specialists. Surgery should achieve both structural and cosmetic correction to reverse the psychological and social impact and achieve patient satisfaction. We aim to provide thoracic surgeons the essential answers for sharing with affected adult individuals during consultations focusing on chest surgical correction.
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Affiliation(s)
- Małgorzata Edyta Wojtyś
- Department of Thoracic Surgery and Transplantation, Pomeranian Medical University in Szczecin, Alfreda Sokołowskiego 11, 70-891 Szczecin, Poland
| | - Dawid Kordykiewicz
- Department of Thoracic Surgery and Transplantation, Pomeranian Medical University in Szczecin, Alfreda Sokołowskiego 11, 70-891 Szczecin, Poland
| | - Janusz Wójcik
- Department of Thoracic Surgery and Transplantation, Pomeranian Medical University in Szczecin, Alfreda Sokołowskiego 11, 70-891 Szczecin, Poland
| | - Periklis Tomos
- Department of Thoracic Surgery, “Attikon” University Hospital of Athens, 12462 Athens, Greece
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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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Fettiplace M, Joudeh L, Bungart B, Boretsky K. Local anesthetic dosing and toxicity of pediatric truncal catheters: a narrative review of published practice. Reg Anesth Pain Med 2024; 49:59-66. [PMID: 37429620 PMCID: PMC10850837 DOI: 10.1136/rapm-2023-104666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/30/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND/IMPORTANCE Despite over 30 years of use by pediatric anesthesiologists, standardized dosing rates, dosing characteristics, and cases of toxicity of truncal nerve catheters are poorly described. OBJECTIVE We reviewed the literature to characterize dosing and toxicity of paravertebral and transversus abdominis plane catheters in children (less than 18 years). EVIDENCE REVIEW We searched for reports of ropivacaine or bupivacaine infusions in the paravertebral and transversus abdominis space intended for 24 hours or more of use in pediatric patients. We evaluated bolus dosing, infusion dosing, and cumulative 24-hour dosing in patients over and under 6 months. We also identified cases of local anesthetic systemic toxicity and toxic blood levels. FINDINGS Following screening, we extracted data from 46 papers with 945 patients.Bolus dosing was 2.5 mg/kg (median, range 0.6-5.0; n=466) and 1.25 mg/kg (median, range 0.5-2.5; n=294) for ropivacaine and bupivacaine, respectively. Infusion dosing was 0.5 mg/kg/hour (median, range 0.2-0.68; n=521) and 0.33 mg/kg/hour (median, range 0.1-1.0; n=423) for ropivacaine and bupivacaine, respectively, consistent with a dose equivalence of 1.5:1.0. A single case of toxicity was reported, and pharmacokinetic studies reported at least five cases with serum levels above the toxic threshold. CONCLUSIONS Bolus doses of bupivacaine and ropivacaine frequently comport with expert recommendations. Infusions in patients under 6 months used doses associated with toxicity and toxicity occurred at a rate consistent with single-shot blocks. Pediatric patients would benefit from specific recommendations about ropivacaine and bupivacaine dosing, including age-based dosing, breakthrough dosing, and intermittent bolus dosing.
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Affiliation(s)
- Michael Fettiplace
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Lana Joudeh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Brittani Bungart
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Karen Boretsky
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Childrens Hospital, Boston, Massachusetts, USA
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Zacha S, Jarosz K, Kokot K, Biłas J, Skonieczna-Żydecka K, Gerus S, Kojder K, Biernawska J. Benefits of the Erector Spinae Plane Block before Cryoanalgesia in Children Undergoing Surgery for Funnel Chest Deformity. J Pers Med 2023; 13:1696. [PMID: 38138923 PMCID: PMC10744559 DOI: 10.3390/jpm13121696] [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: 11/15/2023] [Revised: 11/30/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
Thoracic surgery causes significant pain despite standard multimodal analgesia. Intraoperative cryoanalgesia may be a solution. The onset of the clinical effect of cryoanalgesia can take 12-36 h. The addition of a regional anaesthesia before the cryoanalgesia procedure can enable analgesic protection for the patient during this period. The main aim of the study was to evaluate the benefits of the erector spinae plane (ESP) block prior to Nuss surgery. The 'control' group consisted of 10 teenagers who underwent cryoablation together with intravenous multimodal analgesia according to the standard protocol. The 'intervention' group included 26 teenage patients who additionally received an erector spinae plane block before operation. Pain relief (p = 0.015), opioid use (p = 0.009), independent physical activity and rehabilitation (p = 0.020) were faster in the intervention group. No features of local anaesthetic drug toxicity or complications of the ESP block were observed. The bilateral ESP block together with intraoperative intercostal nerve cryoablation performed prior to Nuss correction of funnel chest were more effective in terms of pain control.
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Affiliation(s)
- Sławomir Zacha
- Department of Paediatric Orthopaedics and Musculoskeletal Oncology, Pomeranian Medical University, 71-252 Szczecin, Poland; (S.Z.); (J.B.)
| | - Konrad Jarosz
- Department of Clinical Nursing, Pomeranian Medical University, 70-204 Szczecin, Poland
| | - Karolina Kokot
- Department of Anaesthesiology and Intensive Therapy, Pomeranian Medical University, 71-252 Szczecin, Poland; (K.K.); (K.K.); (J.B.)
| | - Jarosław Biłas
- Department of Paediatric Orthopaedics and Musculoskeletal Oncology, Pomeranian Medical University, 71-252 Szczecin, Poland; (S.Z.); (J.B.)
| | - Karolina Skonieczna-Żydecka
- Department of Biochemical Science, Faculty of Health Sciences, Pomeranian Medical University, 70-204 Szczecin, Poland;
| | - Sylwester Gerus
- Department of Paediatric Surgery and Urology, Wroclaw Medical University, 50-367 Wrocław, Poland;
| | - Klaudyna Kojder
- Department of Anaesthesiology and Intensive Therapy, Pomeranian Medical University, 71-252 Szczecin, Poland; (K.K.); (K.K.); (J.B.)
| | - Jowita Biernawska
- Department of Anaesthesiology and Intensive Therapy, Pomeranian Medical University, 71-252 Szczecin, Poland; (K.K.); (K.K.); (J.B.)
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Breglio AM, Fitzgerald TN, Moore CB, Einhorn LM. Evaluation of Analgesic Practice Changes Following the Nuss Procedure in Pediatric Patients. J Surg Res 2023; 291:289-295. [PMID: 37481964 PMCID: PMC10528185 DOI: 10.1016/j.jss.2023.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 05/26/2023] [Accepted: 06/19/2023] [Indexed: 07/25/2023]
Abstract
INTRODUCTION Pectus excavatum repair by the Nuss procedure results in severe postoperative pain. Regional blocks and intercostal nerve cryoablation (INC) have emerged as potential strategies to manage analgesia. This study compares pain-related outcomes following these perioperative interventions. METHODS We reviewed charts of patients <18 y who underwent the Nuss procedure at Duke Children's Hospital from July 2018 to June 2022. Patients were divided into three groups by analgesic strategy: no block, regional catheters, or INC, representing the chronologic change in our practice. The primary outcome was total and daily in-hospital opioid utilization measured by oral morphine equivalents (OMEs). Secondary outcomes included average daily pain scores, length of stay, opioid refills after discharge, and complications. RESULTS Twenty-one patients were included and analyzed: no block (n = 6), regional catheters (n = 7), and INC (n = 8). INC-treated patients required significantly lower total postoperative, in-hospital OMEs (64 ± 47 [mean ± standard deviation]) than those with no block (270 ± 217, P = 0.04) or those with regional catheters (273 ± 176, P = 0.03). INC was associated with longer average operative times (161 ± 36 min) than no block (105 ± 21 min, P = 0.005) or regional catheters (90 ± 11 min, P < 0.001). INC-treated patients had shorter hospital length of stays (median 68 h) than those with regional catheters (median 74 h, P = 0.006). CONCLUSIONS INC was associated with longer operative times but decreased in-hospital OMEs when compared to bilateral regional block catheters and multimodal analgesia alone.
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Affiliation(s)
- Andrew M Breglio
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Tamara N Fitzgerald
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Carrie B Moore
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Lisa M Einhorn
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.
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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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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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Chen LJ, Chen SH, Hsieh YL, Yu PC. Continuous nerve block versus thoracic epidural analgesia for post-operative pain of pectus excavatum repair: a systematic review and meta-analysis. BMC Anesthesiol 2023; 23:266. [PMID: 37559029 PMCID: PMC10410789 DOI: 10.1186/s12871-023-02221-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/26/2023] [Indexed: 08/11/2023] Open
Abstract
Surgery to repair pectus excavatum (PE) is often associated with severe postoperative pain, which can impact the length of hospital stay (LOS). While thoracic epidural analgesia (TEA) has traditionally been used for pain management in PE, its placement can sometimes result in severe neurological complications. Recently, paravertebral block (PVB) and erector spinae plane block (ESPB) have been recommended for many other chest and abdominal surgeries. However, due to the more severe and prolonged pain associated with PE repair, it is still unclear whether continuous administration of these blocks is as effective as TEA. Therefore, we conducted this systematic review and meta-analysis to demonstrate the equivalence of continuous PVB and ESPB to TEA.
