Implementation of a Cryoablation-based Pain Management Protocol for Pectus Excavatum

IntroductionThe Nuss repair for pectus excavatum is associated with significant postoperative pain. Our institution developed protocols to standardize pain management for pectus excavatum patients in the immediate postoperative period. We present our experience with protocol implementation and patient outcomes.MethodsWe standardized regional anesthesia with a 0.25% bupivacaine incisional soaker catheter (post-implementation 1, PI1) before transitioning to intercostal nerve cryoablation (INC) (post-implementation 2, PI2). Patient outcomes were tracked using statistical process control charts in AdaptX™ OR Advisor and run charts in Tableau. Chi-squared tests assessed demographic differences between cohorts.Results244 patients were included: 78 pre-implementation, 108 PI1, and 58 PI2. Average age was 15.9–16.5 years. Patients were majority male, non-Hispanic white, and English speaking. Hospital length of stay decreased 4.1–2.4 days. INC increased surgery time (99–125 min) but decreased PACU time (112-78 min). Maximum pain scores improved in PACU (7.7–6.0) and 0–24 h postoperatively (8.3–6.8) but were not different 24–48 h postoperatively (5.4–5.8). Average opioid dosing decreased 0–48 h from 1.9 to 0.8 mg/kg morphine milliequivalents and was associated with reduction in post-operative nausea and constipation. There were no 30-day readmissions.ConclusionAn institution-wide pain management protocol using INC for pectus excavatum patients was implemented. Intercostal nerve cryoablation was found to be superior to bupivacaine incisional soaker catheters and reduced hospital length of stay, immediate postoperative pain scores, morphine milliequivalent opioid dosing, postoperative nausea, and constipation.Level of EvidenceLevel IV.     

Impact of Cryoanalgesia Use During Minimally Invasive Pectus Excavatum Repair on Hospital Days and Total Hospital Costs Among Pediatric Patients

IntroductionSurgical repair of pectus excavatum is a painful procedure requiring multimodal pain control with historically prolonged hospital stay. This study aimed to evaluate the impact of cryoanalgesia during minimally invasive repair of pectus excavatum (MIRPE) on hospital days (HDs), total hospital costs (HCs), and complications. We hypothesized that cryoanalgesia would be associated with reduced HDs and total HCs with no increase in post-operative complications.MethodsWe conducted a retrospective review of pediatric patients who underwent MIRPE from 2011 to 2021. MIRPE details and post-operative outcomes within 90 days were abstracted. Total HDs included the index MIRPE admission and readmissions within 90 days. HCs were obtained from the hospital accounting system, retroactively adjusting for medical inflation. Bayesian generalized linear models with neutral prior assuming no effect were used. Differences between treatment groups were assessed using gamma distribution (HDs and HCs) and poisson (post-operative complications). All models used log link and controlled for age, gender, race, and Haller index.ResultsForty-four patients underwent MIRPE during the study period. Cryoanalgesia was utilized in 29 (66%) patients. The probability of a reduction with cryoanalgesia vs. no cryoanalgesia was 99% for HDs (3.0 vs. 5.4 days; Bayesian RR: 0.6, 95% CrI: 0.5–0.8), 89% for HCs ($18,787 vs. $19,667; RR: 0.9, 95% CrI: 0.8–1.1), and 70% for postoperative complications (17% vs 33%; RR: 0.8, 95% CrI: 0.3–1.9).ConclusionCryoanalgesia use in MIRPE likely reduced HDs, HCs, and post-operative complications. Further research is warranted to confirm these findings in large prospective studies.Level of EvidenceLevel III.     

漏斗胸患者Nuss手术后慢性疼痛的危险因素

目的 探讨漏斗胸微创矫正术(Nuss手术)后慢性疼痛的危险因素.方法 回顾性分析2013年1月至2019年9月择期行胸腔镜Nuss手术患者168例,男130例,女38例.收集患者联系方式、人口学资料、术前合并症、漏斗胸严重程度分级、神经阻滞情况、手术时间和术后24 h VAS疼痛评分.电话随访患者或家属完成术后慢性疼痛...     

