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Eubanks AL, Grabski DF, Pollack J, Levin DE, McGahren E, Martin LW, Gander J. A multimodal protocol utilizing liposomal bupivacaine rib blocks leads to opioid reduction in patients undergoing the Nuss procedure. J Thorac Dis 2022; 13:6363-6372. [PMID: 34992816 PMCID: PMC8662494 DOI: 10.21037/jtd-21-1314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/09/2021] [Indexed: 12/05/2022]
Abstract
Background A major challenge associated with the Nuss procedure for pectus excavatum repair is postoperative pain control. Early Recovery Program (ERP) protocols for the Nuss procedure are becoming common, but there is a paucity of experience using liposomal bupivacaine (LB), a long-acting local anesthetic, for rib blocks in this setting. We investigated whether a protocol utilizing LB rib blocks decreased opioid use after the Nuss procedure while achieving equivalent pain control. Methods All adolescent patients undergoing the Nuss procedure at our institution between January 2013 and January 2021 were included. Patients were divided into a pre-intervention cohort (n=15), a transition cohort (n=4), and a post-intervention cohort (n=13). Patients in all groups received scheduled acetaminophen and non-steroidals postoperatively. The pre-intervention cohort received an opioid patient-controlled analgesia (PCA) pump postoperatively, with a transition to oral opiates. The transition and post-intervention cohorts received scheduled gabapentin in addition to intraoperative bilateral rib blocks with longer-acting local anesthetic. Rib blocks were performed using 0.25% Bupivacaine in the pre-intervention group. In the transition group, epinephrine (1 mg/kg) was added to 0.25% bupivacaine for the rib block. Following approval in patients aged 13–18 years, 1.3% LB (2.25 mg/kg) was given for a rib block in the post-intervention cohort. Results Demographic and clinical variables were equivalent in all groups. Post-intervention patients received 90% fewer opioids [median morphine equivalent (MME) mg/kg] compared to the pre-intervention cohort (0.8 vs. 8.2 MME mg/kg, P<0.0001), with no significant difference in pain scores between groups. Hospital length of stay was decreased among the intervention cohort (3 vs. 4 days, P=0.002). Conclusions Significant decreases in opioid use and length of stay after the Nuss procedure were achieved by the implementation of a multimodal ERP for pain management, without increase in patient-reported pain scores.
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Affiliation(s)
- Alicia L Eubanks
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - David F Grabski
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Jessica Pollack
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Daniel E Levin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eugene McGahren
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Linda W Martin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Jeffrey Gander
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
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Shi R, Xie L, Chen G, Zeng Q, Mo X, Tang J, Zhou H, Zhang D, Ye X, Zhou Z, Tian D, Deng C, Ben X, Qiao G. Surgical management of pectus excavatum in China: results of a survey amongst members of the Chinese Association of Thoracic Surgeons. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:202. [PMID: 31205920 DOI: 10.21037/atm.2019.05.03] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background At present, there are no randomized trial or higher levels of evidence than case studies to guide thoracic surgeons in the field of thoracic deformities, typically for pectus excavatum. This study investigates the current clinical practices amongst the Chinese Association of Thoracic Surgeon (CATS) members in order to seek potential consensus and divergence. Methods A web-based questionnaire was designed by a subgroup of CATS Pectus Excavatum Management Working Group and was sent to all of the CATS members. The questionnaire was composed of 27 questions concerning debatable sections, including preoperative evaluations, indications, timings of surgery, anesthesia and analgesia methods, rehabilitations. Results A total of 385 questionnaires were mailed to available CATS members. Moreover, 208 questionnaires were retrieved, of them 170 were finally available for analysis. Results of high consensus were extracted. Besides well-known factors such as complaints of symptoms, a moderate to severe deformity by physical exam, a Haller CT index >3.2, pulmonary function deviance, and cardiology evaluation abnormality, cosmetic requests and severe social-psychological problems from deformity come to be the most common reasons (17.34% and 56.89%) for PE patients' demands for surgery, and also occupy high percentages (49.41% and 89.41%) in indications of surgery. Concerning CT scan, 3D reconstruction of the chest is performed additionally by two thirds (64.12%) of the investigated cohort. Two surgeons out of three (66.47%) responders