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Evaluation of Analgesic Practice Changes Following the Nuss Procedure in Pediatric Patients
Andrew M Breglio1, Tamara N Fitzgerald2, Carrie B Moore2
1Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.
Insights
Intercostal nerve cryoablation (INC) significantly reduced postoperative opioid use in pediatric patients undergoing the Nuss procedure compared to regional blocks or no analgesia. This pain management strategy also led to shorter hospital stays.
Area of Science:
- Pediatric Surgery
- Pain Management
- Thoracic Surgery
Background:
- The Nuss procedure for pectus excavatum often results in severe postoperative pain.
- Effective analgesia is crucial for patient recovery after pectus excavatum repair.
- Regional blocks and intercostal nerve cryoablation (INC) are emerging pain management strategies.
Purpose of the Study:
- To compare the effectiveness of intercostal nerve cryoablation (INC) versus regional blocks and no analgesia for pain management after the Nuss procedure.
- To evaluate opioid utilization, pain scores, and length of stay in patients undergoing pectus excavatum repair with different analgesic strategies.
Main Methods:
- Retrospective chart review of patients under 18 years old who underwent the Nuss procedure.
- Categorization of patients into three groups: no block, regional catheters, or INC.
- Primary outcome: total in-hospital opioid utilization (oral morphine equivalents - OMEs). Secondary outcomes: pain scores, length of stay, and complications.
Main Results:
- Intercostal nerve cryoablation (INC) group showed significantly lower total in-hospital opioid utilization (64 ± 47 OMEs) compared to no block (270 ± 217 OMEs) and regional catheters (273 ± 176 OMEs).
- INC was associated with longer operative times but resulted in shorter hospital lengths of stay (median 68 hours) compared to regional catheters (median 74 hours).
Conclusions:
- Intercostal nerve cryoablation (INC) is an effective strategy for reducing postoperative opioid requirements after the Nuss procedure.
- While INC may increase operative time, it offers benefits in decreased opioid use and potentially shorter hospital stays.
- INC represents a valuable alternative for managing severe postoperative pain in pediatric patients undergoing pectus excavatum repair.
Introduction:
Pectus excavatum repair by the Nuss procedure results in severe postoperative pain. Regional blocks and intercostal nerve cryoablation (INC) have emerged as potential strategies to manage analgesia. This study compares pain-related outcomes following these perioperative interventions.
Methods:
We reviewed charts of patients <18 y who underwent the Nuss procedure at Duke Children's Hospital from July 2018 to June 2022. Patients were divided into three groups by analgesic strategy: no block, regional catheters, or INC, representing the chronologic change in our practice. The primary outcome was total and daily in-hospital opioid utilization measured by oral morphine equivalents (OMEs). Secondary outcomes included average daily pain scores, length of stay, opioid refills after discharge, and complications.
Results:
Twenty-one patients were included and analyzed: no block (n = 6), regional catheters (n = 7), and INC (n = 8). INC-treated patients required significantly lower total postoperative, in-hospital OMEs (64 ± 47 [mean ± standard deviation]) than those with no block (270 ± 217, P = 0.04) or those with regional catheters (273 ± 176, P = 0.03). INC was associated with longer average operative times (161 ± 36 min) than no block (105 ± 21 min, P = 0.005) or regional catheters (90 ± 11 min, P < 0.001). INC-treated patients had shorter hospital length of stays (median 68 h) than those with regional catheters (median 74 h, P = 0.006).
Conclusions:
INC was associated with longer operative times but decreased in-hospital OMEs when compared to bilateral regional block catheters and multimodal analgesia alone.
