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Brussels AR, Kim MS. Perioperative considerations in anesthesia for minimally invasive repair of pectus excavatum, Nuss procedure. Semin Pediatr Surg 2024; 33:151459. [PMID: 39418783 DOI: 10.1016/j.sempedsurg.2024.151459] [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: 10/19/2024]
Abstract
Pectus excavatum (PE) is a common anterior chest wall deformity that affects the heart and lungs depending on the severity of compression. The Nuss procedure, a minimally invasive repair of pectus excavatum, has evolved over the years with thoracoscopic assistance and minimal incision. Despite improved surgical techniques, pain and nausea are often the most common factors determining hospital length of stay. This review will explore the preoperative, intraoperative, and postoperative anesthetic considerations necessary for improving patient outcomes, reducing surgical stress, and shortening hospital stays for patients undergoing the Nuss procedure.
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Affiliation(s)
- Aaron R Brussels
- Anesthesiology Resident. Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA; Anesthesiology Fellow. Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, USA
| | - Michelle S Kim
- Clinical Professor of Anesthesiology and Child Health, University of Arizona, School of Medicine, Phoenix. Department of Pediatric Anesthesiology, Phoenix Children's Hospital, 1919 E Thomas Road, Phoenix, AZ 85016, USA.
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Coppens S, Dewinter G, Hoogma DF, Raudsepp M, Vogelaerts R, Brullot L, Neyrinck A, Van Veer H, Dreelinck R, Rex S. Safety and efficacy of high thoracic epidural analgesia for chest wall surgery in young adolescents: A retrospective cohort analysis and a new standardised definition for success rate. Eur J Anaesthesiol 2024:00003643-990000000-00225. [PMID: 39363622 DOI: 10.1097/eja.0000000000002064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2024]
Abstract
BACKGROUND Chest wall surgery for the correction of pectus excavatum or pectus carinatum has gained increased interest in recent years. Adequate pain treatment, respiratory physiotherapy and early ambulation are key to improving the outcomes. Although thoracic epidural analgesia is highly effective, its safety is controversial, leading to extensive scrutiny and questioning of its role. OBJECTIVES We hypothesise that thoracic epidural analgesia is effective and well tolerated to use in adolescents, with a high success rate and low pain scores. DESIGN Observational retrospective cohort study. SETTING All adolescent cases in a high-volume academic tertiary chest wall surgery centre between March 1993 and December 2017 were included. PATIENTS A total of 1117 patients aged from 12 to 19 years of age and receiving either Ravvitch, Nuss or Abramson chest wall reconstruction for pectus excavatum were identified in our institutional chest wall surgery database. After applying selection and exclusion criteria, 532 patients were included in the current analysis. MAIN OUTCOME MEASURES The primary endpoint of this study was the safety of epidural analgesia, assessed by the incidence of acute adverse events. Secondary endpoints were block success rates using a specific novel definition, and analgesic efficacy using recorded postoperative pain scores. RESULTS More than 60% of patients experienced one or more adverse events. However, all events were minor and without consequences. No serious or long-term adverse events were detected. The success rate of thoracic epidural placement was 81%. Low postoperative pain scores were observed. CONCLUSION Thoracic epidural analgesia is an extremely effective pain control technique, with a surprisingly high number of minor adverse events but safe with regard to serious adverse events. TRIAL REGISTRATION The local research ethics committee approved and registered this study on 16 May 2022 (registration number: S66594).
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Affiliation(s)
- Steve Coppens
- From the Department of Anesthesiology, University Hospitals of Leuven (SC, GD, DFH, MR, RV, LB, AN, RD, SR), Department of Cardiovascular Sciences, Biomedical Sciences Group, University of Leuven (SC, GD, DFH, AN, HvV, SR) and Department of Thoracic Surgery, University Hospitals of Leuven, Leuven, Belgium (HvV)
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Chen T, Xu Y, Chen Y, Chen S, Zhang Y. Analgesic Effectiveness of Truncal Plane Blocks in Patients Undergoing the Nuss Procedure: A Randomized Controlled Trial. Pain Ther 2024; 13:909-917. [PMID: 38888719 PMCID: PMC11255141 DOI: 10.1007/s40122-024-00627-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Accepted: 06/05/2024] [Indexed: 06/20/2024] Open
Abstract
INTRODUCTION Most patients undergoing the Nuss procedure reported moderate to severe pain after surgery. This study aimed to investigate the efficacy and safety of ultrasound-guided serratus anterior plane block (SAPB) combined with transversus thoracic muscle plane (TTMP) block for relieving acute pain in patients undergoing the Nuss procedure. METHODS The enrolled patients in our study were allocated to either receive combined nerve blocks with ropivacaine (NB group) or saline (CON group). The primary outcome of this study was postoperative pain at 2, 4, 8, 16, 24, 36, and 48 h during rest and movement (coughing). Secondary outcomes included intraoperative dosage of remifentanil, the time to extubation and the length of stay in the post-anesthesia care unit (PACU), the total acetaminophen and codeine tablet consumption, time to first bowel movement, time to first flatus, opioid-related adverse events, and the length of hospital stay. RESULTS Patients in the NB group had significantly lower Numerical Rating Scale (NRS) pain scores compared with the CON group. The NB group required significantly less postoperative acetaminophen consumption and lower dosages of perioperative sufentanyl and remifentanil compared with the CON group. The length of stay in the PACU and time to extubation were significantly increased in the CON group compared with the NE group. Time to first bowel movement and time to first flatus were earlier in the NB group. But there were no significant differences between the groups in terms of the length of hospital stay and codeine tablet consumption. CONCLUSION Ultrasound-guided SAPB and TTMP blocks in patients undergoing the Nuss procedure could provide effective analgesia. TRIAL REGISTRATION This study was registered in the Chinese Clinical Trial Registry (ChiCTR2000038506).