Modified Nuss procedure for the treatment of pectus excavatum: Experience of 259 patients

BackgroundPectus excavatum is not rare in China. Many treatments for this disease have proved to have many shortcomings. Nuss procedure has been a ground-breaking technology, but it also has some disadvantages. Hence, this study was conducted to review our experience in the use of modified Nuss procedure in our hospital.MethodsData from 259 patients suffered from pectus excavatum between August 2020 and August 2021 who were treated with modified Nuss procedure was analyzed retrospectively.ResultAge was from 3 to 37 years. The average was 15.54 years. The male was 213 cases and the female was 46 cases. The time patients or their family members found pectus excavatum varied. 10 cases had been repaired previously when patients were admitted in our hospital. The clinical symptoms also varied. Each case had an improvement in Haller index. The average of the postoperative hospitalization was 3.97 days. Most cases were inserted 1 bar. Complication rate was also very low. All patients or their parents or their guardians were satisfied with the appearance of the chest wall after operation. There was no death in the whole observation period.ConclusionFrom our experience, this modified Nuss procedure have obtained optimistic outcomes with more minimal invasion and low complication rate. This surgical method may be applied to many other hospitals in the future.     

Next day discharge after the Nuss procedure using intercostal nerve cryoablation,intercostal nerve blocks,and a perioperative ERAS pain protocol

BackgroundThe Nuss procedure for pectus excavatum has historically been associated with significant postoperative pain, which has been the major factor contributing to hospital length of stay (LOS).MethodsA single-institution, prospective study of 40 consecutive patients undergoing Nuss bar placement for pectus excavatum between November 2019 and January 2021 was conducted to assess the effectiveness of a multimodality pain management protocol. All patients received T3-T8 intercostal nerve cryoablation (INC), T3-T8 bupivacaine intercostal nerve blocks, Exparel at the skin incisions, and management with a perioperative analgesia regimen that minimized narcotic usage. The primary outcome was LOS. Secondary outcomes included opioid use, pain scores, and time to sensory recovery.Results37/40 patients (92.5%) were discharged home on postoperative day (POD) 1, and 3/40 (7.5%) were discharged on POD 2 (mean LOS = 1.1 days). The median average postoperative pain score was 2/10. After eliminating IVPCA from our protocol, total oral morphine equivalent (OME) decreased by 73% (55.5 mg to 15 mg) with no change in pain scores or discharge timing.ConclusionsINC combined with bupivacaine intercostal nerve blocks and a pre- and post-hospital analgesia protocol facilitated discharge one day after the Nuss procedure, achieved excellent pain control, and eliminated the need for intravenous opioids.     

Intraoperative intercostal nerve cryoablation During the Nuss procedure reduces length of stay and opioid requirement: A randomized clinical trial

PurposeMinimally-invasive repair of pectus excavatum by the Nuss procedure is associated with significant postoperative pain, prolonged hospital stay, and high opiate requirement. We hypothesized that intercostal nerve cryoablation during the Nuss procedure reduces hospital length of stay (LOS) compared to thoracic epidural analgesia.DesignThis randomized clinical trial evaluated 20 consecutive patients undergoing the Nuss procedure for pectus excavatum between May 2016 and March 2018. Patients were randomized evenly via closed-envelope method to receive either cryoanalgesia or thoracic epidural analgesia. Patients and physicians were blinded to study arm until immediately preoperatively.SettingSingle institution, UCSF-Benioff Children's Hospital.Participants20 consecutive patients were recruited from those scheduled for the Nuss procedure. Exclusion criteria were age < 13 years, chest wall anomaly other than pectus excavatum, previous repair or other thoracic surgery, and chronic use of pain medications.Main outcomes and measuresPrimary outcome was postoperative LOS. Secondary outcomes included total operative time, total/daily opioid requirement, inpatient/outpatient pain score, and complications. Primary outcome data were analyzed by the Mann–Whitney U-test for nonparametric continuous variables. Other continuous variables were analyzed by two-tailed t-test, while categorical data were compared via Chi-squared test, with alpha = 0.05 for significance.Results20 patients were randomized to receive either cryoablation (n = 10) or thoracic epidural (n = 10). Mean operating room time was 46.5 min longer in the cryoanalgesia group (p = 0.0001). Median LOS decreased by 2 days in patients undergoing cryoablation, to 3 days from 5 days (Mann–Whitney U, p = 0.0001). Cryoablation patients required significantly less inpatient opioid analgesia with a mean decrease of 416 mg oral morphine equivalent per patient (p = 0.0001), requiring 52%–82% fewer milligrams on postoperative days 1–3 (p < 0.01 each day). There was no difference in mean pain score between the groups at any point postoperatively, up to one year, and no increased incidence of neuropathic pain in the cryoablation group. No complications were noted in the cryoablation group; among patients with epidurals, one patient experienced a symptomatic pneumothorax and another had urinary retention.Conclusions and relevanceIntercostal nerve cryoablation during the Nuss procedure decreases hospital length of stay and opiate requirement versus thoracic epidural analgesia, while offering equivalent pain control.Type of studyTreatment study.Level of evidenceLevel I.     