consider the optimal age for surgery is 6-12 years old. After the Nuss procedure, the majority of responders (79.41%) agree on the removal of the bar 2-3 years after surgery. To deal with complicated or severe deformities, 84.71% of surgeons utilize the double bar or multiple bar techniques. The majority of responders (92.35%) prefer general anesthesia combined with intubation in PE surgery, as well as in the procedure of the Nuss bar removal (72.35%). Conclusions The survey reveals a remarkable consistency of practice patterns in several aspects. Adequate preoperative evaluations are needed. Cosmetic request and psychological discomfort from deformity are crucial indications for surgery. We had better perform PE surgery before patients' puberty and bar removal 3 years after surgery. Several surgical skills are fully debated to enhance orthopedic effect and diminish complications. General anesthesia combined with intubation is considered as a standard maneuver. Surgeons now pay more and more attention to perioperative rehabilitations. The given results can be used as evidence in guiding clinical practice in circumstances where no evidence of higher levels exists, although divergences exist. Future studies, especially randomized trials, are needed to establish clinical practice guidelines for thoracic surgeons in PE surgery.
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Affiliation(s)
- Ruiqing Shi
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Liang Xie
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Gang Chen
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Qi Zeng
- Department of Thoracic Surgery, Beijing Children's Hospital, Capital Medical University, Beijing 100045, China
| | - Xuming Mo
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing 210008, China
| | - Jiming Tang
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Haiyu Zhou
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Dongkun Zhang
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xiong Ye
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Zihao Zhou
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Dan Tian
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Cheng Deng
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xiaosong Ben
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Guibin Qiao
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
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Menlah A, Garti I, Amoo SA, Atakro CA, Amponsah C, Agyare DF. Knowledge, Attitudes, and Practices of Postoperative Pain Management by Nurses in Selected District Hospitals in Ghana. SAGE Open Nurs 2018; 4:2377960818790383. [PMID: 33415201 PMCID: PMC7774443 DOI: 10.1177/2377960818790383] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 06/21/2018] [Accepted: 06/28/2018] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION There is documented evidence pointing to the fact that there are numerous challenges with postoperative pain (POP) management globally. However, these challenges with POP management are more profound in developing countries. PURPOSE The purpose of this study is to examine the knowledge, attitude, and practices of nurses concerning POP management in four selected district hospitals in Ghana. METHODOLOGY A descriptive, cross-sectional survey was employed to evaluate nurse's knowledge, attitude, and practices pertaining to POP management. Multistaged sampling was used to draw the respondents. An adapted version of the Nurses Knowledge and Attitudes Survey Regarding Pain instrument was used to test the knowledge, attitude, and practices of nurses and midwives. Descriptive statistics were used to analyze the data in order to present quantitative descriptions of variables in this study. RESULTS This study showed that nurses in the four district hospitals had knowledge deficits regarding POP management. Eighty-one representing 48% of nurses had low knowledge on POP management. An overwhelming majority of nurses (97.6%) relied on routinely rendered basic nursing skills to relieve POP and a few used pharmacological interventions. However, nurses had good attitudes toward POP management. CONCLUSIONS POP is ineffectively managed by nurses in district hospitals in Ghana. Nurses and midwives in Ghana need to adhere to best practices in POP management by increasing their theoretical and practical knowledge, so that there will be tangible positive change in POP management in Ghana. RECOMMENDATIONS Nurses must be empowered through continuous development programs to keep abreast with changing trends that pertain to POP management.
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Affiliation(s)
- Awube Menlah
- Department of Nursing, Valley View University, Adenta, Ghana
| | - Isabella Garti
- Department of Nursing, Valley View University, Adenta, Ghana
| | - Sarah Ama Amoo
- Intensive Care Unit, Cape Coast Teaching Hospital, Ghana
| | | | - Caleb Amponsah
- Department of Nursing, Valley View University, Adenta, Ghana
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