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Affiliation(s)
- Tao Chen
- Department of Anesthesiology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, China
| | - Yu Xu
- Department of Anesthesiology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, China
| | - Yu Chen
- Department of Anesthesiology, Jiangxi Provincial Children's Hospital, 122 Yang Ming Road, Nanchang, 330006, Jiangxi, China
| | - Shibiao Chen
- Department of Anesthesiology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, China
| | - Yang Zhang
- Department of Anesthesiology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, China.
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Clasie KA, Deshpande AV, Holland AJ, Jiwane AV, Da Silva VG, Filtness FA, Allen MM, Smith GH. Reduction of Urinary Tract Infection in Pediatric Surgical Patients Using NSQIP-P and Quality Improvement Methodology. J Am Coll Surg 2024; 238:1057-1066. [PMID: 38345219 DOI: 10.1097/xcs.0000000000001037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
BACKGROUND Hospital-acquired urinary tract infections (UTIs) have a detrimental effect on patients, families, and hospital resources. The Sydney Children's Hospital Network (SCHN) participates in the NSQIP-Pediatric (NSQIP-P) to monitor postoperative complications. NSQIP-P data revealed that the median UTI rate at SCHN was 1.75% in 2019, 3.5 times higher than the NSQIP-P target rate of 0.5%. Over three quarters of the NSQIP-P identified patients with UTI also had a urinary catheterization performed intraoperatively. A quality improvement project was conducted between mid-2018 and 2021 to minimize catheter-associated UTIs (CAUTIs) at SCHN. STUDY DESIGN NSQIP-P samples include pediatric (younger than 18 years) surgical patients from an 8-day cycle operative log. NSQIP-P data are statistically analyzed by the American College of Surgeons and provide biannual internationally benchmarked reports. The project used clinical redesign methodology with a 6-phase process for quality improvement projects. RESULTS The objectives of the project were to reduce urinary catheter duration of use, educate parents or carers, and improve catheter care and insertion technique by health staff. The duration of a urinary catheter in situ reduced from a median of 4.5 to 3 days from 2017 to 2021. The median NSQIP-P UTI rate at SCHN was reduced by 47.4% from 1.75% in 2019 to 0.9% in 2022. CONCLUSIONS A multifactorial approach in quality improvement has been shown to be an effective strategy to reduce UTI rates at SCHN, and patient outcomes were improved within a 3-year timeframe. Although this project has reduced UTI rates at SCHN, there remain opportunities for further improvement.
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Affiliation(s)
- Kyla A Clasie
- From the Department of Surgery, Sydney Children's Hospital Network, Sydney, New South Wales, Australia (Clasie)
| | - Aniruddh V Deshpande
- School of Medicine and Public Health, Newcastle University, Newcastle, New South Wales, Australia (Deshpande)
- Departments of Urology (Deshpande, Holland, Smith), Children's Hospital at Westmead, Sydney, New South Wales, Australia
- Surgery (Deshpande, Holland, Filtness, Smith), Children's Hospital at Westmead, Sydney, New South Wales, Australia
- The Children's Hospital at Westmead Clinical School, Discipline of Paediatrics and Child Health, Sydney Medical School, Faculty of Health, The University of Sydney, Sydney, New South Wales, Australia (Deshpande, Holland, Smith)
| | - Andrew Ja Holland
- Departments of Urology (Deshpande, Holland, Smith), Children's Hospital at Westmead, Sydney, New South Wales, Australia
- Surgery (Deshpande, Holland, Filtness, Smith), Children's Hospital at Westmead, Sydney, New South Wales, Australia
- Department of Paediatric Surgery (Holland)
- The Children's Hospital at Westmead Clinical School, Discipline of Paediatrics and Child Health, Sydney Medical School, Faculty of Health, The University of Sydney, Sydney, New South Wales, Australia (Deshpande, Holland, Smith)
| | - Ashish V Jiwane
- Department of Surgery, Sydney Children's Hospital, Sydney, New South Wales, Australia (Jiwane, Da Silva, Allen)
| | - Vanessa G Da Silva
- Department of Surgery, Sydney Children's Hospital, Sydney, New South Wales, Australia (Jiwane, Da Silva, Allen)
| | - Fiona A Filtness
- Surgery (Deshpande, Holland, Filtness, Smith), Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Margaret M Allen
- Department of Surgery, Sydney Children's Hospital, Sydney, New South Wales, Australia (Jiwane, Da Silva, Allen)
| | - Grahame Hh Smith
- Departments of Urology (Deshpande, Holland, Smith), Children's Hospital at Westmead, Sydney, New South Wales, Australia
- Surgery (Deshpande, Holland, Filtness, Smith), Children's Hospital at Westmead, Sydney, New South Wales, Australia
- The Children's Hospital at Westmead Clinical School, Discipline of Paediatrics and Child Health, Sydney Medical School, Faculty of Health, The University of Sydney, Sydney, New South Wales, Australia (Deshpande, Holland, Smith)
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Aranda-Valderrama P, Greenberg RS, Vecchione TM, Finney AG, Prichett LM, Vanderhoek SM. Combined erector spinae plane block with surgical intercostal nerve cryoablation for Nuss procedure is associated with decreased opioid use and length of stay. Reg Anesth Pain Med 2024; 49:248-253. [PMID: 37407278 DOI: 10.1136/rapm-2023-104407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/24/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Pain management for patients undergoing the Nuss procedure for treatment of pectus excavatum can be challenging. In an effort to improve pain management, our institution added bilateral single injection erector spinae plane (ESP) blocks to surgeon placed intercostal nerve cryoablation. We aimed to assess the efficacy of this practice change. METHODS Retrospective clinical data from a single academic medical center were evaluated. Due to an institutional change in clinical management, we were able to perform a before and after study. Twenty patients undergoing Nuss procedure who received bilateral ultrasound-guided single-shot T6 level ESP blocks and intercostal nerve cryoablation were compared with a historical control cohort of 20 patients who underwent Nuss procedure with intercostal nerve cryoablation alone. The primary outcome variables included postoperative pain scores, total hospital opioid use, and hospital length of stay. RESULTS Median total hospital intravenous morphine milligram equivalents was lower for the ESP group than for the control group (0.60 (IQR 0.35-0.88) vs 1.15 mg/kg (IQR 0.74-1.68), p<0.01). There was no difference in postoperative pain scores between the two groups. Mean hospital length of stay was 2.45 (SD 0.69) days for the control group and 1.95 (SD 0.69) days for the ESP group (p=0.03). No adverse events related to block placement were identified. CONCLUSIONS In a single-center academic practice, the addition of bilateral single injection ESP blocks at T6 to surgeon performed cryoablation reduced opioid consumption without a change in subjectively reported pain scores. The results from this pilot study can provide effect size estimates to guide the design of future randomized trials.