Ultrasound-guided erector spinae plane block versus thoracic epidural analgesia: Postoperative pain management after Nuss repair for pectus excavatum

Aim of the StudyPostoperative pain management is a significant challenge in patients undergoing Nuss repair for pectus excavatum chest wall deformity. Therapeutic anesthetic options primarily include patient-controlled intravenous analgesia, thoracic epidural analgesia (TEA), and cryoanalgesia. However, TEA is limited to inpatient use and both TEA and cryoanalgesia can result in neurologic injury. The novel technique of ultrasound-guided erector spinae plane regional analgesia has been used recently in our patients undergoing the Nuss repair and has shown impressive pain relief, but without the potential complications of other modalities. Erector spinae plane block (ESPB) postoperative pain management outcomes were studied as compared to TEA.MethodsThirty consecutive patients with severe pectus excavatum undergoing Nuss repair and placement of ultrasound-guided ESPB were each paired to a historical cohort control patient with TEA postoperative pain management. The cohort patient match was defined by age (± 2 years), gender, and CT pectus index (± 15%). Study variables included hospital length of stay (LOS), pain scores, and pain medication usage.ResultsPain scores as measured by area under the curve per hour (Day 1: 2.72 (SD = 1.37) vs. 3.90 (SD = 1.81), P = 0.006; Day 2: 2.83 (SD = 1.32) vs. 3.97 (SD = 1.82), P = 0.007) and oral morphine equivalent (OME) pain medication usage (Day 1: 11.9 (SD = 4.9) vs 56.0 (SD = 32.2), P < 0.001; Day 2: 14.7 (SD = 7.1) vs. 38.0 (SD = 21.7), P < 0.001) were higher for the first two postoperative days in the ESPB group. However, mean hospital LOS was nearly one day shorter for ESPB patients (3.78 (SD = 0.82) vs. 2.90 (SD = 0.87), P < 0.001) who were discharged home with the catheter in place until removal, typically at 5–7 days postoperatively.ConclusionUltrasound-guided ESPB is thus a feasible, safe, and effective alternative to TEA in postoperative pain management after Nuss repair and results in decreased hospital stay.Level of evidenceIII     

Reduced hospitalization cost for patients with pectus excavatum treated using minimally invasive surgery

Background: Currently, few data exist regarding the relative costs associated with open and minimally invasive pectus excavatum repair. The aim of this study was to compare the surgical and hospitalization costs for these two surgical techniques and to identify factors responsible for cost differences. Methods: A retrospective review of hospital charts, patient and parent questionnaires, and hospital accounting records was performed for 68 patients who underwent surgical correction of pectus excavatum between June 1996 and December 1999. Results: In this series, 25 patients underwent open repair, whereas 43 patients underwent minimally invasive repair of pectus excavatum (MIRPE). The patient ages ranged from 4 to 19 years. The average ages for open repair (12 years) and MIRPE (11 years) did not differ significantly. As compared with open repair, MIRPE was associated with a 27% lower overall cost of hospitalization (p < 0.05). The operating room costs were 12% higher for the patients who underwent MIRPE (p < 0.05). The mean operative time for open repair was 3 h 15 min, whereas MIRPE required 1 h 10 min (p < 0.001). The hospital stay for open repair averaged 4.4 days, as compared with 2.4 days for MIRPE (p < 0.001). In contrast to other published series, the postoperative analgesia after MIRPE in this series consisted of narcotics, ketorolac, and methocarbamol. No patient received epidural analgesia, regardless of the repair technique selected. The postoperative complication rate was 4% in the open group and 14% in the MIRPE group. Most of the patients treated with either open or MIRPE reported postoperative oral narcotic usage for 2 weeks or less and returned to routine activities within 3 weeks. The patients and parents alike reported good to excellent overall outcomes in 85% or more of the open repair cases and 90% or more of the MIRPE cases. Conclusions: These data demonstrate for the first time that the use of an alternate pain management strategy including, narcotics, NSAIDs, and methocarbamol, but without epidural catheters, results in reduced hospital length of stay and decreased overall hospitalization costs for MIRPE, as compared with open pectus repair. This cost benefit was achieved without compromising pain management or patient satisfaction with surgical care.     