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Affiliation(s)
- Li-Jung Chen
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No.289, Jianguo Rd., Xindian Dist, 231405, New Taipei City, Taiwan
| | - Shih-Hong Chen
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No.289, Jianguo Rd., Xindian Dist, 231405, New Taipei City, Taiwan
| | - Yung-Lin Hsieh
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No.289, Jianguo Rd., Xindian Dist, 231405, New Taipei City, Taiwan
| | - Po-Chuan Yu
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No.289, Jianguo Rd., Xindian Dist, 231405, New Taipei City, Taiwan.
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Feng J, Wang H, Peng L, Xu H, Song X. Effects of Thoracic Paravertebral Block on Postoperative Analgesia in Infants and Small Children undergoing Ultra-Fast Track Cardiac Anesthesia: A Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2023; 37:539-546. [PMID: 36717316 DOI: 10.1053/j.jvca.2022.12.006] [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: 08/11/2022] [Revised: 11/21/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To assess whether a preoperative bilateral thoracic paravertebral block (TPVB) would improve postoperative analgesia in infants and small children undergoing open cardiac surgery in the protocol of an ultra-fast track cardiac anesthesia (UFTCA). DESIGN A single-center, prospective, randomized, controlled study. SETTING At a tertiary children's medical center. PARTICIPANTS A total of 180 children undergoing cardiac surgery, aged 1 month to 3 years. INTERVENTIONS Patients are allocated randomly to TPVB and parent- and/or nurse-controlled intravenous analgesia (PNCA) group (Group T) or PNCA group (Group P). MEASUREMENTS AND MAIN RESULTS The primary outcome is the postoperative pain scores. The secondary outcome are intraoperative consumption of sufentanil, time to extubation, using of neostigmine, cumulative total and invalid PCA attempts in 24 and 48 hours after surgery, hospitalization characteristics, perioperative blood glucose, postoperative arterial oxygen partial pressure, arterial carbon dioxide partial pressure (PaCO2) and brain natriuretic peptide (BNP). The postoperative pain scores within 24 hours, intraoperative consumption of sufentanil, total, and invalid PCA attempts in 24 and 48 hours, perioperative blood glucose and BNP on the seventh day in Group T were all significantly lower than those in Group P (p < 0.001). The time to extubation, the use of neostigmine, and PaCO2 on the sixth hour, postoperatively, were significantly smaller in Group T than those in Group P (p < 0.05). There were no significant differences in the hospitalizations between the 2 groups. CONCLUSIONS A combination of bilateral single dose TPVB and PNCA pain management is superior to a PNCA pain management alone in infants and small children undergoing open cardiac surgery and contributes to a rapid recovery with preferable perioperative outcomes in the protocol of UFTCA.
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Affiliation(s)
- Jumian Feng
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Huaizhen Wang
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Liangming Peng
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Haiping Xu
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Xingrong Song
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China.
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Cockrell HC, Hrachovec J, Schnuck J, Nchinda N, Meehan J. Implementation of a Cryoablation-based Pain Management Protocol for Pectus Excavatum. J Pediatr Surg 2023:S0022-3468(23)00096-9. [PMID: 36894442 DOI: 10.1016/j.jpedsurg.2023.01.059] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 01/25/2023] [Indexed: 02/17/2023]
Abstract
INTRODUCTION The Nuss repair for pectus excavatum is associated with significant postoperative pain. Our institution developed protocols to standardize pain management for pectus excavatum patients in the immediate postoperative period. We present our experience with protocol implementation and patient outcomes. METHODS We standardized regional anesthesia with a 0.25% bupivacaine incisional soaker catheter (post-implementation 1, PI1) before transitioning to intercostal nerve cryoablation (INC) (post-implementation 2, PI2). Patient outcomes were tracked using statistical process control charts in AdaptX™ OR Advisor and run charts in Tableau. Chi-squared tests assessed demographic differences between cohorts. RESULTS 244 patients were included: 78 pre-implementation, 108 PI1, and 58 PI2. Average age was 15.9-16.5 years. Patients were majority male, non-Hispanic white, and English speaking. Hospital length of stay decreased 4.1-2.4 days. INC increased surgery time (99-125 min) but decreased PACU time (112-78 min). Maximum pain scores improved in PACU (7.7-6.0) and 0-24 h postoperatively (8.3-6.8) but were not different 24-48 h postoperatively (5.4-5.8). Average opioid dosing decreased 0-48 h from 1.9 to 0.8 mg/kg morphine milliequivalents and was associated with reduction in post-operative nausea and constipation. There were no 30-day readmissions. CONCLUSION An institution-wide pain management protocol using INC for pectus excavatum patients was implemented. Intercostal nerve cryoablation was found to be superior to bupivacaine incisional soaker catheters and reduced hospital length of stay, immediate postoperative pain scores, morphine milliequivalent opioid dosing, postoperative nausea, and constipation. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Hannah C Cockrell
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA; Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA, 98195, USA.
| | - Jennifer Hrachovec
- Center for Quality & Patient Safety, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Jamie Schnuck
- Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Nzuekoh Nchinda
- Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - John Meehan
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA; Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA, 98195, USA
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Fiorelli S, Menna C, Andreetti C, Peritore V, Rocco M, De Blasi RA, Rendina EA, Massullo D, Ibrahim M. Bilateral Ultrasound-Guided Erector Spinae Plane Block for Pectus Excavatum Surgery: A Retrospective Propensity-Score Study. J Cardiothorac Vasc Anesth 2022; 36:4327-4332. [PMID: 36163156 DOI: 10.1053/j.jvca.2022.08.018] [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: 04/07/2022] [Revised: 08/17/2022] [Accepted: 08/22/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Pectus excavatum (PE) repair is burdened by severe postoperative pain. This retrospective study aimed to determine whether the analgesic effect of ultrasound-guided erector spinae plane block (ESPB) plus standard intravenous analgesia (SIVA) might be superior to SIVA alone in pain control after PE surgical repair via Ravitch or Nuss technique. DESIGN A retrospective cohort study. SETTING At a university hospital. PARTICIPANTS All participants were scheduled for surgical repair of PE. INTERVENTIONS From January 2017 to December 2019, all patients who received ESPB plus SIVA or SIVA alone were investigated retrospectively. A 2:1 propensity-score matching analysis considering preoperative variables was used to compare analgesia efficacy in 2 groups. All patients received a 24-hour continuous infusion of tramadol, 0.1 mg/kg/h, and ketorolac, 0.05 mg/kg/h, via elastomeric pump, and morphine, 2 mg, intravenously as a rescue drug. The ESPB group received preoperative bilateral ESPB block. Postoperative pain, reported using a numerical rating scale at 1, 12, 24, and 48 hours after surgery; the number of required rescue doses; total postoperative morphine milligram equivalents consumption; and the incidence of postoperative nausea and vomit were analyzed. MEASUREMENT AND MAIN RESULTS A total of 105 patients were identified for analysis. Propensity-score matching resulted in 38 patients in the SIVA group and 19 patients in the ESPB group. Postoperative pain, the number of rescue doses, and postoperative nausea and vomit incidences were lower in the ESPB group (p < 0.005). CONCLUSIONS Erector spinae plane block may be an effective option for pain management after surgical repair of PE as part of a multimodal approach. This study showed good perioperative analgesia, opioid sparing, and reduced opioid-related adverse effects.
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Affiliation(s)
- Silvia Fiorelli
- Anesthesia and Intensive Care Medicine, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.
| | - Cecilia Menna
- Thoracic Surgery, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Claudio Andreetti
- Thoracic Surgery, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Valentina Peritore
- Thoracic Surgery, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Monica Rocco
- Anesthesia and Intensive Care Medicine, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Roberto Alberto De Blasi
- Anesthesia and Intensive Care Medicine, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Erino Angelo Rendina
- Thoracic Surgery, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Domenico Massullo
- Anesthesia and Intensive Care Medicine, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Mohsen Ibrahim
- Thoracic Surgery, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
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Ganescu O, Emil S, Saint-Martin C, Guadagno E, Laberge JM, LaRusso K, Frigon C. Postoperative pain following minimally invasive repair of pectus excavatum: A descriptive study. J Pediatr Surg 2022; 57:918-926. [PMID: 35105456 DOI: 10.1016/j.jpedsurg.2021.12.051] [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: 12/12/2021] [Accepted: 12/29/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Minimally Invasive Repair of Pectus Excavatum (MIRPE) is associated with significant postoperative pain. The objective of our study was to characterize the severity and duration of this pain, and to investigate possible associations with pectus severity. METHODS We conducted a retrospective cohort study of pediatric patients who underwent MIRPE from January 2014 to April 2018. Pectus excavatum (PE) severity was determined with 3 indices measured from computed tomography: Depression Index (DI), Correction Index (CI), and Haller index (HI). Mean pain scores for every 6-hour period and the presence of pain and intake of analgesics during follow-up were extracted from the medical record. RESULTS The cohort included 57 patients with a mean age of 15.9 ± 1.3 years. All 3 severity indices were positively correlated, with a correlation coefficient of 0.8 between the DI and CI. The requirement for 2 bars was significantly associated with higher indices (95% CI:0.18-0.63, p = 0.01). Pain was managed with thoracic epidural analgesia for all but one patient. Growth linear modeling identified five different pain trajectory subgroups of patients up to post-operative day 5. None of the tested predictors (age, gender, body image, physical activity level, DI, CI, HI, difference deformity-epidural level) were significantly associated with class membership. Persistent pain at one-year follow-up was present in 18% of patients, all with severe deformity (DI≥0.8). CONCLUSION Pain trajectory and intensity after MIRPE can be classified into discrete patterns but are not influenced by PE severity. Severe deformity seems to predict persistent pain at one year.