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Affiliation(s)
- Paola Aranda-Valderrama
- Division of Pediatric Anesthesia, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robert S Greenberg
- Division of Pediatric Anesthesia, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tricia M Vecchione
- Division of Pediatric Anesthesia, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amanda G Finney
- Biostatistics, Epidemiology and Data Management (BEAD) Core, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Laura M Prichett
- Biostatistics, Epidemiology and Data Management (BEAD) Core, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Samuel M Vanderhoek
- Division of Pediatric Anesthesia, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Massaguer C, Saura-García L, Palazón P, Echaniz G, Roqueta Alcaraz MC, Tarrado X. Bilateral Lung Injury with Delayed Pneumothorax following Preoperative Cryoanalgesia for Pectus Excavatum Repair in a 13-year-old Boy. European J Pediatr Surg Rep 2024; 12:e50-e53. [PMID: 39071096 PMCID: PMC11281861 DOI: 10.1055/a-2349-9668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 02/29/2024] [Indexed: 07/30/2024] Open
Abstract
A 13-year-old male patient with marfanoid features and pectus excavatum with Haller index 4 and correction index of 38% underwent the Nuss procedure with cryoanalgesia 9 days prior, which transpired uneventfully. Preoperative spirometry was normal, and echocardiogram showed light aortic valve dilation. A month later, during a routine outpatient checkup, he referred middle abdominal pain, denying respiratory symptoms nor thoracic pain. He presented bilateral apical and right basal hypophonesis. Chest X-ray revealed bilateral pneumothorax and right pleural effusion. Consequently, the patient was admitted to the emergency room, and a chest computed tomography was ordered, reporting right apical blebs. Bilateral thoracoscopy was performed, and apexes were checked for pulmonary blebs to rule out primary pneumothorax. In the right chest, a wedge resection of a distorted area on the apex and pleuroabrasion were done. Four air leaking eschars were found when performing lung expansion under water as leaking test, corresponding to cryoanalgesia intercostal eschars, and subsequently closed by primary suture. In the left chest, there were no blebs. However, another four pleural lesions with intact pleura in the left lower lobe were also found. Postoperative course was uneventful and chest drains were removed 48 hours after surgery. He remains asymptomatic 21 months after discharge. Cryoanalgesia in pectus excavatum is spreading due to the improvement in postoperative pain control. However, some complications may occur.
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Affiliation(s)
- Clara Massaguer
- Department of Pediatric Surgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Laura Saura-García
- Department of Pediatric Surgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Pedro Palazón
- Department of Pediatric Surgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Gastón Echaniz
- Department of Anesthesiology, Hospital Sant Joan de Déu Barcelona, Catalunya, Spain
| | | | - Xavier Tarrado
- Department of Pediatric Surgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Catalunya, Spain
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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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Walter CM, Lee CS, Moore DL, Abbasian N, Clay SJ, Mecoli MD, Olbrecht VA, Batra M, Ding L, Yang F, Nair M, Huq A, Simpson BE, Brown RL, Garcia VF, Chidambaran V. Retrospective study comparing outcomes of multimodal epidural and erector spinae catheter pain protocols after pectus surgery. J Pediatr Surg 2023; 58:397-404. [PMID: 35907711 DOI: 10.1016/j.jpedsurg.2022.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/10/2022] [Accepted: 06/28/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION There are no optimal postoperative analgesia regimens for Nuss procedures. We compared the effectiveness of thoracic epidurals (EPI) and novel ambulatory erector spinae plane (ESP) catheters as part of multimodal pain protocols after Nuss surgery. METHODS Data on demographics, comorbidities, perioperative details, length of stay (LOS), in hospital and post discharge pain/opioid use, side effects, and emergency department (ED) visits were collected retrospectively in children who underwent Nuss repair with EPI (N = 114) and ESP protocols (N = 97). Association of the group with length of stay (LOS), in hospital opioid use (intravenous morphine equivalents (MEq)/kg over postoperative day (POD) 0-2), and oral opioid use beyond POD7 was analyzed using inverse probability of treatment weighting (IPTW) with propensity scores, followed by multivariable regression. RESULTS Groups had similar demographics. Compared to EPI, ESP had longer block time and higher rate of ketamine and dexmedetomidine use. LOS for ESP was 2 days IQR (2, 2) compared to 3 days IQR (3, 4) for EPI (p < 0.01). Compared to EPI, ESP group had higher opioid use (in MEq/kg) intraoperatively (0.32 (IQR 0.27, 0.36) vs. 0.28 (0.24, 0.32); p < 0.01) but lower opioid use on POD 