Intravenous Morphine Infusion versus Thoracic Epidural Infusion of Ropivacaine with Fentanyl after the Ravitch Procedure-A Single-Center Cohort Study

A Randomized Controlled Trial of Cryoanalgesia for Pain Management following Pectus Excavatum Repair: A Single-Center, Single-Blind, Parallel Design Study

INTRODUCTION

 Conventional postoperative pain management, with an intravenous patient-controlled approach or thoracic epidural analgesia, has proved suboptimal following a minimally invasive repair of pectus excavatum. Considering its postulated mechanism of action, we encouraged cryoanalgesia as an effective method for postrepair pain management and a possibly superior alternative.

METHODS

 A randomized, single-blind clinical trial was tested on patients undergoing pectus excavatum (PE) repair in March and December 2022. Among 101 patients, consenting study participants were randomly assigned to one of two groups: cryoanalgesia (group C, n = 24) or noncryoanalgesia (group N, n = 24). Group N received conventional pain management. Comparing the results, pain levels were measured using the visual analog scale (VAS-R for resting and VAS-D for dynamic) and the total rescue analgesic consumption was determined. Intrathoracic cryoablation was performed bilaterally on the fourth and seventh intercostal nerves using a cryoprobe at -80°C for 2 minutes.

RESULTS

 The two groups had similar baseline-patient characteristics; however, group C had a longer mean operative time (159 vs. 125 minutes, p < 0.01) and experienced significantly less pain throughout the postoperative course, with VAS at 6 hours (5.38 vs. 7.04, p < 0.01) and 48 hours (3.17 vs. 5.67, p < 0.01).

CONCLUSION

 Cryoanalgesia improved postoperative pain control at rest and during movement following PE repair. However, the outcome was less favorable than expected because the VAS was greater than 4 (moderate pain), although after a day or two, it decreased to lower levels (VAS < 4) in the cyro group. Considering its extra invasiveness and instrumentation, a routine cryoanalgesia procedure for pectus surgery is yet to be determined.

Serratus anterior plane block for acute pain management after pectus excavatum repair

Introduction

Conventional postoperative pain management using an intravenous (IV) patient-controlled approach or thoracic epidural analgesia is suboptimal following minimally invasive repair of the pectus excavatum (MIRPE). Recently, cryoanalgesia has gained popularity owing to its superior pain control outcomes compared to those associated with conventional methods. However, because of its invasiveness, additional instrumentation requirement, and limited effect at early postoperative periods, we hypothesized that serratus anterior plane block (SAPB) could be an effective method for post-repair pain management and a possibly superior alternative.

Methods

We conducted a retrospective cohort study of pediatric patients who had undergone MIRPE between March 2022 and August 2023. We compared the efficacy of pain control in three groups among 74 patients: Group N (conventional pain management, n = 24), Group C (cryoanalgesia, n = 24), and Group S (SAPB, n = 26). Group N received IV patient-controlled analgesia (PCA) and a subcutaneous local anesthetic infusion. Group C received bilateral cryoanalgesia on the fourth and seventh intercostal nerves using a cryoprobe at -80°C for 2 min during the operation and IV-PCA postoperatively. Group S received continuous bilateral SAPB with 0.25% ropivacaine and IV-PCA. The pain levels were measured using the visual analog scale (VAS; resting and dynamic), and the total IV rescue analgesic consumption was determined.

Results

The three groups had similar baseline characteristics. Group S showed significantly less pain throughout the immediate postoperative course, resting VAS score at 3 h (Group N, 7.21 vs. Group C, 5.75 vs. Group S, 3.81; p < 0.001), and prominent less total IV rescue analgesic consumption (Group N, 116.16 mg vs. Group C, 52.75 mg vs. Group S, 16.61 mg; p < 0.001).

Conclusion

SAPB resulted in better postoperative pain control than that associated with cryoanalgesia and conventional pain management after pectus excavatum repair, As it was effective in the immediate postoperative period, achieving a VAS score of <4 points (moderate pain) at 3 h postoperatively, it may play an important role and replace invasive cryoanalgesia in the management of pain after pectus surgery.

Factors Related to Anxiety in Paediatric Patients and Their Parents before and after a Modified Ravitch Procedure-A Single-Centre Cohort Study

OBJECTIVE

To assess the factors related to perioperative state anxiety in paediatric patients and their parents.

METHODS

A cohort study was conducted on paediatric patients 9-17 years of age, who underwent the modified Ravitch procedure (n = 96), and their parents (n = 96). The level of anxiety was measured using the State-Trait Anxiety Inventory questionnaire. Multivariable linear regression models were calculated to find the relationships between the pre- and postoperative state anxiety of the patients/parents and the independent variables, both demographic (age, gender) and clinical (e.g., postoperative pain, trait anxiety).

RESULTS

Preoperative anxiety in the paediatric patients was positively correlated with their trait anxiety (β = 0.47; 95% CI: 0.29 to 0.64) and preoperative parental anxiety (β = 0.24; 95% CI: 0.07 to 0.42). The high level of preoperative anxiety (vs. low and moderate) (β = 0.40; 95% CI: 0.22 to 0.58), trait anxiety (β = 0.22; 95% CI: 0.04 to 0.40) and average postoperative pain at rest (β = 0.18; 95% CI: 0.01 to 0.34) had a positive impact on the postoperative anxiety in patients. However, the patients' age was negatively correlated with postoperative anxiety (β = -0.19; 95% CI: -0.35 to -0.02). Three variables were found to predict preoperative parental anxiety: their trait anxiety (β = 0.41; 95% CI: 0.23 to 0.59), female gender (β = 0.18; 95% CI: 0.002 to 0.36) and the intravenous route for the postoperative pain management in the patients (β = -0.18; 95% CI: -0.36 to -0.001). The parental postoperative anxiety was influenced by their trait anxiety (β = 0.24; 95% CI: 0.04 to 0.43), preoperative anxiety in patients (β = 0.21; 95% CI: 0.02 to 0.40) and female gender of children (β = 0.19; 95% CI: 0.001 to 0.39).

CONCLUSIONS

Trait anxiety was a strong factor positively affecting the perioperative state anxiety. In addition, paediatric patient anxiety before surgery was related to their parents' anxiety, and, after surgery, this was associated with high preoperative anxiety, pain and age. The parents' anxiety before surgery was influenced by gender and the type of postoperative analgesia in the patients, while, after surgery, this was influenced by the patients' preoperative anxiety/gender.