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Wharton K, Chidiac C, Lopez C, Hunsberger J, Rhee D, Cappiello C, Garcia AV. Enhanced Recovery After Surgery 2.0: Optimizing Pain Management in Nuss Procedure: Cryoablation and Nerve Block Strategies for Reduced Opioid Use. J Surg Res 2024; 301:563-571. [PMID: 39053171 DOI: 10.1016/j.jss.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 06/24/2024] [Accepted: 07/03/2024] [Indexed: 07/27/2024]
Abstract
INTRODUCTION Our study assesses the association between cryoablation, with and without nerve block supplementation, post-Nuss procedure pain, and opioid use in pectus excavatum (PE) patients. METHODS We conducted a retrospective cohort study at a single center for PE patients who underwent the Nuss procedure from 2017 to 2022. Outcomes included postoperative opioid use (measured in oral morphine milligram equivalent per kilogram [OME/kg]), average pain score (scale 0-10), and length of stay (LOS). RESULTS One hundred sixty-four patients (146 males and 18 females) were included, with 79 (48.2%) receiving neither cryoablation nor nerve block, 60 (36.6%) receiving intraoperative cryoablation alone, and 25 (15.2%) receiving both cryoablation and nerve block. The median age was 16 y. Nerve block recipients consumed fewer opioids during hospitalization than cryoablation alone and nonintervention groups (1.5 versus 2.3 versus 5.8 OME/kg, respectively, P < 0.0001). Average pain scores over the total LOS were lower in nerve block recipients (3.5 versus 3.8 versus 4.2, P = 0.03), particularly on postoperative day 0 (P = 0.002). Nerve block recipients had a shorter LOS than cryoablation alone and nonintervention groups (43.4 versus 54.7 versus 66.2 h, P < 0.0001). On multivariate analysis, cryoablation alone resulted in significantly less opioid use compared to no intervention (3.32 OME/kg reduction, 95% confidence interval -4.16 to -2.47, P < 0.0001). Addition of nerve block further reduced opioid use by 1.10 OME/kg (95% confidence interval -2.07 to -0.14, P = 0.04). CONCLUSIONS Cryoablation with nerve block supplementation is associated with reduced pain, opioid use, and LOS post-Nuss for PE repair compared to cases without cryoablation or with cryoablation only. Cryoablation with regional nerve blocks should be considered for Nuss repair under the enhanced recovery after surgery pathway.
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Affiliation(s)
- Kristin Wharton
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Charbel Chidiac
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carla Lopez
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joann Hunsberger
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel Rhee
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Clint Cappiello
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alejandro V Garcia
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Ren Y, Nie X, Zhang F, Ma Y, Hua L, Zheng T, Xu Z, Gao J, Zhang J. Ultrasound-guided erector spinae plane block versus thoracic epidural block for postoperative analgesia in pediatric Nuss surgery: a randomized noninferiority trial. J Anesth 2024:10.1007/s00540-024-03354-0. [PMID: 38829406 DOI: 10.1007/s00540-024-03354-0] [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: 11/10/2023] [Accepted: 05/24/2024] [Indexed: 06/05/2024]
Abstract
PURPOSE Thoracic epidural anesthesia (TEA) is often used for analgesia after thoracic surgery. Erector spinae plane block (ESPB) has been proposed to provide adequate analgesia. We hypothesized that ESPB would be noninferior to TEA as a part of multimodal analgesia in pediatric patients undergoing the Nuss procedure. METHODS Patients aged 7-18 years and scheduled for the Nuss procedure were randomly allocated to receive bilateral single-shot ESPB or TEA and a multimodal analgesic regimen including parent-controlled intravenous analgesia (PCIA). At 6 h, 12 h, 18 h, and 24 h postoperatively, pain was evaluated using the numeric rating scale (NRS) and opioid consumption was assessed by counting the number of PCIA boluses. The joint primary outcomes were the average pain score and opioid consumption at 24 h after surgery. The secondary outcomes were the NRS scores and the number of opioid boluses administered at different postoperative time points, adverse events, and recovery quality. RESULTS Three hundred patients underwent randomization, and 286 received ESPB (147 patients) or TEA (139 patients). At 24 h postoperatively, ESPB was noninferior to TEA in terms of the average NRS score (mean difference, - 0.1, 95% confidence interval [CI], - 0.3-0.1, margin = 1, P for noninferiority < 0.001) and the number of opioid boluses administered (mean difference, - 1.1, 95% CI, - 2.8-0.6, margin = 7, P for noninferiority < 0.001). Adverse events and patient recovery were comparable between groups. CONCLUSIONS The results demonstrate that combined with a multimodal analgesia, ESPB provides noninferior analgesia compared to TEA with respect to pain score and opioid consumption among pediatric patients undergoing the Nuss procedure.