0 (0.09 (IQR 0.04, 0.17) vs. 0.11 (0.08, 0.17); p = 0.03) and POD2 (0.00 (IQR 0.00, 0.00) vs. 0.04 (0.00, 0.06) ; p < 0.01). ESP group also had lower total in hospital opioid use (0.57 (IQR 0.42, 0.73) vs.0.82 (0.71, 0.91); p < 0.01), and shorter duration of post discharge opioid use (6 days (IQR 5,8) vs. 9 days (IQR 7,12) (p < 0.01). After IPTW adjustment, ESP continued to be associated with shorter LOS (difference -1.20, 95% CI: -1.38, -1.01, p < 0.01) and decreased odds for opioid use beyond POD7 (OR 0.11, 95% CI: 0.05, 0.24); p < 0.01). However, total in hospital opioid use in MEq/kg (POD0-2) was now similar between groups (difference -0.02 (95% CI: -0.09, -0.04); p = 0.50). The EPI group had higher incidence of emesis (29% v 4%, p < 0.01), while ESP had higher catheter malfunction rates (23% v 0%; p < 0.01) but both groups had comparable ED visits/readmissions. DISCUSSION/CONCLUSION Compared to EPI, multimodal ambulatory ESP protocol decreased LOS and postoperative opioid use, with comparable ED visits/readmissions. Disadvantages included higher postoperative pain scores, longer block times and higher catheter leakage/malfunction. LEVELS OF EVIDENCE Level III.
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Affiliation(s)
- Charlotte M Walter
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Christopher S Lee
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - David L Moore
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Niekoo Abbasian
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Smokey J Clay
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States.
| | - Marc D Mecoli
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Vanessa A Olbrecht
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Meenu Batra
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Lili Ding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, MLC 5041, 3333 Burnet Ave, Cincinnati, OH 45229, United States; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Fang Yang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, MLC 5041, 3333 Burnet Ave, Cincinnati, OH 45229, United States; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Manu Nair
- Summer Undergraduate Research Fellow, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States
| | - Abraar Huq
- Summer Undergraduate Research Fellow, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States
| | - Blair E Simpson
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, MLC 3024, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Rebeccah L Brown
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States; Division of Pediatric, General and Thoracic Surgery Department, Cincinnati Children's Hospital Medical Center, MLC 2023, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Victor F Garcia
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States; Division of Pediatric, General and Thoracic Surgery Department, Cincinnati Children's Hospital Medical Center, MLC 2023, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States.
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Patient-Controlled Intravenous Analgesia with or without Ultrasound-Guided Bilateral Intercostal Nerve Blocks in Children Undergoing the Nuss Procedure: A Randomized, Double-Blinded, Controlled Trial. Pain Res Manag 2022; 2022:5776833. [PMID: 35910406 PMCID: PMC9337970 DOI: 10.1155/2022/5776833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 04/19/2022] [Indexed: 11/29/2022]
Abstract
Background Two analgesic strategies have been described for pain treatment after the pectus excavatum surgery: the patient-controlled intravenous analgesia (PCIA) and ultrasound-guided intercostal nerve block. In this prospective, randomized and double-blinded trial and the short and long-term outcomes were compared in patients after surgery. Methods The children were randomized to either the intercostal or control group. Ultrasound-guided intercostal nerve block was with 0.25% ropivacaine and 5 mg dexamethasone in the intercostal group, while the control group was with 0.9% normal saline. The block was performed in the intercostal space corresponding to the lowest depression of the sternum and repeated bilaterally in the spaces above and below. Postoperatively, the children in the two-groups received PCIA with fentanyl for 48 hours. The primary outcome was a pain score on the postoperative day 1, as measured by the Visual Analogue Scale (VAS). Results Sixty children undergoing the Nuss procedure were enrolled in the trial. The mean differences in VAS scores between the two groups were 3.2 in the PACU (p < 0.001), 1.7 on postoperative day 1 (p < 0.001) and 0.7 on postoperative day 2 (p=0.015). The opioid consumption was significantly lower in the intercostal group during the postoperative 48 hours (p < 0.05). The anxiety and QOL scores in the intercostal group were significantly improved on some points of time (p < 0.05). The incidence of adverse events was markedly lower in the intercostal group during the postoperative 48 hours (p < 0.05). Conclusions Our results suggest ultrasound-guided intercostal nerve block with PCIA may be more effective than PCIA alone in children who underwent the Nuss procedure.
