A pilot study of multi-modal pain management for same-day discharge after minimally invasive repair of pectus excavatum (Nuss procedure) in children

Abstract

Background Despite advancements in minimally invasive repair of pectus excavatum (MIRPE), Nuss procedure, postoperative pain control remains challenging. This report covers a multimodal regimen using bilateral single-shot paravertebral block (PVB) and bilateral thoracoscopic intercostal nerve (T3–T7) cryoablation, leading to significant reduction in length of stay (LOS) and high rate of same-day discharge. Methods This is a comparative study of pain management protocols for patients undergoing the Nuss procedure at a single center from 2016 through 2020. All patients underwent the the same surgical technique for the treatment of pectus excavatum at a single center. Patients received bilateral PVB with continuous infusion (Group 1, n = 12), bilateral PVB with infusion and right-side cryoablation (Group 2, n = 9), or bilateral single-shot PVB and bilateral cryoablation (Group 3, n = 17). The primary outcome was LOS with focus on same-day discharge, and the secondary outcome was decreased opioid usage. Results Eleven of 17 patients in Group 3 (65%) (bilateral single-shot PVB and bilateral cryoablation) were discharged the same day as surgery. The remaining Group 3 patients were discharged the following day with no complications or interventions. Compared to Group 1 (no cryoablation), Group 3 had shorter LOS (median 4.4 days vs. 0.7 days, respectively, p < 0.001) and significantly decreased median opioid use on the day of surgery (0.92 mg/kg vs. 0.47 mg/kg, p = 0.006). Conclusion Findings demonstrate the feasibility of multimodal pain management for same-day discharge after the Nuss procedure. Future multisite studies are needed to investigate the superiority of this approach to established methods. Level of Evidence III.

Intercostal nerve cryoablation therapy for the repair of pectus excavatum: a systematic review

“…EPP only provides analgesia while in place whereas INC provides a prolonged analgesic effect; in the prior studies, EPPs were typically in place for 48–72 h postoperatively and were discontinued prior to discharge. When INC is used in combination with a multimodal pain regimen, the researchers found that patients were able to be routinely discharged on post operative day (POD) 1 ( 33 , 37 , 40 , 48 , 49 , 51 , 56 , 57 ). Recent publications have demonstrated the feasibility of a same-day discharge when INC is combined with a peripheral nerve block (PNB) with 65%–66% of patients being discharged on POD 0 ( 49 , 55 , 58 ).…”

“…When INC is used in combination with a multimodal pain regimen, the researchers found that patients were able to be routinely discharged on post operative day (POD) 1 ( 33 , 37 , 40 , 48 , 49 , 51 , 56 , 57 ). Recent publications have demonstrated the feasibility of a same-day discharge when INC is combined with a peripheral nerve block (PNB) with 65%–66% of patients being discharged on POD 0 ( 49 , 55 , 58 ).…”

“…The effect of INC on visual analog pain scores (VAPS) varied between investigators, with less than half (5/11) of the articles finding a significant decrease in VAPS when INC was used ( Table 2 ) ( 13 , 28 – 30 , 33 , 41 , 44 , 46 , 48 , 49 , 53 ). INC was associated with significantly lower VAPS only during the initial postoperative hospitalization.…”

A Serratus Posterior Superior Intercostal Plane Block for Postoperative Analgesia in Minimally Invasive Pectus Excavatum Repair Surgery with a Video-Assisted Thoracic Surgery Technique: Case Report

“…Effective control of severe postoperative pain due to stretching of the intercostal nerves and chest wall is necessary to ensure early mobilization, adequate respiratory function, and overall patient satisfaction. 4…”

“…3 Effective control of severe postoperative pain due to stretching of the intercostal nerves and chest wall is necessary to ensure early mobilization, adequate respiratory function, and overall patient satisfaction. 4 The most commonly used drugs for postoperative analgesia management are opioids, but these drugs have undesirable side effects such as nausea, vomiting, urinary retention, and ventilatory depression. 5 For this reason, clinicians are using regional anesthesia techniques for postoperative analgesia management.…”