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Affiliation(s)
- Olivia Ganescu
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital McGill University Health Center, Montreal, QC, Canada
| | - Sherif Emil
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital McGill University Health Center, Montreal, QC, Canada; Chest Wall Anomaly Centre, Shriners Hospitals for Children-Canada, Montreal, QC, Canada
| | | | - Elena Guadagno
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital McGill University Health Center, Montreal, QC, Canada
| | - Jean-Martin Laberge
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital McGill University Health Center, Montreal, QC, Canada; Chest Wall Anomaly Centre, Shriners Hospitals for Children-Canada, Montreal, QC, Canada
| | - Kathryn LaRusso
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital McGill University Health Center, Montreal, QC, Canada
| | - Chantal Frigon
- Division of Pediatric Radiology, McGill University Health Center, The Montreal Children's Hospital, McGill University Health Center, Montreal, QC, Canada; Department of Anesthesiol+ogy, The Montreal Children's Hospital, McGill University Health Center, Montréal, QC, Canada.
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Dey S, Kohli JK, Magoon R, ItiShri I, Kashav RC. Feasibility of Opioid-Free Anesthesia for Cervical Rib Excision: A Case Series and Review of Literature. JOURNAL OF CARDIAC CRITICAL CARE TSS 2022. [DOI: 10.1055/s-0041-1741492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Abstract
Background Perioperative pain management following cervical rib excision can be compounded in the background of chronic pain disorder caused by the neurovascular compression. The former mandates an enhanced analgesic requirement wherein the perioperative opioid use, in particular, can be associated with a peculiar adverse-effect profile and abuse potential. Appropriate to the context, an opioid-free anesthesia (OFA) protocol can be instrumental in minimizing the incidence of the aforementioned.
Case Series While two patients necessitated OFA owing to opioid contraindication, the formulated protocol was evaluated in another six consecutive patients posted for elective cervical rib excision. A combined paravertebral block and superficial cervical plexus block was employed alongside general anesthesia. Intravenous dexmedetomidine and lignocaine assisted the conduct of OFA, and paracetamol dosing was continued into the postoperative period. Intraoperative rescue analgesia was ensured by a ketofol bolus (1:1 mixture of ketamine and propofol) whereas intravenous diclofenac was used for postoperative rescue analgesia.
Results OFA could be successfully contemplated in all eight patients. A single bolus rescue dose of ketofol had to be administered in two patients intraoperatively and diclofenac had to be administered as postoperative rescue analgesic in two patients. There was no incidence of postoperative nausea/vomiting or any block-related complications. The postoperative stay was uneventful with an acceptable patient satisfaction.
Conclusion The index experience reiterates the fact that a prudent combination of nonopioid multimodal analgesics with case-based locoregional techniques can feature as a successful OFA protocol, albeit mandating future prospective studies in this novel area of clinical interest.
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Affiliation(s)
- Souvik Dey
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), New Delhi, India
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), New Delhi, India
| | - Jasvinder Kaur Kohli
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), New Delhi, India
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), New Delhi, India
| | - Rohan Magoon
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), New Delhi, India
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), New Delhi, India
| | - ItiShri ItiShri
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), New Delhi, India
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), New Delhi, India
| | - Ramesh Chand Kashav
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), New Delhi, India
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), New Delhi, India
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Ultrasound-guided erector spinae plane block versus thoracic epidural analgesia: Postoperative pain management after Nuss repair for pectus excavatum. J Pediatr Surg 2022; 57:207-212. [PMID: 34949445 DOI: 10.1016/j.jpedsurg.2021.10.030] [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: 10/17/2021] [Accepted: 10/23/2021] [Indexed: 01/22/2023]
Abstract
AIM OF THE STUDY Postoperative pain management is a significant challenge in patients undergoing Nuss repair for pectus excavatum chest wall deformity. Therapeutic anesthetic options primarily include patient-controlled intravenous analgesia, thoracic epidural analgesia (TEA), and cryoanalgesia. However, TEA is limited to inpatient use and both TEA and cryoanalgesia can result in neurologic injury. The novel technique of ultrasound-guided erector spinae plane regional analgesia has been used recently in our patients undergoing the Nuss repair and has shown impressive pain relief, but without the potential complications of other modalities. Erector spinae plane block (ESPB) postoperative pain management outcomes were studied as compared to TEA. METHODS Thirty consecutive patients with severe pectus excavatum undergoing Nuss repair and placement of ultrasound-guided ESPB were each paired to a historical cohort control patient with TEA postoperative pain management. The cohort patient match was defined by age (± 2 years), gender, and CT pectus index (± 15%). Study variables included hospital length of stay (LOS), pain scores, and pain medication usage. RESULTS Pain scores as measured by area under the curve per hour (Day 1: 2.72 (SD = 1.37) vs. 3.90 (SD = 1.81), P = 0.006; Day 2: 2.83 (SD = 1.32) vs. 3.97 (SD = 1.82), P = 0.007) and oral morphine equivalent (OME) pain medication usage (Day 1: 11.9 (SD = 4.9) vs 56.0 (SD = 32.2), P < 0.001; Day 2: 14.7 (SD = 7.1) vs. 38.0 (SD = 21.7), P < 0.001) were higher for the first two postoperative days in the ESPB group. However, mean hospital LOS was nearly one day shorter for ESPB patients (3.78 (SD = 0.82) vs. 2.90 (SD = 0.87), P < 0.001) who were discharged home with the catheter in place until removal, typically at 5-7 days postoperatively. CONCLUSION Ultrasound-guided ESPB is thus a feasible, safe, and effective alternative to TEA in postoperative pain management after Nuss repair and results in decreased hospital stay. LEVEL OF EVIDENCE III.
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16
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Rettig RL, Rudikoff AG, Annie Lo HY, Lee CW, Vazquez WD, Rodriguez K, Shaul DB, Conte AH, Banzali FM, Sydorak RM. Same-day discharge following the Nuss repair: A comparison. J Pediatr Surg 2022; 57:135-140. [PMID: 34670678 DOI: 10.1016/j.jpedsurg.2021.09.023] [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: 09/06/2021] [Accepted: 09/08/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Intercostal Nerve Cryoablation (INC) has significantly improved pain control following the Nuss repair of pectus excavatum (PE). This study sought to evaluate patients undergoing the Nuss repair with INC compared to the Nuss repair with an ERAS protocol, INC, and intercostal nerve blocks (INB). METHODS In June 2020, a new protocol was implemented involving surgery, anesthesia, nursing, physical therapy, and child life with the goal of safe same day discharge for patients undergoing the Nuss repair. They were compared to a control group who underwent the Nuss repair with INC alone in 2017-2019. The primary outcome measure was hospital length of stay (LOS) in hours, secondary outcomes were number of patients discharged on postoperative day (POD) 0, and returns to the emergency department (ED), urgent care (UC), and operating room (OR). RESULTS The characteristics between the groups were the same (Table 1). The mean LOS was 11.8 h in the INB group versus 58.2 h in the INC group, p < 0.01. 10 of 15 patients in the INB group went home on POD 0 (average of 5.5 h postop), versus 0 patients in the INC only group, p < 0.01. Five patients in the INB stayed overnight. Two patients stayed owing to anxiety, one owing to urinary retention, one owing to nausea, and one owing to drowsiness. None stayed for pain control. Four patients in the INC group returned to the ED for pain control, versus 0 in the INB group, and 1 patient in the INB returned to UC for constipation. CONCLUSIONS The majority of patients undergoing the Nuss repair of PE with a multidisciplinary regimen of pre and postoperative nursing education, precise intraoperative anesthesia care, performance of direct vision INB and INC, as well as careful surgery can go home on the day of surgery without adverse outcomes or unanticipated returns to the hospital. LEVEL-OF-EVIDENCE Level II.
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Affiliation(s)
- R Luke Rettig
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA
| | - Andrew G Rudikoff
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles, CA 90027 USA
| | - Hoi Yee Annie Lo
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA
| | - Constance W Lee
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA
| | - Walter D Vazquez
- Department of Pediatric Surgery, Kaiser Permanente San Diego Medical Center, 9455 Clairemont Mesa Blvd, San Diego, CA 92123 USA
| | - Karen Rodriguez
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA
| | - Donald B Shaul
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA
| | - Antonio Hernandez Conte
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles, CA 90027 USA
| | - Franklin M Banzali
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles, CA 90027 USA
| | - Roman M Sydorak
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA.
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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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Thoracic paravertebral nerve catheter reduces postoperative opioid use for vertebral body tethering patients. Spine Deform 2021; 9:1601-1607. [PMID: 34264474 DOI: 10.1007/s43390-021-00381-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 06/22/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Vertebral body tethering is increasingly being performed, yet postoperative pain management has not yet been optimized. We sought to determine whether the addition of a thoracic paravertebral block in addition to a standard multimodal postoperative pain management program could provide greater pain relief, reduced analgesic requirement, and reduced length of stay. METHODS Patients who underwent VBT at a single tertiary referral center were retrospectively reviewed. All patients received a single-shot intrathecal (IT) injection at the completion of the procedure in addition to a standardized multimodal pain management program. 45 patients received a thoracic paravertebral catheter with lidocaine infusion (TPVB) which was left in place for 4-6 days, whereas 24 control patients did not have a TPVB. Length of stay, maximum postoperative Numeric Pain Intensity Scale (NPIS), and total dose of opioids, ibuprofen, ketorolac and acetaminophen administered during hospitalization were evaluated. RESULTS 69 patients met inclusion criteria. The mean cumulative dose of opioids administered during hospitalization was 148 oral morphine milligram equivalent (MME) in the control group vs. 47 MME in the TPVB group (p < 0.0001). Severe postoperative NPIS of ≥ 7 was reported in 9 out of the 24 control patients (38%) and in 13 out of the 45 patients (29%) who received a TPVB in addition to the standardized care (p = 0.46). There was no significant difference in the mean cumulative dose of NSAIDs (ibuprofen, ketorolac) consumed by the control group compared to the TPVB group (2632 mg vs. 1630 mg, p = 0.77). Mean length of stay in the control group was 3.8 vs. 3.0 days in the TPVB group (p < 0.001). There were no major complications associated with use of the TPVB. CONCLUSION In this series compared to controls, patients treated with a TPVB had reduced postoperative requirement of opioids and decreased length of hospital stay.