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Sertcakacilar G, Kose S. Bilateral PECS II block is associated with decreased opioid consumption and reduced pain scores for up to 24 hours after minimally invasive repair of pectus excavatum (Nuss procedure): a retrospective analysis. J Cardiothorac Vasc Anesth 2022; 36:3833-3840. [DOI: 10.1053/j.jvca.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/21/2022] [Accepted: 06/01/2022] [Indexed: 11/11/2022]
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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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Abstract
BACKGROUND Minimally invasive repair of pectus excavatum (MIRPE) involves placement of a transthoracic, retrosternal support bar under thoracoscopic guidance. Despite its minimally invasive technical approach, postoperative pain is a significant morbidity that often results in increased length of stay. Multi-modal pain control strategies have been used in the past with limited success. Recently, the use of intraoperative intercostal nerve cryoablation (CA) has been added. In the present study, we aim to evaluate the effects of CA on postoperative pain control, opioid requirements, and perioperative outcomes. STUDY DESIGN A single-center, retrospective chart review of all patients (less than 18 years old) who underwent MIRPE from 2009 to 2020 was performed. CA was started in June 2018. Data collection included demographics, preoperative characteristics, intraoperative findings, and postoperative outcomes. We hypothesized that CA would be associated with improved pain scores, lower doses of total inpatient opioid requirement, and shorter length of stay (LOS). RESULTS One hundred sixty-one patients met inclusion criteria: 75 underwent intraoperative CA and 86 underwent MIRPE without CA (NCA group). CA significantly decreased median LOS from 4 days in NCA to 2 days; the use of CA was the only significant predictor of LOS on linear regression. CA was also associated with decreased total PCA, intravenous opioid, and oral opioid dosages. There was no difference in inpatient pain scores and a slight increase in mean procedure time. However, CA was associated with significantly decreased postoperative complications. CONCLUSIONS The use of cryoablation during MIRPE significantly decreases LOS, perioperative opioid requirements, and postoperative complications, with a minimal increase in operative time. Cryoablation is an effective pain control modality in the surgical management of chest wall deformities in children.
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Xu M, Zhang G, Gong J, Yang J. Comparison of erector spinae plane and paravertebral nerve blocks for postoperative analgesia in children after the Nuss procedure: study protocol for a randomized controlled non-inferiority clinical trial. Trials 2022; 23:139. [PMID: 35164831 PMCID: PMC8842927 DOI: 10.1186/s13063-022-06044-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 01/19/2022] [Indexed: 11/28/2022] Open
Abstract
Background Thoracic paravertebral block (TPVB) is a widely advocated regional technique for alleviating postoperative pain in children undergoing elective pectus excavatum repair. However, this technique is associated with some undesirable adverse events. Recently, the erector spinae plane block (ESPB) has been introduced as a practical alternative to the TPVB in thoracic surgery. This interfascial regional anesthesia technique interrupts pain sensation by injecting local anesthetics between the muscular layers of the thoracic wall. Several case series described it as an effective pain management technique following pectus excavatum repair. Therefore, this trial is designed to test the hypothesis that ESPB is non-inferior to TPVB in postoperative pain control after pectus excavatum repair. Methods This is a prospective randomized double-blind non-inferiority trial. A total of 40 patients aged 4 to 18 years undergoing Nuss surgery will be randomly assigned to receive pain treatment with either ESPB or TPVB. All patients will receive additional systemic multimodal analgesia with an intravenous patient-controlled analgesia pump and acetaminophen. The primary outcome is the pain intensity at rest, 24 h postoperatively. Secondary outcomes include accumulated morphine-equivalent consumption, postoperative pain scores, emergence agitation incidence, time of the first mobilization, time to first rescue analgesia, complications related to pain treatment, and morphine-related adverse events. Discussion This will the first randomized controlled trial to compare ESPB with TPVB for analgesia after pectus excavatum repair. This trial aims to provide important clinical evidence to elaborate on the analgesic mechanism of ESPB in children. Trial registration ClinicalTrials.govNCT05034601. This trial was prospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06044-y.
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Media A, de Paoli F, Pilegaard H, Hvas AM, Juhl-Olsen P, Christensen T. Epidural analgesia and abnormal coagulation in patients undergoing minimal invasive repair of pectus excavatum. Ann Card Anaesth 2022; 25:153-157. [PMID: 35417960 PMCID: PMC9244249 DOI: 10.4103/aca.aca_115_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Epidural analgesia (EA) is effective in patients undergoing minimal invasive repair of pectus excavatum (MIRPE) but is associated with major complications such as epidural hematomas. It is recommended to assess coagulation status in patients receiving anticoagulant therapy prior to EA, although no consensus exists in patients without a history of bleeding tendency or anticoagulant therapy. Thus, the aim of this paper was to assess 1) the prevalence of abnormal routine coagulation parameters, i.e., international normalized ratio (INR) and platelet count, and 2) the safety of EA in patients undergoing MIRPE. Methods: In this retrospective study, we identified 1,973 patients undergoing MIRPE at our center between 2001 and 2019. Complications related to EA were registered for all patients. Information on coagulation parameters was present in 929 patients. Patients with spontaneously elevated INR ≥1.5 were referred for assessment of coagulation factor VII in order to assess the cause of the elevated INR. Results: Of 929 patients with coagulation information available, 18 patients had spontaneously elevated INR ≥1.5 (1.9%). In patients with INR ≥1.5, 12 patients underwent further assessment of factor VII, with all patients having a slightly reduced factor VII close to the lower reference range. The majority of the 1,973 patients undergoing MIRPE received EA (99.6%) with very low complication rates (0.2%) and no incidence of epidural hematomas. Conclusion: In patients undergoing MIRPE, coagulation screening prior to EA should not be mandatory as it revealed no clinically relevant consequences. EA is safe with very low complication rates.
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Abstract
Over the past few decades, there have been many advances in pediatric surgery, some using new devices (eg, VEPTR, MAGEC rods) and others using less invasive approaches (eg, Nuss procedure, endoscopic cranial suture release, minimally invasive tethered cord release). Although many of these procedures were initially met with caution or skepticism, continued experience over the past few decades has shown that these procedures are safe and effective. This article reviews the anesthetic considerations for these conditions and procedures.
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Affiliation(s)
- Johanna Meehyun Lee
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, GRB 444, Boston, MA 02114, USA
| | - Erica Gee
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, GRB 444, Boston, MA 02114, USA
| | - Chang Amber Liu
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, GRB 444, Boston, MA 02114, USA.