Postoperative pain management in pediatric patients undergoing minimally invasive repair of pectus excavatum: The role of intercostal block

Purpose

There are no published data regarding value of intercostal block following pectus excavatum repair. Our aim was to evaluate the efficacy of intercostal block in children following minimally invasive repair of pectus excavatum (MIRPE).

Methods

Forty-five patients given patient-controlled analgesia (PCA) with morphine postoperatively were studied. Twenty-six patients were given bilateral intercostal blocks after induction of anesthesia (PCA-IB group), and nineteen patients were retrospective controls without regional blockade (PCA group). All patients were followed up 24 h postoperatively.

Results

A loading dose of morphine (0,1 ± 0,49 mg/kg) before starting PCA was used in seventeen patients in PCA group vs. no patient in PCA-IB group. Cumulative used morphine doses were lower up to 12 h after surgery in PCA-IB group (0,29 ± 0,08 μg/kg) than in the PCA group (0,46 ± 0,18 μg/kg), p < 0,01. There were no differences in pain scores, oxygen saturation values, sedation scores, and the incidence of pulmonary adverse events between the two groups. There was a tendency towards less morphine-related adverse effects in PCA-IB group compared to PCA group (p < 0,05). No complications related to the intercostal blocks were observed.

Conclusion

Bilateral intercostal blocks following MIRPE are safe and easy to perform and can diminish postoperative opioid requirement. Double-blind randomized study is required to confirm the potential to diminish opioid related side effects.     

Complications of the minimally invasive repair of pectus excavatum

Background

Minimally invasive repair of pectus excavatum (MIRPE) has become widely popular since its introduction in the late 1990s by Nuss. We describe 1 unusual complication after MIRPE and 1 life-threatening bleeding during removal of the pectus bar.

Methods

We report the cases of 2 patients in a single institution, more than 100 MIRPE procedures performed so far, and review of literature.

Cases

A 14-year-old girl presented 6 months after MIRPE in another institution. During removal of the pectus bar, a massive hemorrhage from both chest wounds occurred, requiring emergency sternotomy. Arrosion of a pulmonary vessel close to the metal bar had led to the bleeding. The second case was a bilateral sternoclavicular dislocation after MIRPE, which has not caused symptoms so far, in a 13-year-old girl.

Conclusions

Numerous operative and postoperative complications after MIRPE are feasible. This is the first report of a life-threatening bleeding during removal of the pectus bar. Minimally invasive repair of pectus excavatum procedure and removal of the pectus bar should only occur in specialized institutions with wide experience in thoracic surgery.     

A case report of anesthetic management of the minimally invasive Nuss operation for pectus excavatum

We describe the anesthetic management of a patient with pectus excavatum, receiving the minimally invasive Nuss operation, which corrects chest wall deformity by insertion of a convex steel bar (pectus bar). An 8-year-old female patient was scheduled for the Nuss operation. The manipulation of the bar in the thorax was guided by thoracic endoscopy. Anesthesia was maintained with a combination of general and epidural anesthesia. The intraarterial catheter and epidural catheter were inserted after the induction of general anesthesia. During the manipulation of the pectus bar in the anterior mediastinum, a sudden decrease in arterial pressure might occur due to the compression of the heart. Therefore, the intraarterial line was essential for continuous monitoring of arterial pressure. The pectus bar causes severe postoperative pain, and the patient was required to remain at bed rest for several days. Continuous epidural infusion of ropivacaine and morphine eliminated the postoperative pain and enabled the patient to maintain bed rest. For the anesthetic managements of patients undergoing the Nuss operation, close monitoring of arterial pressure intraoperatively and postoperative analgesia are important.     