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Thoracic epidural-based Enhanced Recovery After Surgery (ERAS) pathway for Nuss repair of pectus excavatum shortened length of stay and decreased rescue intravenous opiate use. Pediatr Surg Int 2021; 37:1191-1199. [PMID: 34089071 DOI: 10.1007/s00383-021-04934-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND PCA- and block-based enhanced recovery after surgery (ERAS) pathways have been shown to decrease hospital length of stay (HLOS) and opiate use following Nuss Repair for Pectus Excavatum (NRPE). No thoracic epidural-based ERAS pathway has demonstrated similar benefits. METHODS In this pre-post single-center study, data were retrospectively collected for patients ≤ 21 years undergoing NRPE from May 2015 to August 2019. Univariate and multivariate methods were used to evaluate whether implementation of a thoracic epidural-based ERAS in April 2017 was associated with HLOS, opiate use, or pain scores. RESULTS There were 110 patients: 35 pre- and 75 post-ERAS. HLOS decreased from median 4.8 (1.1) to 3.3 (0.6) days with ERAS (p < 0.001). Use of rescue intravenous opiates decreased from 35.3% pre- to 9.3% with ERAS (p = 0.013). When adjusted for baseline characteristics, ERAS was associated with a 1.3 ± 0.2 day decrease in HLOS and 0.188 times the odds of rescue intravenous opiate use (p = 0.011). CONCLUSIONS Pain scores, ED visits, and readmissions did not change with ERAS (p > 0.05). Implementation of a thoracic epidural-based ERAS following NRPE was associated with decreased HLOS and need for any rescue intravenous opiates without a change in pain scores, ED visits, or readmission.
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Rettig RL, Rudikoff AG, Lo HYA, Shaul DB, Banzali FM, Conte AH, Sydorak RM. Cryoablation is associated with shorter length of stay and reduced opioid use in pectus excavatum repair. Pediatr Surg Int 2021; 37:67-75. [PMID: 33210165 DOI: 10.1007/s00383-020-04778-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/04/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The use of intercostal nerve cryoablation (INC) is becoming increasingly common in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate the use of INC compared to traditional use of thoracic epidural (TE). METHODS A retrospective review of 79 patients undergoing PE repair with either INC or TE from May 2009 to December 2019 was conducted. The operations were performed by four surgeons who worked together at four different hospitals and have the same standardized practice. The primary outcome measure was hospital length of stay (LOS). Secondary variables included surgical time, total operating room time, operating room time cost, total hospital cost, inpatient opioid use, long-term opioid use after discharge, and postoperative complications. RESULTS LOS decreased to 2.5 days in the INC group compared to 5 days in the TE group (p < 0.0001). Surgical time was increased in the INC group, but there was no difference in total OR time. The INC group experienced significantly lower hospital costs. Total hospital opioid administration was significantly lower in INC group, and there was a significant decrease in long-term opioid use in the INC group. CONCLUSIONS INC is a newer modality that decreases LOS, controls pain, and results in overall cost savings. We recommend that INC be included in the current practice for postoperative pain control in PE patients undergoing Nuss procedure.
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Affiliation(s)
- R Luke Rettig
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Andrew G Rudikoff
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Hoi Yee Annie Lo
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Donald B Shaul
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Franklin M Banzali
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Antonio Hernandez Conte
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Roman M Sydorak
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA. .,Kaiser Permanente Los Angeles Medical Center, 4760 Sunset Blvd, 3rd Floor, Los Angeles, CA, 90027, USA.
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Kelley-Quon LI, Kirkpatrick MG, Ricca RL, Baird R, Harbaugh CM, Brady A, Garrett P, Wills H, Argo J, Diefenbach KA, Henry MCW, Sola JE, Mahdi EM, Goldin AB, St Peter SD, Downard CD, Azarow KS, Shields T, Kim E. Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion. JAMA Surg 2021; 156:76-90. [PMID: 33175130 PMCID: PMC8995055 DOI: 10.1001/jamasurg.2020.5045] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
IMPORTANCE Opioids are frequently prescribed to children and adolescents after surgery. Prescription opioid misuse is associated with high-risk behavior in youth. Evidence-based guidelines for opioid prescribing practices in children are lacking. OBJECTIVE To assemble a multidisciplinary team of health care experts and leaders in opioid stewardship, review current literature regarding opioid use and risks unique to pediatric populations, and develop a broad framework for evidence-based opioid prescribing guidelines for children who require surgery. EVIDENCE REVIEW Reviews of relevant literature were performed including all English-language articles published from January 1, 1988, to February 28, 2019, found via searches of the PubMed (MEDLINE), CINAHL, Embase, and Cochrane databases. Pediatric was defined as children younger than 18 years. Animal and experimental studies, case reports, review articles, and editorials were excluded. Selected articles were graded using tools from the Oxford Centre for Evidence-based Medicine 2011 levels of evidence. The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument was applied throughout guideline creation. Consensus was determined using a modified Delphi technique. FINDINGS Overall, 14 574 articles were screened for inclusion, with 217 unique articles included for qualitative synthesis. Twenty guideline statements were generated from a 2-day in-person meeting and subsequently reviewed, edited, and endorsed externally by pediatric surgical specialists, the American Pediatric Surgery Association Board of Governors, the American Academy of Pediatrics Section on Surgery Executive Committee, and the American College of Surgeons Board of Regents. Review of the literature and guideline statements underscored 3 primary themes: (1) health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids, (2) nonopioid analgesic use should be optimized in the perioperative period, and (3) patient and family education regarding perioperative pain management and safe opioid use practices must occur both before and after surgery. CONCLUSIONS AND RELEVANCE These are the first opioid-prescribing guidelines to address the unique needs of children who require surgery. Health care professionals caring for children and adolescents in the perioperative period should optimize pain management and minimize risks associated with opioid use by engaging patients and families in opioid stewardship efforts.
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Affiliation(s)
- Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
- Department of Preventive Medicine, University of Southern California, Los Angeles
- Keck School of Medicine, Department of Surgery, University of Southern California, Los Angeles
| | | | - Robert L Ricca
- Department of Pediatric Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Robert Baird
- Division of Pediatric Surgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Ashley Brady
- Department of Pediatric Surgery, University of Michigan, Ann Arbor
| | - Paula Garrett
- Department of Pediatric Surgery, University of Michigan, Ann Arbor
| | - Hale Wills
- Division of Pediatric Surgery, Hasbro Children's Hospital, Providence, Rhode Island
- Department of Surgery, Alpert Medical School, Brown University, Providence, Rhode Island
| | - Jonathan Argo
- Department of Pediatric Anesthesiology, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Karen A Diefenbach
- Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Marion C W Henry
- Department of Surgery, University of Arizona College of Medicine, Tucson
| | - Juan E Sola
- Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Elaa M Mahdi
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
- Keck School of Medicine, Department of Surgery, University of Southern California, Los Angeles
| | - Adam B Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, Washington
- Department of Surgery, University of Washington School of Medicine, Seattle
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Cynthia D Downard
- Division of Pediatric Surgery, Hiram C. Polk Jr MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Kenneth S Azarow
- Division of Pediatric Surgery, Department of Surgery, Oregon Health & Science University, Portland
| | - Tracy Shields
- Division of Library Services, Naval Medical Center, Portsmouth, Virginia
| | - Eugene Kim
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
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Xie J, Mooney DP, Cravero J. Comparison of regional analgesia techniques for pleurodesis pain in pediatric patients. Paediatr Anaesth 2020; 30:1102-1108. [PMID: 32780896 DOI: 10.1111/pan.13996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/28/2020] [Accepted: 08/07/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mechanical pleurodesis can prevent recurrence of spontaneous pneumothorax but is associated with significant postoperative pain. Adequate pain control is not only beneficial for patient comfort but also critical for mobilization and pulmonary recovery. Thoracic epidural catheters and paravertebral blocks have been used to alleviate pain after thoracoscopic surgery. However, no studies have evaluated the safety and efficacy of paravertebral block vs epidural analgesia vs no block in children undergoing pleurodesis. METHODS In this retrospective case series review, data were extracted from a single institution's integrated patient outcome database on children who underwent thoracoscopic pleurodesis from 2013 to 2018. Demographics, operative indication, procedure performed, and perioperative pain management were assessed by chart review. Patients whose operation was converted to thoracotomy, who had an underlying diagnosis of chronic pain, or who underwent pleurodesis for other indications were excluded. The primary outcomes were postoperative pain scores and opioid consumption. Secondary outcomes included psot anesthesia care unit length of stay, hospital length of stay, functional outcomes during recovery, and any adverse events. RESULTS 66 patients met inclusion criteria: 23 received thoracic epidurals, 34 received paravertebral blocks, and 9 received no epidural/paravertebral block. Patient characteristics did not significantly differ among groups. Although mean pain scores were statistically significantly lower in the epidural group on post-op day 1, all three groups' pain scores were in the 1 to 3 out of 10 range during the entire postoperative period. Thus, this statistical significance had little clinical significance as all groups had good pain control. The epidural group had significantly lower opioid consumption on post-op days 0 - 2 compared to paravertebral block. No adverse events related to epidural or paravertebral block were noted. DISCUSSION We present the an analysis of epidural vs paravertebral block (with comparison to no regional analgesia) following pleurodesis in children. Pain is well managed, regardless of the method; however, additional systemic opioid consumption was decreased in the epidural analgesia cohort. Prospective trials and comparisons with other analgesic techniques for pediatric thoracic surgeries are needed. CONCLUSIONS Thoracic epidural analgesia offers a reduction in opioid use in the first two post-op days after pleurodesis but did not produce a clinically significant reduction in pain scores in comparison with paravertebral block or no block.