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Affiliation(s)
- Yi Ren
- Department of Anesthesiology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56, South Lishi Road, Beijing, 100045, China
| | - Xiaolu Nie
- Center for Clinical Epidemiology and Evidence-Based Medicine, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, 100045, China
| | - Fuzhou Zhang
- Department of Anesthesiology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56, South Lishi Road, Beijing, 100045, China
| | - Yangwei Ma
- Department of Anesthesiology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56, South Lishi Road, Beijing, 100045, China
| | - Lei Hua
- Department of Anesthesiology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56, South Lishi Road, Beijing, 100045, China
| | - Tiehua Zheng
- Department of Anesthesiology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56, South Lishi Road, Beijing, 100045, China
| | - Zenghua Xu
- Department of Anesthesiology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56, South Lishi Road, Beijing, 100045, China
| | - Jia Gao
- Department of Anesthesiology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56, South Lishi Road, Beijing, 100045, China
| | - Jianmin Zhang
- Department of Anesthesiology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56, South Lishi Road, Beijing, 100045, China.
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Wu S, Wu J, Zhang X. Application of an ultrasound-guided bilateral erector spinae plane block after the Nuss procedure for pectus excavatum in children: a retrospective cohort study with propensity score matching. Front Pediatr 2023; 11:1201604. [PMID: 37449266 PMCID: PMC10336535 DOI: 10.3389/fped.2023.1201604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
Objective To retrospectively analyze the effect of applying an ultrasound-guided bilateral erector spine plane block (ESPB) after the Nuss procedure for surgical repair of pectus excavatum (PE) in children. Methods The subjects of the study were patients with severe PE who received the Nuss procedure in our hospital between 1 January 2019 and 30 November 2021. According to different methods for postoperative pain management, the enrolled patients were divided into two groups, the ultrasound-guided ESPB group and the thoracic epidural analgesia (TEA) group. The primary outcome of this study was analgesic drug dosage and the secondary outcome was numerical rating scales (NRSs) between the two groups. Results There was no significant difference between the two groups in terms of demographic, preoperative clinical evaluation, or surgical characteristics (P > 0.05). The catheter duration in the TEA group was significantly shorter than that in the ESPB group (P < 0.05), while the hospitalization time in the ESPB group was significantly shorter than that in the TEA group (P < 0.05). In terms of oral morphine equivalent comparison, the required dose of the TEA group was lower than that of the ESPB group on the 1st and 2nd day after the operation (P < 0.05), and there was no statistical difference between the two groups on the 3rd and 4th day after the operation (P > 0.05). The number of patients with an S-NRS ≥ 7 and D-NRS ≥ 7 in the TEA group at day 1 was lower than that in the ESPB group (P < 0.05). There was no significant difference between the two groups at other time points (P > 0.05). Conclusion An ultrasound-guided ESPB used in Nuss surgery for children with funnel chest can provide good analgesia for surgery and shorten the postoperative rehabilitation and hospitalization time of patients. It is a safe and effective alternative to TEA.
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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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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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