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Gurria JP, Simpson B, Tuncel-Kara S, Bates C, McKenna E, Rogers T, Kraemer A, Platt M, Mecoli M, Garcia VF, Brown RL. Standardization of clinical care pathway leads to sustained decreased length of stay following Nuss pectus repair: A multidisciplinary quality improvement initiative. J Pediatr Surg 2020; 55:2690-2698. [PMID: 32972738 DOI: 10.1016/j.jpedsurg.2020.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 07/17/2020] [Accepted: 08/01/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE Postoperatively, standardized clinical care pathways (SCCPs) help patients reach necessary milestones for discharge. The objective of this study was to achieve 90% compliance with a pectus specific SCCP within 9 months of implementation. We hypothesized that adherence to a pectus SCCP following the Nuss procedure would decrease postsurgical length of stay (LOS). METHODS A multidisciplinary team implemented the pectus SCCP, including goals for mobility, lung recruitment, pain control, intake, and output. The full protocol included 42 components, tracked using chart reviews and a patient-directed checklist. The primary process measure was compliance with the pectus SCCP. The primary outcome measure was LOS; secondary outcomes were patient charges, patient satisfaction, and hospital readmission. RESULTS Total study patients were n = 509: 159 patients pre-intervention, 350 patients post-intervention (80 implementation group; 270 sustain group). SCCP compliance data were collected on 164 patients post-intervention - 80 implementation, 84 sustain. LOS, ED visits, and hospital readmissions were recorded for all 509 patients. Mean LOS decreased from 4.5 days to 3.4 days, with >90% adherence to the pectus SCCP postintervention. There were no readmissions owing to pain despite earlier termination of epidural analgesia. Total patient charges decreased by 30% and patient satisfaction was high. CONCLUSION Using quality improvement methodology with strict adherence to a pectus SCCP, we had significant reduction in LOS and patient charge without compromising effective postoperative pain management or patient satisfaction. TYPE OF STUDY Clinical research; quality improvement. LEVEL OF EVIDENCE V.
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Affiliation(s)
| | - Blair Simpson
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | - Christina Bates
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Emily McKenna
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Tracy Rogers
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Aimee Kraemer
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Michael Platt
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Marc Mecoli
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Victor F Garcia
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Bass KD, Heiss KF, Kelley-Quon LI, Raval MV. Opioid use in children's surgery: Awareness, current state, and advocacy. J Pediatr Surg 2020; 55:2448-2453. [PMID: 32145973 DOI: 10.1016/j.jpedsurg.2020.02.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/04/2020] [Accepted: 02/17/2020] [Indexed: 01/18/2023]
Abstract
In response to the ongoing opioid epidemic, many surgeons who care for children have reflected upon current practices and the history of our own prescribing. In this editorial review, we provide a brief summary of the origins of opioid use in medicine and surgery, we describe how the ongoing opioid epidemic specifically impacts children and adolescents, and we explore contemporary efforts underway to facilitate evidence-based opioid prescribing. Resources for pediatric surgeons including national guidelines related to safe opioid prescribing and web-based toolkits that may be used to implement change locally are highlighted. The goal of the present manuscript is to introduce opioid stewardship as a guiding principle in pediatric surgery. LEVEL OF EVIDENCE: LEVEL V (Expert opinion).
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Affiliation(s)
- Kathryn D Bass
- Division of Pediatric Surgery, Department of Surgery, University of Buffalo, John R. Oishei Children's Hospital, Buffalo, NY
| | - Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University, Children's Healthcare of Atlanta, Atlanta, GA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA; Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.
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Gupta A, Jay MA, Williams G. Evolving pediatric epidural practice: An institution's clinical experience over 20 years-A retrospective observational cohort study. Paediatr Anaesth 2020; 30:25-33. [PMID: 31733116 DOI: 10.1111/pan.13767] [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: 03/26/2019] [Revised: 11/03/2019] [Accepted: 11/12/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Epidural analgesia is an effective, established perioperative intervention in all age-groups. In children, however, epidural-related data are limited compared to the adult population. The aim of this study was to examine the use of pediatric epidural analgesia in our institution and, thereby, add to the existing data pool. METHODOLOGY Patients who received epidural analgesia as part of their perioperative management between 1996 and 2016 at Great Ormond Street Hospital, London, UK, were studied to determine how epidural practice has changed over time, associated incidence of serious adverse events, complications, and patient/parent satisfaction. Epidural use and monitoring were in accordance with standard hospital protocols. Data were prospectively collected and entered into a secure database by trained personnel. These data were subsequently extracted for retrospective analysis. RESULTS A total of 3876 patients were included. The median age was 4.4 years (range 1 day to 20 years), and the median weight was 20.3 kg. Across all age-groups, the lumbar region was the most common site of epidural insertion while urology (42.2%) and general surgery (37.3%) were the specialities for which it was most utilized. Over the study period, the number of epidurals performed declined while the number of surgical procedures performed simultaneously increased. The infusate most commonly used was local anesthetic with preservative-free morphine (71.9%). In 923 (23.2%) patients, systemic opioids were additionally used for analgesic management by means of patient-controlled analgesia or nurse-controlled analgesia. There was one serious adverse event in the form of permanent nerve injury, giving an overall incidence of approximately 1:3800. Other complications included postoperative nausea and vomiting (35.9%), urinary retention (4.4%), and pruritus (31%). Overall global satisfaction with the service was generally high, with 95% providing a rating of "very good" or "good." CONCLUSION This study evaluated two decades of epidural practice in our institution. Epidural analgesia remains a safe, effective option for postoperative analgesia, but its use has declined over time, and this trend is likely to continue. Rates of serious adverse events and complications were low and comparable to those published in other similar studies. Global satisfaction among patients/parents remains high.