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Affiliation(s)
- James Xie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard School of Medicine, Boston, MA, USA
| | - David P Mooney
- Department of Surgery, Boston Children's Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Joseph Cravero
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard School of Medicine, Boston, MA, USA
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Abstract
The scope of pediatric regional anesthesia is expanding, with increased safety and efficacy data over the past few years. As familiarity and expertise has developed with ultrasonography, regional anesthesia has played an important role in the management of acute pain in the postsurgical population.
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Anaesthesia for the surgical correction of chest wall deformities. BJA Educ 2020; 20:287-293. [PMID: 33456962 DOI: 10.1016/j.bjae.2020.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2020] [Indexed: 11/20/2022] Open
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Wei W, Fan Y, Liu W, Zhao T, Tian H, Xu Y, Tan Y, Song X, Ma D. Combined non-intubated anaesthesia and paravertebral nerve block in comparison with intubated anaesthesia in children undergoing video-assisted thoracic surgery. Acta Anaesthesiol Scand 2020; 64:810-818. [PMID: 32145713 DOI: 10.1111/aas.13572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/27/2020] [Accepted: 02/20/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND This study is to investigate if non-intubated anaesthesia combined with paravertebral nerve block (PVNB) can enhance recovery in children undergoing video-assisted thoracic surgery (VATS). METHODS A randomized controlled trial including 60 patients aged 3 to 8 years old who underwent elective VATS was performed. They were randomly assigned to receive non-intubated anaesthesia combined with PVNB or general anaesthesia with tracheal intubation (1:1 ratio). The primary outcome was the length of postoperative in-hospital stay. The secondary outcomes included emergence time, the incidence of emergence delirium, time to first feeding, time to first out-of-bed activity, pain score and in-hospital complications. RESULTS The non-intubated group had shorter postoperative in-hospital stay than the control group (4 days [IQR, 4-6] vs 5 days [IQR, 5-8], 95% CI 0-2; P = .013). When compared to the control group, the incidence of emergence delirium (odds ratio [OR] 3.39, 95% CI 1.01-11.41; P = .043), emergence time, duration in the PACU, time to first eating food, first out-of-bed activity, pain score and consumption of sufentanil (at 6 and 12 hours after surgery) were decreased in the intervention group. In contrast, the incidence of airway complications was higher in the control than the intervention group (27.6% vs 6.9%, P = .037). There was no statistical significance in the occurrence of PONV, pneumothorax and other complications between the two groups. CONCLUSIONS Non-intubated anaesthesia combined with PVNB enhances recovery in paediatric patients for video-assisted thoracic surgery although further multi-centre study is needed.
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Affiliation(s)
- Wei Wei
- Department of Anaesthesiology Guangzhou Women and Children’s Medical Center Guangzhou Medical University Guangzhou China
| | - Yanting Fan
- Department of Anaesthesiology Guangzhou Women and Children’s Medical Center Guangzhou Medical University Guangzhou China
| | - Wei Liu
- Department of Thoracic Surgery Guangzhou Women and Children’s Medical Center Guangzhou Medical University Guangzhou China
| | - Tianyun Zhao
- Department of Anaesthesiology Guangzhou Women and Children’s Medical Center Guangzhou Medical University Guangzhou China
| | - Hang Tian
- Department of Anaesthesiology Guangzhou Women and Children’s Medical Center Guangzhou Medical University Guangzhou China
| | - Yingyi Xu
- Department of Anaesthesiology Guangzhou Women and Children’s Medical Center Guangzhou Medical University Guangzhou China
| | - Yonghong Tan
- Department of Anaesthesiology Guangzhou Women and Children’s Medical Center Guangzhou Medical University Guangzhou China
| | - Xingrong Song
- Department of Anaesthesiology Guangzhou Women and Children’s Medical Center Guangzhou Medical University Guangzhou China
| | - Daqing Ma
- Anaethetics, Pain Medicine and Intensive Care Department of Surgery and Cancer Faculty of Medicine Imperial College London Chelsea and Westminster Hospital London UK
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Pilkington M, Harbaugh CM, Hirschl RB, Geiger JD, Gadepalli SK. Use of cryoanalgesia for pain management for the modified ravitch procedure in children. J Pediatr Surg 2020; 55:1381-1384. [PMID: 31672412 DOI: 10.1016/j.jpedsurg.2019.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 08/31/2019] [Accepted: 09/12/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Intercostal cryoablation(IC) for pain management in children undergoing Nuss Procedure has been previously described. We evaluated postoperative outcomes following Modified Ravitch procedure for pectus disorders comparing IC to thoracic epidural(TE). MATERIALS AND METHODS Single-center retrospective review of pediatric patients (age < 21) undergoing Modified Ravitch procedure (January 2015-March 2019) with either IC(9), or TE(20) analgesia. Primary outcome was length of stay (LOS) and secondary outcomes were inpatient opioid use (in oral morphine equivalents per kilogram; OME/kg), pain scores on each postoperative day (POD), discharge prescriptions, and complications. Pairwise comparisons made with Mann-Whitney U test or Fisher Exact test as appropriate. Two-tailed p values <0.05 were considered significant. RESULTS Patient characteristics were similar. LOS was shorter with IC compared to TE (4 days versus 6; p < 0.006). Postoperative opioid use was not significantly different (IC: 1.5 OME/kg versus TE: 1.1; p = 0.10). There was improved pain control on POD 2 in patients who underwent IC (median pain score 3 versus 4; p < 0.0004). There was no difference in discharge prescription (IC: 3.3 OME/kg; TE: 4.8; p = 0.19) or complication rate (IC: 55.6%, TE:50%; p = 1.0). CONCLUSIONS IC during the Modified Ravitch reduced LOS compared to TE with improved pain control starting on POD 2, with similar narcotic utilization and complication rates. LEVEL OF EVIDENCE Treatment Study, Level III (Retrospective comparative study).
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Affiliation(s)
- Mercedes Pilkington
- Pediatric Surgery Section, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Calista M Harbaugh
- Department of Surgery, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Ronald B Hirschl
- Pediatric Surgery Section, University of Michigan, Ann Arbor, MI, 48109, USA
| | - James D Geiger
- Pediatric Surgery Section, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Samir K Gadepalli
- Pediatric Surgery Section, University of Michigan, Ann Arbor, MI, 48109, USA.
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Zani-Ruttenstock E, Sozer A, O'Neill Trudeau M, Fecteau A. First national survey on opioids prescribing practices of Canadian pediatric surgeons. J Pediatr Surg 2020; 55:954-958. [PMID: 32139031 DOI: 10.1016/j.jpedsurg.2020.01.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 01/25/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE Prescription opioid misuse has become a public health concern globally. In Canada, little is known about the national prescription patterns in children. The purpose of the present study was to evaluate the opioid prescribing practices of pediatric surgeons in Canada. METHODS Following ethical approval, an electronic questionnaire was administered to all pediatric surgeons currently practicing in Canada. Questions included surgeon practice information, patterns of opioid prescription at discharge based on the type of surgery, type of opioid prescribed, and availability of training for surgeons/families. RESULTS Fifty-eight questionnaires were completed (response rate: 84%) by surgeons from 8 out of 8 Canadian provinces with pediatric surgery coverage. 33% of responders prescribed opioids (most commonly morphine) for day surgeries and 73% of Pediatric Surgeons prescribed opioids for major surgeries. Most responders (84%) declared that at their institution there was no formal training for residents/fellows in pain control and opioid prescribing. Similarly, 57% reported no education for families about opioids at discharge. CONCLUSION This first national survey on opioid prescribing practices across Canada reveals that opioids were prescribed to pediatric patients following a broad range of minor and major surgical procedures. Moreover, there seems to be a lack of education for surgeons and families about opioid use. TYPE OF STUDY Descriptive, cross-sectional, practice survey. LEVEL OF EVIDENCE Level 5.
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Affiliation(s)
- Elke Zani-Ruttenstock
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
| | - Aubrey Sozer
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
| | - Maeve O'Neill Trudeau
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
| | - Annie Fecteau
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada.