Efficacy of Ultrasound-Guided Pericapsular Nerve Group (PENG) Block Combined With Local Infiltration Analgesia on Postoperative Pain After Total Hip Arthroplasty: A Prospective,Double-Blind,Randomized Controlled Trial

BackgroundThis study examined whether pericapsular nerve group (PENG) block combined with local infiltration analgesia (LIA) could improve pain management and functional recovery after total hip arthroplasty.MethodsAll patients were randomly assigned to receive PENG block combined with LIA (PENG group) or sham PENG block and LIA (Sham group). The primary outcome was cumulative morphine consumption within 24 hours after surgery. Secondary outcomes were pain scores on a visual analog scale (VAS); time to first rescue analgesia; cumulative morphine consumption during hospitalization; intraoperative consumption of opioids; postoperative recovery; and postoperative complications.ResultsPENG patients consumed significantly less morphine within the first 24 hours and throughout hospitalization and smaller amounts of intraoperative opioids. There were significantly lower pain scores at rest and during motion within 24 hours in PENG patients. PENG patients took significantly longer until the first rescue analgesia and showed significantly better postoperative rehabilitation. However, the absolute change in morphine consumption and VAS scores did not exceed the reported minimal clinically important differences (morphine consumption: 10 mg; VAS scores: 1.5 at rest and 1.8 during movement). The two groups showed no difference in quadriceps muscle strength and postoperative complications.ConclusionPENG block combined with LIA could improve postoperative pain relief, reduce opioid use, and enhance recovery in total hip arthroplasty patients, without weakening the quadriceps muscle strength. This work justifies further trials to examine the safety and efficacy of this block and to explore maximal effective volume of local anesthetic for motor-sparing PENG block.     

不同镇痛方法在儿童漏斗胸Nuss手术术后的应用

背景漏斗胸（pectus excavatum,PE）为最常见的先天性胸廓畸形,Nuss手术为目前常用的手术方式,虽属微创手术,但术后疼痛剧烈,严重影响患儿术后恢复及生活质量。良好的镇痛能促进康复并提高患儿及家属满意度,故Nuss手术术后镇痛具有重要意义。目的对儿童PENuss手术术后镇痛的研究进展予以综述。内容常用的镇痛方式有静脉镇痛、胸段硬膜外镇痛、肋间神经阻滞、椎旁神经阻滞及多模式镇痛等,另外催眠疗法及术后焦虑处理对Nuss术后疼痛也有一定缓解作用。趋向上诉镇痛方法各有优缺点,如何根据患者及医院情况为Nuss手术患儿制定个性化的术后镇痛方案仍待进一步研究。     

Initial Outcomes Using Cryoablation in Surgical Management of Slipping Rib Syndrome

IntroductionMinimally invasive repair of pectus excavatum (MIRPE) and cartilaginous rib excision (CRE) for slipping rib syndrome (SRS) are painful procedures. Intercostal nerve cryoablation (Cryo) controls pain and decreases opioid use in MIRPE. Herein, we describe our experience with cryoablation in CRE.MethodsA retrospective chart review was performed of all patients undergoing CRE between 2018 and 2022. Data on demographics, clinical characteristics, operative details, and hospital course were collected.ResultsA total of 98 patients underwent CRE: 68 CRE without cryo, 22 CRE + Cryo, and 8 combined MIRPE + CRE + Cryo. Ninety percent of patients underwent bioabsorbable rib plating. Patients were predominantly female (79%, 73%, 50% respectively) with median ages 17.6, 16.9, and 14.2 years respectively. CRE + Cryo patients used significantly less opioids in hospital (0.6 OME/kg [0.1,1.2]) compared to CRE without cryo (1.0 OME/kg [0.6,2.1]), p < 0.05. The median length of stay (LOS) in CRE + Cryo was 1 day [1,2] compared to 2 days in CRE without cryo [1,2], p = 0.09. MIRPE + CRE + Cryo patients used 0.6 OME/kg [0.2,8.0] with a 2 day [1,5.5] LOS. Ninety-one percent of Cryo patients had cryoablation of T9 and/or T10 intercostal nerves, with no documented abdominal wall laxity at median follow-up of 16 days. Cryo was applied extra-thoracically in CRE + cryo without thoracoscopy or lung isolation, while MIRPE + CRE + Cryo used a combination extra-/intra-thoracic cryoablation in with thoracoscopy.ConclusionIntercostal nerve cryoablation reduces opioid use and LOS in patients undergoing cartilaginous rib excision for slipping rib syndrome. Cryotherapy to as low as T10 did not result in abdominal wall laxity and can be applied extra-thoracically without the need for thoracoscopy. Ongoing prospective studies are required to assess the long-term outcomes.Level of evidenceIII.     