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Affiliation(s)
- Akhil Gupta
- Department of Anaesthesia, University Hospital Lewisham, Lewisham, UK
| | - Matthew A Jay
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children, London, UK
| | - Glyn Williams
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children, London, UK
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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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Yoshizaki M, Murata H, Ogami-Takamura K, Hara T. Bilateral erector spinae plane block using a programmed intermittent bolus technique for pain management after Nuss procedure. J Clin Anesth 2019; 57:51-52. [DOI: 10.1016/j.jclinane.2019.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 02/26/2019] [Accepted: 03/03/2019] [Indexed: 10/27/2022]
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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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Thaker S, McKenna E, Rader C, Misra MV. Pain Management in Pectus Excavatum Surgery: A Comparison of Subcutaneous Catheters Versus Epidurals in a Pediatric Population. J Laparoendosc Adv Surg Tech A 2019; 29:261-266. [DOI: 10.1089/lap.2018.0244] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Shefali Thaker
- Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Elise McKenna
- Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Christine Rader
- Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Meghna V. Misra
- Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford, Connecticut
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Nardiello MA, Herlitz M. Bilateral single shot erector spinae plane block for pectus excavatum and pectus carinatum surgery in 2 pediatric patients. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2018; 65:530-533. [PMID: 29866441 DOI: 10.1016/j.redar.2018.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/08/2018] [Accepted: 04/11/2018] [Indexed: 06/08/2023]
Abstract
Numerous publications have emerged on the application of erector spinae plane block in adult population. There are few reports of the use of this block in pediatric patients. The objective is to report 2 cases of adolescents, one diagnosed with pectus excavatum and the other one with pectus carinatum undergoing reconstructive surgery in which a bilateral single-shot erector spinae plane block was performed as an analgesic technique. The block was performed before surgery under general anesthesia in lateral decubitus position, guided by ultrasound using 20ml of 0.25% bupivacaine per side. After the surgery they were extubated and transferred to the Intensive Care Unit. During their postoperative period they had visual analogic scale values less than 4 and no long term narcotics were used during the intraoperative and postoperative period. Bilateral single shot erector spinae plane block was effective as an analgesic technique for the intraoperative and postoperative period in pectus excavatum and pectus carinatum surgery in adolescents.
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Affiliation(s)
- M A Nardiello
- Departamento de Cirugía, Hospital Regional Guillermo Grant Benavente, Universidad de Concepción, Concepción, Chile.
| | - M Herlitz
- Departamento de Cirugía, Hospital Regional Guillermo Grant Benavente, Universidad de Concepción, Concepción, Chile
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Sobrino JA, Axt J, Sujka JA, Benedict LA, Wedel L, Millspaugh D, St Peter SD. Withholding Urinary Catheters in Children Receiving Patient-Controlled Analgesia for Appendicitis. J Surg Res 2018; 233:100-103. [PMID: 30502234 DOI: 10.1016/j.jss.2018.07.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 06/11/2018] [Accepted: 07/18/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND In some institutions, urinary catheters (UCs) have been placed in all patients receiving opioid patient-controlled analgesia (PCA) because of the increased incidence of urinary retention. Our institutional data demonstrated no UC replacements in 48 children who had PCA for perforated appendicitis who had their catheters removed before discontinuation of the PCA. As part of a quality improvement initiative, we discontinued the practice of requiring UC with PCA for perforated appendicitis. MATERIALS AND METHODS A prospective list of patients with perforated appendicitis was maintained. Data were gathered regarding 60 consecutive patients. UC placement was allowed for specific indications including urinary retention and surgeon discretion. RESULTS Sixteen patients (27%) received a UC with 14 of these being placed in the operating room (OR). Two UCs were placed outside the OR for urinary retention. Patients who underwent UC placement in the OR weighed significantly more than those who did not (33 versus 42 kg, P = 0.05). No patients required replacement of the catheter once removed. There were no postoperative urinary tract infections. Median PCA duration was 68 h (50, 98) for patients with UC placed in the OR compared with 60 h (47, 78) (P = 0.42). Median postoperative length of stay for patients with UC placed in the OR was 95 h (76, 140) compared with 90 h (70, 113) (P = 0.09). CONCLUSIONS UC can be withheld from patients with perforated appendicitis who are placed on PCA with a very low placement rate. UC placement at time of operation did not lengthen time receiving PCA or length of stay.
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Affiliation(s)
- Justin A Sobrino
- Department of Surgery, The Children's Mercy Hospital, Kansas City, Missouri
| | - Jason Axt
- Department of Surgery, The Children's Mercy Hospital, Kansas City, Missouri
| | - Joseph A Sujka
- Department of Surgery, The Children's Mercy Hospital, Kansas City, Missouri
| | | | - Lisa Wedel
- Department of Surgery, The Children's Mercy Hospital, Kansas City, Missouri
| | - Dan Millspaugh
- Department of Anesthesiology, The Children's Mercy Hospital, Kansas City, Missouri
| | - Shawn D St Peter
- Department of Surgery, The Children's Mercy Hospital, Kansas City, Missouri.
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Darling C, Chao S, Ramamurthi R, Tsui B. Letter to the Editor: Early Consequences of Pectus Excavatum Surgery on Self-Esteem and General Quality of Life. World J Surg 2018; 43:963-964. [PMID: 29882100 DOI: 10.1007/s00268-018-4704-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Curtis Darling
- Pediatric Anesthesia, Lucile Packard Children's Hospital Stanford, Palo Alto, USA
| | - Stephanie Chao
- Pediatric Surgery, Lucile Salter Packard Children's Hospital at Stanford, Palo Alto, USA
| | | | - Ban Tsui
- Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, USA.