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Archer V, Robinson T, Kattail D, Fitzgerald P, Walton JM. Postoperative pain control following minimally invasive correction of pectus excavatum in pediatric patients: A systematic review. J Pediatr Surg 2020; 55:805-810. [PMID: 32081359 DOI: 10.1016/j.jpedsurg.2020.01.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 01/25/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE Surgery for pectus excavatum is associated with significant postoperative pain. The aim of this study was to summarize the current literature regarding postoperative pain control for pediatric patients undergoing minimally invasive repair of pectus excavatum (MIRPE). METHODS A systematic search of Medline, Embase, PubMed, CINAHL, Web of Science, and the Cochrane Library for randomized controlled trials (RCT) comparing methods of pain control in pediatric patients undergoing MIRPE was conducted. Studies were restricted to the English language. RESULTS After screening 1304 references, 9 randomized control trials (RCTs) enrolling 485 patients were included. The average age was 11.9 years (±3.1). Pain scores were decreased with ropivacaine compared to bupivacaine-based epidurals. In studies comparing ketamine to opioid based patient-controlled anesthesia (PCA) pumps, the results were variable. Intercostal and paravertebral nerve blocks had decreased pain scores in 75% of the studies compared to opioid-based PCA. Opioid consumption was decreased in 50% of the trials assessing ketamine-based infusions and 75% of the studies comparing intercostal and paravertebral nerve blocks. Nausea was decreased in several of the ketamine-based infusion and intercostal and paravertebral nerve block studies. CONCLUSION Ketamine-including infusions or paravertebral and intercostal nerve blocks may represent superior methods of postoperative pain control for MIRPE. Further work is needed to confirm results. LEVEL OF EVIDENCE 2A [1].
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Affiliation(s)
- Victoria Archer
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Tessa Robinson
- Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, Hamilton, Ontario, Canada
| | - Deepa Kattail
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada; McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Peter Fitzgerald
- Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, Hamilton, Ontario, Canada; McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - J Mark Walton
- Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, Hamilton, Ontario, Canada; McMaster Children's Hospital, Hamilton, Ontario, Canada.
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Aydin G, Sahin AT, Gencay I, Akcabay ZN, Gunal N, Dural K, Ozpolat B, Buyukkocak U. Which Is More Effective for Minimally Invasive Pectus Repair: Epidural or Paravertebral Block? J Laparoendosc Adv Surg Tech A 2019; 30:81-86. [PMID: 31742471 DOI: 10.1089/lap.2019.0403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: The aim of this study was to compare the effectiveness of epidural block (EDB) and paravertebral block (PVB) for minimally invasive pectus repair with the conventional method in terms of pain control during and after pectus operations, patient comfort, and length of stay in hospital. Materials and Methods: A retrospective review was made of patients who underwent minimally invasive pectus repair. The patients were allocated into three groups as follows: PVB group (Pre-emptive ultrasound-guided bilateral thoracic single injection PVB, n = 15); EDB group (Pre-emptive landmark-guided single injection thoracic EDB, n = 8); and Control group (Neither PVB nor EPB, n = 9). The intraoperative analgesic requirement was recorded, and a visual analog scale (VAS) for pain evaluation and the Postoperative Patient Satisfaction Scale were applied to all patients. Results: The intraoperative analgesic requirement, VAS scores, postoperative satisfaction level, and time to first requirement for postoperative analgesia were different between the control and PVB groups (P < .001) and between the control and EDB groups (P < .001), but not different between the PVB and EDB groups. Although the length of stay in hospital was shorter in the PVB and EDB groups compared to the control group, the difference was not statistically significant (P = .422). Conclusion: Epidural and bilateral paravertebral blockades performed in conjunction with general anesthesia decrease the intraoperative and postoperative need for analgesics, and might be beneficial for pain management and contribute to a shorter length of hospital stay for patients undergoing minimally invasive pectus repair operations. Both blockades also significantly improved the patient satisfaction.
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Affiliation(s)
- Gulcin Aydin
- Department of Anesthesiology and Reanimation, Kırıkkale University School of Medicine, Kirikkale, Turkey
| | - Ahmet Tugrul Sahin
- Department of Anesthesiology and Reanimation, Kırıkkale University School of Medicine, Kirikkale, Turkey
| | - Isin Gencay
- Department of Anesthesiology and Reanimation, Kırıkkale University School of Medicine, Kirikkale, Turkey
| | - Zeynep Nur Akcabay
- Department of Anesthesiology and Reanimation, Kırıkkale University School of Medicine, Kirikkale, Turkey
| | - Nesimi Gunal
- Department of Thoracic Surgery, Kırıkkale University School of Medicine, Kirikkale, Turkey
| | - Koray Dural
- Department of Thoracic Surgery, Kırıkkale University School of Medicine, Kirikkale, Turkey
| | - Berkant Ozpolat
- Department of Thoracic Surgery, Kırıkkale University School of Medicine, Kirikkale, Turkey
| | - Unase Buyukkocak
- Department of Anesthesiology and Reanimation, Yüksek İhtisas University School of Medicine, Ankara, Turkey
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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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Merella F, Canchi-Murali N, Mossetti V. General principles of regional anaesthesia in children. BJA Educ 2019; 19:342-348. [DOI: 10.1016/j.bjae.2019.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2019] [Indexed: 01/22/2023] Open
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Holmes DM, Polites SF, Roskos PL, Moir CR. Opioid use and length of stay following minimally invasive pectus excavatum repair in 436 patients - Benefits of an enhanced recovery pathway. J Pediatr Surg 2019; 54:1976-1983. [PMID: 30922685 DOI: 10.1016/j.jpedsurg.2019.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 01/29/2019] [Accepted: 02/03/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE The purpose of this study was to determine outcomes of an enhanced recovery pathway (ERP) for minimally invasive repair of pectus excavatum (MIRPE) at a high volume center, hypothesizing it is associated with decreased opioid requirement and shorter hospital stay. METHODS Patients were categorized into pre-ERP (1998-2006), transition (2007-2011), and ERP (2012-2017) cohorts. Data were abstracted from medical records. Univariate and multivariable analyses compared opioid utilization, length of stay (LOS), and complications between cohorts. Opioids were converted to morphine daily dose per kilogram (MEDD/kg). RESULTS Of 436 patients, 186 were ERP, 104 were transition, and 146 were pre-ERP. ERP was associated with decreased hospital opioid utilization (mean MEDD/kg 0.5 ± 0.2 vs 0.7 ± 0.4 vs 0.7 ± 0.8 p < .001) and shorter median LOS (3 vs 4 vs 5 days, p < .001) despite equivalent pain scores at discharge (2.7 ± 0.1 vs 2.8 ± 0.2 vs 2.9 ± 0.3, p = .73). Most ERP patients (76%) had LOS ≤3 days. Differences in LOS between ERP, transition, and pre-ERP persisted on multivariable analysis after adjusting for confounding factors. Post-operative complications were rare and not different between groups (p > .05). CONCLUSIONS Implementation of our ERP was associated with decreased opioid requirement and shorter hospital stay. ERPs are a valuable tool in pediatric surgery given the current emphasis on optimizing opioid and resource utilization. LEVELS OF EVIDENCE Level III (Retrospective comparative study).
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Affiliation(s)
- David M Holmes
- University of Illinois at Chicago College of Medicine, Chicago, IL.
| | | | - Penny L Roskos
- Division of Pediatric Surgery, Mayo Clinic, Rochester, MN
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Tore Altun G, Arslantas MK, Corman Dincer P, Aykac ZZ. Ultrasound-Guided Serratus Anterior Plane Block for Pain Management Following Minimally Invasive Repair of Pectus Excavatum. J Cardiothorac Vasc Anesth 2019; 33:2487-2491. [PMID: 31097336 DOI: 10.1053/j.jvca.2019.03.063] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/25/2019] [Accepted: 03/29/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The Nuss procedure is a preferred technique for minimally invasive repair of pectus excavatum (MIRPE), but it is associated with significant postoperative pain. We assessed the efficacy and safety of an ultrasound-guided bilateral serratus anterior plane block (SAPB) for relieving acute pain from MIRPE. DESIGN A retrospective cohort study. SETTING This study was conducted at the Marmara University Pendik Training and Research Hospital, Turkey. PARTICIPANTS All participants were scheduled for MIRPE. INTERVENTIONS This study was conducted from November 2017 to May 2018. Postoperative pain control was achieved with bilateral SAPB done after induction of anesthesia and IV PCA in 50 patient (SABP group) and with only IV PCA in 45 patients (Control group). SAPB was achieved, targeting the interfascial plane between the serratus anterior and latissimus dorsi muscles, with a single injection of 30 mL (20 mL if patient weighed < 40 kg) of 0.25% bupivacaine and 0.5% lidocaine into each side. Pain scores were recorded for 24 h. MEASUREMENT AND MAIN RESULTS Patients in the Control group had a higher demand (mean difference, 61; 95% confidence interval [CI] 30.5-136; P < 0.0001) and delivery dose (mean difference, 25; 95% CI 15-41.5 P = 0.001) during the first postoperative 24 h. SAPB did not affect the median (interquartile range) length of hospital stay: 5 (5-7) days vs. 5 (4-6) days, (P =0.085). CONCLUSIONS Bilateral single-injection SAPB in patients undergoing MIRPE decreases pain and opioid consumption during the early postoperative period.