Feasibility of combined paravertebral block and subcostal transversus abdominis plane block in postoperative pain control after minimally invasive esophagectomy

ObjectivesSubcostal transversus abdominis plane (TAP) block and paravertebral block (PVB) offer postoperative analgesia for laparoscopic and thoracoscopic surgery, respectively. We investigated the early postoperative analgesic effects of PVB in combination with subcostal TAP block in patients undergoing minimally invasive esophagectomy (MIE) for esophageal cancer.MethodsSeventeen patients undergoing MIE without nerve block for postoperative analgesia and 16 patients undergoing MIE with PVB and subcostal TAP block for postoperative analgesia were enrolled for the study. The surgeon performed PVB with bupivacaine at T4, T6, and T8 levels under video-assisted thoracoscopy at the end of the thoracoscopic stage. The anesthesiologist responsible for the anesthesia performed ultrasound-guided bilateral subcostal TAP with bupivacaine at the end of the surgery. Postoperative morphine consumption, pain severity, vital capacity, intensive care unit (ICU) stay, and complication rate were compared between groups.ResultsThe group receiving nerve blocks consumed less morphine on postoperative Day 0 (p = 0.016), experienced lower levels of pain at postoperative 0 hour (p = 0.005) and 2 hours (p = 0.049), and had a shorter ICU stay (p = 0.02). No between-group differences in postoperative vital capacity and respiratory complications were observed.ConclusionPVB in combination with subcostal TAP block could reduce morphine consumption and pain severity in the early postoperative period but did not offer other clinical benefits in MIE.     

Significant reduction of postoperative pain and opioid analgesics requirement with an Enhanced Recovery After Thoracic Surgery protocol

ObjectiveTo evaluate differences in postoperative pain control and opioids requirement in thoracic surgical patients following implementation of an Enhanced Recovery after Thoracic Surgery protocol with a comprehensive postoperative pain management strategy.Material and MethodsA retrospective analysis of a prospectively maintained database of patients undergoing pulmonary resections by robotic thoracoscopy or thoracotomy from January 1, 2017, to January 31, 2019, was conducted. Multimodal pain management strategy (opioid-sparing analgesics, infiltration of liposomal bupivacaine to intercostal spaces and surgical sites, and elimination of thoracic epidural analgesia use in thoracotomy patients) was implemented as part of Enhanced Recovery after Thoracic Surgery on February 1, 2018. Outcome metrics including patient-reported pain levels, in-hospital and postdischarge opioids use, postoperative complications, and length of stay were compared before and after protocol implementation.ResultsIn total, 310 robotic thoracoscopy and 62 thoracotomy patients met the inclusion criteria. This pain management strategy was associated with significant reduction of postoperative pain in both groups with an overall reduction of postoperative opioids requirement. Median in-hospital opioids use (morphine milligram equivalent per day) was reduced from 30 to 18.36 (P = .009) for the robotic thoracoscopy group and slightly increased from 15.48 to 21.0 (P = .27) in the thoracotomy group. More importantly, median postdischarge opioids prescribed (total morphine milligram equivalent) was significantly reduced from 480.0 to 150.0 (P < .001) and 887.5 to 150.0 (P < .001) for the thoracoscopy and thoracotomy groups, respectively. Similar short-term perioperative outcomes were observed in both groups before and following protocol implementation.ConclusionsImplementation of Enhanced Recovery after Thoracic Surgery allows safe elimination of epidural use, better pain control, and less postoperative opioids use, especially a drastic reduction of postdischarge opioid need, without adversely affecting outcomes.     