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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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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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Morikawa N, Laferriere N, Koo S, Johnson S, Woo R, Puapong D. Cryoanalgesia in Patients Undergoing Nuss Repair of Pectus Excavatum: Technique Modification and Early Results. J Laparoendosc Adv Surg Tech A 2018; 28:1148-1151. [PMID: 29672193 DOI: 10.1089/lap.2017.0665] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE The Nuss procedure for surgical correction of pectus excavatum often causes severe postoperative pain. Cryoanalgesia of intercostal nerves is an alternative modality for pain control. We describe our modification of the cryoICE™ probe that allows for nerve ablation through the ipsilateral chest along with early results utilizing this technique. METHODS To allow for ipsilateral nerve ablation, a 20-French chest tube was cut and secured to the cryoICE probe, thus providing insulation for the malleable end of the probe. A 3-year retrospective review of patients undergoing Nuss repair at our institution was performed. Patients who received cryoanalgesia (cryo, n = 6) were compared with a historical control cohort who did not receive cryoanalgesia (nocryo, n = 13) during Nuss repair. Hospital length of stay, postoperative narcotic requirement (PNR), and highest postoperative pain score were collected. RESULTS Both cohorts were similar regarding age, BMI, and pectus index. The cryo group had a significantly less PNR (6.4 versus 17.9 doses, P = .05) and was discharged on average >1 day earlier than nocryo patients (3.7 versus 2.2 days, P = .01). No complications occurred in either group. CONCLUSIONS Our technique modification simplifies previously described approaches to intercostal nerve cryoablation. Patients undergoing this adjunct benefit with less PNR and a faster discharge time.
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Affiliation(s)
- Nicole Morikawa
- 1 University of Hawaii John A. Burns School of Medicine , Honolulu, Hawaii
| | - Nicole Laferriere
- 2 Department of General Surgery, Tripler Army Medical Center , Honolulu, Hawaii
| | - Sylvia Koo
- 3 University of Hawaii at Manoa , Honolulu, Hawaii
| | - Sidney Johnson
- 4 Department of Pediatric Surgery, Kapiolani Medical Center for Women and Children , Honolulu, Hawaii
| | - Russell Woo
- 4 Department of Pediatric Surgery, Kapiolani Medical Center for Women and Children , Honolulu, Hawaii
| | - Devin Puapong
- 4 Department of Pediatric Surgery, Kapiolani Medical Center for Women and Children , Honolulu, Hawaii
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Are Foley catheters needed after minimally invasive repair of pectus excavatum? Surgery 2018; 163:854-856. [PMID: 29397201 DOI: 10.1016/j.surg.2017.10.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 09/20/2017] [Accepted: 10/18/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND High narcotic requirements after minimally invasive repair of pectus excavatum (MIRPE) can increase the risk of urinary retention. Placement of intraoperative Foley catheters to minimize this risk is variable. This study determines the rate of urinary retention in this population to guide future practice. MATERIALS AND METHODS We reviewed retrospectively all patients who underwent MIRPE from January 2012 to July 2016 at 2 academic children's hospitals. Data collected included demographics, BMI, severity of the pectus defect, postoperative pain management, and the incidence of urinary retention and urinary tract infection (UTI). RESULTS Of 360 total patients who underwent MIRPE, 218 had an intraoperative Foley catheter. Patients with epidural pain control were more likely to receive a Foley catheter. The urinary retention rate was 34% for patients without an intraoperative Foley, and 1% in patients after removal of an intraoperatively placed Foley. Urinary retention was greater with an epidural compared with patient-controlled anesthesia (55% vs 26%, P = .002) in the no intraoperative Foley group. No urinary tract infections were identified. Epidural pain control was the only risk factor on multivariate analysis for retention in patients without an intraoperatively Foley catheter. CONCLUSION Intraoperative Foley catheters obviate urinary retention without increasing the risk of urinary tract infection after MIRPE. These results will allow surgeons to better counsel patients regarding Foley placement.
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Anesthesia for Pleural and Chest Wall Surgery. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_15] [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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Shah SB, Hariharan U, Bhargava AK, Darlong LM. Anesthesia for minimally invasive chest wall reconstructive surgeries: Our experience and review of literature. Saudi J Anaesth 2017; 11:319-326. [PMID: 28757834 PMCID: PMC5516496 DOI: 10.4103/sja.sja_13_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Minimal access procedures have revolutionized the field of surgery and opened newer challenges for the anesthesiologists. Pectus carinatum or pigeon chest is an uncommon chest wall deformity characterized by a protruding breast bone (sternum) and ribs caused by an overgrowth of the costal cartilages. It can cause a multitude of problems, including severe pain from an intercostal neuropathy, respiratory dysfunction, and psychologic issues from the cosmetic disfigurement. Pulmonary function indices, namely, forced expiratory volume over 1 s, forced vital capacity, vital capacity, and total lung capacity are markedly compromised in pectus excavatum. Earlier, open surgical correction in the form of the Ravitch procedure was followed. Currently, in the era of minimally invasive surgery, Nuss technique (pectus bar procedure) is a promising step in chest wall reconstructive surgery for pectus excavatum. Reverse Nuss is a corrective, minimally invasive surgery for pectus carinatum chest deformity. A tailor-made anesthetic technique for this new procedure has been described here based on the authors’ personal experience and thorough review of literature based on Medline, Embase, and Scopus databases search.
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Affiliation(s)
| | - Uma Hariharan
- Department of Anaesthesia and Intensive Care, Dr. Ram Manohar Lohia Hospital and PGIMER, CHS, New Delhi, India
| | | | - Laleng M Darlong
- Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
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