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Affiliation(s)
- Gulbin Tore Altun
- Department of Anesthesiology and Reanimation, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Kemal Arslantas
- Department of Anesthesiology and Reanimation, School of Medicine, Marmara University, Istanbul, Turkey.
| | - Pelin Corman Dincer
- Department of Anesthesiology and Reanimation, School of Medicine, Marmara University, Istanbul, Turkey
| | - Zeynep Zuhal Aykac
- Department of Anesthesiology and Reanimation, School of Medicine, Marmara University, Istanbul, Turkey
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Muhly WT, Beltran RJ, Bielsky A, Bryskin RB, Chinn C, Choudhry DK, Cucchiaro G, Fernandez A, Glover CD, Haile DT, Kost-Byerly S, Schnepper GD, Zurakowski D, Agarwal R, Bhalla T, Eisdorfer S, Huang H, Maxwell LG, Thomas JJ, Tjia I, Wilder RT, Cravero JP. Perioperative Management and In-Hospital Outcomes After Minimally Invasive Repair of Pectus Excavatum. Anesth Analg 2019; 128:315-327. [DOI: 10.1213/ane.0000000000003829] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kendall MC, Alves LJC, Suh EI, McCormick ZL, De Oliveira GS. Regional anesthesia to ameliorate postoperative analgesia outcomes in pediatric surgical patients: an updated systematic review of randomized controlled trials. Local Reg Anesth 2018; 11:91-109. [PMID: 30532585 PMCID: PMC6244583 DOI: 10.2147/lra.s185554] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Regional anesthesia is becoming increasingly popular among anesthesiologists in the management of postoperative analgesia following pediatric surgery. The main objective of this review was to systematically evaluate the last 5 years of randomized controlled trials on the role of regional anesthesia techniques in alleviating postoperative pain associated with various pediatric surgical procedures. Forty studies on 2,408 pediatric patients were evaluated. The majority of the articles published from 2013 to 2017 reported that the use of regional anesthesia minimized postoperative pain and reduced opioid consumption. Only a few surgical procedures (cholecystectomy, inguinal hernia repair, and non-laparoscopic major abdominal surgery) reported no significant difference in the postoperative pain relief compared with the standard anesthetic management. The growing number of randomized controlled trials in the pediatric literature is very promising; however, additional confirmation is needed to reinforce the use of specific regional anesthesia techniques to provide optimal postoperative pain relief for a few surgical procedures (reconstructive ear surgery, chest wall deformity, hypospadias, umbilical hernia, cleft palate repair) in pediatric patients. More randomized controlled trials are needed to establish regional anesthesia as an essential component of postoperative analgesia management in children.
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Affiliation(s)
- Mark C Kendall
- Department of Anesthesiology, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA,
| | | | - Edward I Suh
- Department of Anesthesiology, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA,
| | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, USA
| | - Gildasio S De Oliveira
- Department of Anesthesiology, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA,
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T1 Paravertebral Catheter for Postoperative Pain Management After First Rib Resection for Venous Thoracic Outlet Syndrome: A Case Report. A A Pract 2018; 11:1-3. [PMID: 29634572 DOI: 10.1213/xaa.0000000000000698] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
While it has been shown that a paravertebral block provides effective postoperative analgesia for patients undergoing thoracic surgeries, including first rib resection, this is the first reported case of a paravertebral catheter used for perioperative analgesia in a patient undergoing first rib resection. We present the case of a 76-year-old woman with right upper extremity swelling who underwent infraclavicular first rib resection for venous thoracic outlet syndrome. Continuous infusion of ropivacaine through a T1 paravertebral catheter, which was placed before induction of general anesthesia but after T1 and T2 paravertebral blocks, provided effective postoperative pain control. Our experience suggests that paravertebral catheter infusions of local anesthetics may be effective adjuncts to general anesthesia in patients undergoing first rib resection and warrants further investigation.
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Harbaugh CM, Johnson KN, Kein CE, Jarboe MD, Hirschl RB, Geiger JD, Gadepalli SK. Comparing outcomes with thoracic epidural and intercostal nerve cryoablation after Nuss procedure. J Surg Res 2018; 231:217-223. [PMID: 30278932 DOI: 10.1016/j.jss.2018.05.048] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/18/2018] [Accepted: 05/24/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study aimed to evaluate postoperative outcomes after minimally invasive repair of pectus excavatum (Nuss procedure) using video-assisted intercostal nerve cryoablation (INC) compared to thoracic epidural (TE). MATERIALS AND METHODS We performed a single center retrospective review of pediatric patients who underwent Nuss procedure with INC (n = 19) or TE (n = 13) from April 2015 to August 2017. Preoperative, intraoperative, and postoperative characteristics were collected. The primary outcome was length of stay (LOS) and secondary outcomes were intravenous and oral opioid use, pain scores, and complications. Opioids were converted to oral morphine milligram equivalents per kilogram (oral morphine equivalent [OME]/kg). Mann-Whitney U test was used for continuous and chi-squared analysis for categorical variables. RESULTS There were no significant differences in patient characteristics, except Haller Index (INC: median [interquartile range] 4.3 [3.6-4.9]; TE: 3.2 [2.8-4.0]; P = 0.03). LOS was shorter with INC (INC: 3 [3-4] days; TE: 6 [5-7] days; P < 0.001). Opioid use was higher intraoperatively (INC: 1.08 [0.87-1.37] OME/kg; TE: 0.46 [0.37-0.67] OME/kg; P = 0.002) and unchanged postoperatively (INC: 1.78 [1.26-3.77] OME/kg; TE: 1.82 [1.05-3.37] OME/kg; P = 0.80), and prescription doses were lower at discharge in INC (INC: 30 [30-40] doses; TE: 42 [40-60] doses; P = 0.005). There was no significant difference in postoperative complications (INC: 42.1%; TE: 53.9%; P = 0.51). CONCLUSIONS INC during Nuss procedure reduced LOS, shifting postoperative opioid use earlier during admission. This may reflect the need for improved early pain control until INC takes effect. Prospective evaluation after INC is needed to characterize long-term pain medication requirements.
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Affiliation(s)
- Calista M Harbaugh
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Kevin N Johnson
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan
| | - Courtney E Kein
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Marcus D Jarboe
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ronald B Hirschl
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan
| | - James D Geiger
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan
| | - Samir K Gadepalli
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan
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Singhal NR, Jerman JD. A review of anesthetic considerations and postoperative pain control after the Nuss procedure. Semin Pediatr Surg 2018; 27:156-160. [PMID: 30078486 DOI: 10.1053/j.sempedsurg.2018.05.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Neil Raj Singhal
- Department of Anesthesia and Division of Pain Management, Phoenix Children's Hospital, 1919 East Thomas Road 4th Floor, Perioperative, Phoenix, AZ 85016, United States .
| | - Jonathan D Jerman
- Department of Anesthesia and Division of Pain Management, Phoenix Children's Hospital, 1919 East Thomas Road 4th Floor, Perioperative, Phoenix, AZ 85016, United States
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Velazco CS, Arsanjani R, Jaroszewski DE. Nuss procedure in the adult population for correction of pectus excavatum. Semin Pediatr Surg 2018; 27:161-169. [PMID: 30078487 DOI: 10.1053/j.sempedsurg.2018.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Minimally invasive repair of pectus excavatum has been successfully modified for use in adult patients. Many patients present in adulthood with progression of symptoms as the chest wall becomes less compliant with age. A thorough workup is completed including echocardiogram and chest CT to evaluate for anatomic abnormalities. Cardiopulmonary exercise testing is done to quantify the physiologic impact. Modifications of the original Nuss procedure required to allow for successful adult repair include the use of forced sternal elevation, the use of multiple bars, medial bar fixation, and interspace support to prevent bar rotation and migration. Occasionally, fractures may occur that require an open procedure and osteotomy or cartilage resection and hybrid approach incorporating the principals of intrathoracic support and osteotomy with bar stabilization.
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Affiliation(s)
- Cristine S Velazco
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States.
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Gui L, Shen S, Mei W. Anaesthesia for chest wall reconstruction in a patient with Poland syndrome: CARE-compliant case report and literature review. BMC Anesthesiol 2018; 18:57. [PMID: 29793431 PMCID: PMC5968485 DOI: 10.1186/s12871-018-0518-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 05/04/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Poland syndrome is a rare congenital disease, characterized by agenesis/hypoplasia of the pectoralis major muscle, usually associated with variable thoracic anomalies that needed chest wall reconstruction under general anesthesia. Anaesthetic management in Poland syndrome has scarcely been described. CASE PRESENTATION Here, we present our anaesthetic management of Nuss procedure for chest wall correction in a 5 years old patient with Poland syndrome. We also reviewed the reports of anaesthetic management of Poland syndrome by searching Pubmed, and summarize the perioperative procedures that may warrant a safe surgery. CONCLUSIONS Examinations before surgery, intraoperative monitoring, choice of general anesthetics and pain management after surgery should all be contemplated.
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Affiliation(s)
- Lingli Gui
- Department of Anesthesiology and Pain medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Road, Wuhan, 430030, People's Republic of China
| | - Shiqian Shen
- Department of Anesthesia, Critical Care and Pain Medicine, Massachsetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02129, USA
| | - Wei Mei
- Department of Anesthesiology and Pain medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Road, Wuhan, 430030, People's Republic of China.