The impact of dexamethasone as a perineural additive to ropivacaine for PECS II blockade in patients undergoing unilateral radical mastectomy – A prospective,randomized, controlled and double-blinded trial

Study objectiveDexamethasone is commonly used as an adjuvant to local anesthetics to prolong duration of peripheral nerve blocks with minimal side-effects. The present study investigates the efficacy of dexamethasone added to ropivacaine 0.2% as compared to ropivacaine 0.2% alone for pectoral nerves block II (PECS II) in unilateral radical mastectomy.DesignA prospective, randomized, controlled and double-blinded trial.SettingThe study was performed at Innsbruck Medical University Hospital, Austria, between January 2019 and October 2020.PatientsSixty female patients with an American Society of Anesthesiologists Score I-II (18–90 years, BMI 18–35) scheduled for unilateral radical mastectomy without one-stage immediate autologous breast reconstruction were randomly assigned to receive PECS II block with ropivacaine 0.2% with or without dexamethasone 8 mg.InterventionsPatients were randomly assigned to receive PECS II block with ropivacaine 0.2% with or without dexamethasone 8 mg.MeasurementsPrimary outcome parameter was the cumulative opioid consumption during the first 72 postoperative hours. Secondary outcome parameters were the duration of analgesia and the course of the visual analogue scale (VAS) and the area under the curve VAS (AUC-VAS).Main resultsThere was no difference in cumulative opioid consumption after 72 h between the ropivacaine 0.2% plus dexamethasone group and the ropivacaine 0.2% plus placebo group (11.89 vs 11.90 morphine milligram equivalent, respectively; p 0.831). Duration of analgesia also did not differ significantly between the ropivacaine 0.2% plus dexamethasone group and the ropivacaine 0.2% plus placebo group (12.75 versus 8.75 h, respectively; p 0.680). There also was no difference in the course of VAS and AUC-VAS.ConclusionsDexamethasone 8 mg when added to ropivacaine 0.2% for PECS II block in unilateral radical mastectomy was not found to reduce total opioid consumption over 72 postoperative hours or to prolong duration of analgesia as compared to pure ropivacaine 0.2%.     

Development of a five point enhanced recovery protocol for pectus excavatum surgery

PurposeWe implemented and evaluated an Enhanced Recovery after Surgery (ERAS) protocol for Nuss procedures consisting of patient education, bowel management, pre/post-operative transitional pain service involvement, serratus anterior plane blocks and intercostal nerve cryoablation.MethodsA 5-point ERAS protocol was implemented using multiple plan-do-study-act (PDSA) cycles. Data was collected prospectively for patients in the full ERAS protocol and retrospectively for previous patients. The primary outcome was length of stay (LOS). Secondary outcomes were opioid consumption, pain scores, protocol compliance and patient satisfaction. The impact of PDSA cycles and the ERAS protocol was quantified using statistical process control charts and Mann Whitney U test.ResultsA total of 53 patients were identified, 13 within the ERAS protocol and 40 prior to introduction. There was no difference in age, sex, or Haller index between the two cohorts. The median LOS was decreased by 3 days in the ERAS cohort (P = 0.00001). There was decreased opioid consumption on post-operative day 1 (1.47 vs 1.96 MME/kg, p = 0.009) and overall (3.12 vs 6.35 MME/kg, p = 0.0042) in the ERAS cohort. Median pain scores did not differ between cohorts. ERAS bundle element compliance was: education 92%, bowel management 100%, transitional pain involvement 100%, serratus block 100% and cryoablation 100%. The 1-month survey revealed that 92% of patients were satisfied with their experience.ConclusionOur results demonstrate significant reduction in LOS and a trend to decreasing opioid consumption in hospital following ERAS protocol implementation and support the further application of ERAS protocols in pediatrics.Level of evidence:III – Retrospective comparative study.