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Ropivacaine has no advantage over bupivacaine in thoracic epidural analgesia for patients with pectus excavatum undergoing the Nuss procedure - a single blind randomized clinical trial comparing efficacy and safety. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2018; 15:5-9. [PMID: 29681955 PMCID: PMC5907610 DOI: 10.5114/kitp.2018.74668] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 02/03/2018] [Indexed: 12/01/2022]
Abstract
Introduction Pectus excavatum repair (Nuss procedure) is a painful procedure requiring effective postoperative analgesia. Aim To establish whether thoracic epidural analgesia with ropivacaine is non-inferior to epidural analgesia with bupivacaine following the Nuss procedure in children. Material and methods The prospective, randomized, controlled, single blind study included 81 children. Computer-generated random numbers were used to allocate treatment. All children received general anesthesia. Intraoperative and postoperative analgesia was achieved with either 0.5% and 0.1% ropivacaine (group R) or 0.375% and 0.0625% bupivacaine (group B). The Numeric Rating Scale (NRS) and the Prince Henry Hospital Pain Score (PHHPS) were used to assess postoperative pain directly after and 1, 8, 20 and 24 hours after awakening from general anesthesia. NRS scores of more than 2 and a PHHPS score of more than 1 were considered as pain requiring intervention. Hemodynamic stability and side effects were also compared between the groups. Results The durations of the procedure and extubation times in groups R and B were similar (59 ±7 vs. 56 ±10 minutes and 9 ±5 vs. 10 ±5 minutes, respectively). Pain scores requiring intervention were below 10% and were recorded with similar frequency in both groups, except for one difference in the PHHPS score in favor of group R after 24 hours (12% vs. 40%, p < 0.05). The frequency of side effects and hemodynamic stability were similar in both groups. Conclusions 0.1% epidural ropivacaine has no advantage over 0.0625% epidural bupivacaine for pectus excavatum repair in children.
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Ewais MM, Chaparala S, Uhl R, Jaroszewski DE. Outcomes in adult pectus excavatum patients undergoing Nuss repair. PATIENT-RELATED OUTCOME MEASURES 2018; 9:65-90. [PMID: 29430201 PMCID: PMC5796466 DOI: 10.2147/prom.s117771] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Pectus excavatum (PEx) is one of the most common congenital chest wall deformities. Depending on the severity, presentation of PEx may range from minor cosmetic issues to disabling cardiopulmonary symptoms. The effect of PEx on adult patients has not been extensively studied. Symptoms may not occur until the patient ages, and they may worsen over the years. More recent publications have implied that PEx may have significant cardiopulmonary implications and repair is of medical benefit. Adults presenting for PEx repair can undergo a successful repair with a minimally invasive "Nuss" approach. Resolution of symptoms, improved quality of life, and satisfying results are reported.
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Affiliation(s)
- MennatAllah M Ewais
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Shivani Chaparala
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Rebecca Uhl
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Dawn E Jaroszewski
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
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Anesthesia for Thoracic Surgery. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Anesthesia for Nuss Procedures (Pectus Deformity). Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Man JY, Gurnaney HG, Dubow SR, DiMaggio TJ, Kroeplin GR, Adzick NS, Muhly WT. A retrospective comparison of thoracic epidural infusion and multimodal analgesia protocol for pain management following the minimally invasive repair of pectus excavatum. Paediatr Anaesth 2017; 27:1227-1234. [PMID: 29063665 DOI: 10.1111/pan.13264] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/10/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Pain management following minimally invasive repair of pectus excavatum is variable. We recently adopted a comprehensive multimodal analgesic protocol that standardizes perioperative analgesic management. We hypothesized that patients managed with this protocol would use more opioids postoperatively, have similar pain control, and shorter length of stay compared to patients managed with thoracic epidural infusion. AIMS We retrospectively compared opioid consumption, pain scores, and length of stay between a cohort of patients managed with our multimodal analgesic protocol and a cohort managed with a thoracic epidural infusion. METHODS This retrospective cohort comparison includes patients, 8 to 21 years of age, managed with either thoracic epidural infusion (n = 21) or multimodal analgesic protocol (n = 29) following minimally invasive repair of pectus excavatum from January 1, 2011 through September 15, 2015. The primary outcome, total daily opioid consumption in morphine equivalents, is presented as an average by postoperative day. Secondary outcomes included median daily pain score and length of stay. RESULTS Patients were similar in age, weight, sex, and physical status. Patients managed with thoracic epidural infusion received less opioid (morphine equivalents-mg/kg) intraoperatively compared to multimodal analgesic protocol (difference of mean [95% confidence interval] 0.22 [0.16-0.28] P ≤ .01) but required more total opioid through postoperative day 3 (difference of mean [95% confidence interval] 1.2 [0.26-2.14] P = .01). We did not observe a difference in pain scores. Median length of stay was 1 day less in patients managed with multimodal analgesic protocol (difference of median [95% confidence interval] 1 [0.3-1.7] P = .003). CONCLUSION Implementation of a standardized comprehensive multimodal analgesic protocol following minimally invasive repair of pectus excavatum resulted in equivalent analgesia with a modest reduction in length of stay when compared to thoracic epidural. We did not observe an opioid sparing effect in our thoracic epidural which may reflect technique variability.
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Affiliation(s)
- Janice Y Man
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pediatric Anesthesiology, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, CA, USA.,Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Harshad G Gurnaney
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Scott R Dubow
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Theresa J DiMaggio
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Gina R Kroeplin
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Scott Adzick
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Wallis T Muhly
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Yeying G, Liyong Y, Yuebo C, Yu Z, Guangao Y, Weihu M, Liujun Z. Thoracic paravertebral block versus intravenous patient-controlled analgesia for pain treatment in patients with multiple rib fractures. J Int Med Res 2017. [PMID: 28635359 PMCID: PMC5805206 DOI: 10.1177/0300060517710068] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Objectives To assess the effect of thoracic paravertebral block (PVB) on pain management
and preservation of pulmonary function compared with intravenous,
patient-controlled analgesia (IVPCA) in patients with multiple rib fractures
(MRFs). Methods Ninety patients with unilateral MRFs were included in this prospective study
and randomly assigned to the TPVB or IVPCA group. The visual analogue scale
(VAS) pain score, blood gas analysis, and bedside spirometry were measured
and recorded at different time points after analgesia. Results TPVB and IVPCA provided good pain relief. VAS scores were significantly lower
in the TPVB group than in the IVPCA group at rest and during coughing
(P < 0.05). Patients in the TPVB group had a higher
PaO2 and PaO2/FiO2 and lower
P(A–a)O2 compared with the IVPCA group
(P < 0.05). Moreover, patients in the TPVB group
showed higher FVC, FEV1/FVC, and PEFR, and fewer complications than did the
IVPCA group (P < 0.05). Conclusion TPVB is superior to IVPCA in pain relief and preservation of pulmonary
function in patients with MRFs.
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Affiliation(s)
- Ge Yeying
- 1 Department of Anesthesiology, Ningbo 6th Hospital, Ningbo 315040, China
| | - Yuan Liyong
- 1 Department of Anesthesiology, Ningbo 6th Hospital, Ningbo 315040, China
| | - Chen Yuebo
- 1 Department of Anesthesiology, Ningbo 6th Hospital, Ningbo 315040, China
| | - Zhang Yu
- 1 Department of Anesthesiology, Ningbo 6th Hospital, Ningbo 315040, China
| | - Ye Guangao
- 1 Department of Anesthesiology, Ningbo 6th Hospital, Ningbo 315040, China
| | - Ma Weihu
- 2 Department of Orthopeadic Surgery, Ningbo 6th Hospital, Ningbo 315040, China
| | - Zhao Liujun
- 2 Department of Orthopeadic Surgery, Ningbo 6th Hospital, Ningbo 315040, China
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Epidural Versus Paravertebral Nerve Block for Postoperative Analgesia in Patients Undergoing Open Liver Resection: A Randomized Clinical Trial. Reg Anesth Pain Med 2017; 41:460-8. [PMID: 27281726 DOI: 10.1097/aap.0000000000000422] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Although many studies have found no difference between thoracic epidural block and unilateral thoracic paravertebral block after thoracotomy, no previous studies have compared epidural block with bilateral thoracic paravertebral block (bTPVB) in patients undergoing open liver resection. We aimed to investigate whether there was a significant analgesic advantage of thoracic epidural over bTPVB after liver resection. METHODS This randomized, prospective, open-label study included adult patients undergoing elective open liver resection. Patients were randomized to receive either thoracic epidural block or bTPVB, through which ropivacaine (0.2%) was infused for 3 days. The primary outcome was pain Verbal Rating Scale (VRS) score (0-10) at rest and with postoperative incentive spirometry. Secondary outcomes included VRS at rest, inspired volumes during incentive spirometry, patient-controlled analgesia hydromorphone utilization, measures of hemodynamic stability, and postoperative bowel function. RESULTS Eighty patients completed the study and received thoracic epidural block (n = 41) or bTPVBs (n = 39). No catheter-related complications were noted. The primary outcome, pain (VRS) with incentive spirometry, was significantly lower in the epidural group (epidural vs bTPVB, mean [SD]) (4.5 [2.7] vs 5.4 [2.7] at 24 hours postoperatively, and 3.2 [2.1] vs 4.6 [2.4] at 48 hours postoperatively). Maximal inspired volumes at 24 hours postoperatively (917 [379] vs 1042 [468] mL) and cumulative utilization of patient-controlled analgesia hydromorphone during the first 48 hours postoperatively (10.7 [7.9] vs 13.6 [8.5] mg) were not significantly different between groups. Decrease in mean arterial pressure from baseline at 24 hours postoperatively was greater for the epidural group (-12.6 [15.8] vs -3.8 [16.2]; P = 0.016). CONCLUSIONS This study suggests that there is a modest analgesic advantage of thoracic epidural over bTPVBs for patients after open liver resection.
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