Are Foley catheters needed after minimally invasive repair of pectus excavatum?

Background

High narcotic requirements after minimally invasive repair of pectus excavatum (MIRPE) can increase the risk of urinary retention. Placement of intraoperative Foley catheters to minimize this risk is variable. This study determines the rate of urinary retention in this population to guide future practice.

Is epidural anesthesia truly the best pain management strategy after minimally invasive pectus excavatum repair?

Objective

The repair of pectus excavatum with bar placement is associated with substantial postoperative pain. Optimal pain control strategy has not been addressed with level 1 or substantial level 2 evidence. Many institutions operate under the assumption that a thoracic epidural offers the best pain control for these patients. Therefore, we conducted a retrospective evaluation to examine the validity of this assumption.

Methods

A retrospective review of patients undergoing pectus excavatum repair with bar placement from January 2000 to February 2006 was conducted. The demographic variables collected included age, sex, weight, and Haller's index scores. Outcome variables included total operating room time, number of calls to the anesthesiologist, hours of urinary catheterization, hours until complete transition to oral pain medication, length of hospitalization, and maximum pain scores for each of the first 5 postoperative days.

Results

There were a total of 203 patients, of which 188 had an epidural, compared with 15 with intravenous narcotic therapy. Of the 188 patients committed to an epidural, 65 had a failed attempt in the operating room or a dysfunctional catheter removed within 24 hours. Patients without an epidural had a shorter operating room time, less time of urinary catheterization, decreased time to complete transition to oral medication, and decreased length of hospitalization with lower maximum scores.

Conclusions

Our data challenge the assumption that routine epidural catheter placement on all patients undergoing pectus excavatum repair with bar placement offers the best pain management strategy. There is clearly a role for a prospective randomized trial to clarify the best management for these patients.     

Recent experiences with minimally invasive pectus excavatum repair “nuss procedure”

Objective: To review the new technical modifications and results of 668 patients who have had pectus excavatum repair utilizing the minimally invasive technique. Methods: A retrospective chart review was conducted of 668 patients undergoing minimally invasive pectus repair from 1987 through July 2004. Since 1997, a standardized treatment pathway was implemented. Preoperative evaluation included computed tomography (CT) scan, pulmonary function tests, and cardiac evaluations with electrocardiogram and echocardiogram. Indications for operation included at least 2 of the following: progression of the deformity, Haller CT index greater than 3.25, mitral valve prolapse, cardiac compression or displacement, pulmonary function studies that indicate restrictive or obstructive airway disease, previous failed open or minimally invasive pectus repair. Technical and design modifications since 1998 have included routine thoracoscopy, the use of an introducer/dissector for creating the substernal tunnel, elevating the sternum, and routine use of a wired lateral stabilizer and polydioxanone suture (PDS) sutures around the bar and underlying rib to prevent bar displacement. The bar is removed as an outpatient procedure in 2 to 4 years. Results: In 668 patients undergoing minimally invasive pectus repairs, single bars were used in 78.1% and double in 21.7%. Lateral stabilizers were applied in 99.8% and were wired for further stability in 71%. Bar shifts before the use of stabilizers were 14.3%, which decreased to 4.6% after stabilizers were placed and 0.8% with a wired stabilizer and PDS sutures. Results were excellent in 78.5%, good in 13.1%, fair in 4.7% and failed in 3.7% after more than 1 year post bar removal. Conclusion: The minimally invasive technique has evolved into an effective method of pectus excavatum repair. Modifications of the technique have reduced complications. Long-term results continue to be excellent.     

Use of antifibrinolytics in pediatric cardiac surgery: Where are we now?

Fibrinolytic activation is a major and preventable source of bleeding in neonates and children undergoing cardiac surgery with cardiopulmonary bypass. Based on the existing literature (adult and pediatric; cardiac and noncardiac), prophylactic administration of antifibrinolytic agents can help reduce fibrinolytic activation, and consequently reduces perioperative bleeding and the requirement for blood product transfusion. Due to the increased risk of renal failure and mortality reported in adults undergoing cardiac surgery, aprotinin should not be considered as a safe option in neonates and children. Further well‐designed studies would be required before the prophylactic administration of aprotinin could be considered in pediatric cardiac surgery. The lysine analogs, tranexamic acid and ?‐aminocaproic acid,, should be considered as safe and effective antifibrinolytic agents. Although no major side effects have been reported following the administration of lysine analogs in children undergoing cardiac surgery, high‐dose tranexamic acid should not be recommended in order to avoid the increased risk of clinical seizures. Despite the recent advances made in our understanding of the pharmacokinetics of tranexamic acid and ?‐aminocaproic acid,, the optimal plasmatic concentration to be targeted remains unknown. Further studies are therefore urgently needed to better define the optimal dose regimen to be used in neonates and children. In the meantime, the dose regimen published in the most recent pharmacokinetic studies can be used. Although no studies have assessed the effect of massive bleeding and transfusion on the plasmatic concentrations of the lysine analogs, additional boluses might be considered in the presence of bleeding and/or when signs of fibrinolytic activations are observed on viscoelastic hemostatic assays.     

Opioid use and length of stay following minimally invasive pectus excavatum repair in 436 patients – Benefits of an enhanced recovery pathway

PurposeThe purpose of this study was to determine outcomes of an enhanced recovery pathway (ERP) for minimally invasive repair of pectus excavatum (MIRPE) at a high volume center, hypothesizing it is associated with decreased opioid requirement and shorter hospital stay.MethodsPatients were categorized into pre-ERP (1998–2006), transition (2007–2011), and ERP (2012–2017) cohorts. Data were abstracted from medical records. Univariate and multivariable analyses compared opioid utilization, length of stay (LOS), and complications between cohorts. Opioids were converted to morphine daily dose per kilogram (MEDD/kg).ResultsOf 436 patients, 186 were ERP, 104 were transition, and 146 were pre-ERP. ERP was associated with decreased hospital opioid utilization (mean MEDD/kg 0.5 ± 0.2 vs 0.7 ± 0.4 vs 0.7 ± 0.8 p < .001) and shorter median LOS (3 vs 4 vs 5 days, p < .001) despite equivalent pain scores at discharge (2.7 ± 0.1 vs 2.8 ± 0.2 vs 2.9 ± 0.3, p = .73). Most ERP patients (76%) had LOS ≤ 3 days. Differences in LOS between ERP, transition, and pre-ERP persisted on multivariable analysis after adjusting for confounding factors. Post-operative complications were rare and not different between groups (p > .05).ConclusionsImplementation of our ERP was associated with decreased opioid requirement and shorter hospital stay. ERPs are a valuable tool in pediatric surgery given the current emphasis on optimizing opioid and resource utilization.Levels of EvidenceLevel III (Retrospective comparative study).     

Perioperative blood management strategies for patients undergoing total knee replacement:Where do we stand now?

Total knee replacement(TKR) is one of the most common surgeries over the last decade. Patients undergoing TKR are at high risk for postoperative anemia and furthermore for allogeneic blood transfusions(ABT). Complications associated with ABT including chills, rigor, fever, dyspnea, light-headedness should be early recognized in order to lead to a better prognosis. Therefore, perioperative blood management program should be adopted with main aim to reduce the risk of blood transfusion while maximizing hemoglobin simultaneously. Many blood conservation strategies have been attempted including preoperative autologous blood donation, acute normovolemic haemodilution, autologous blood transfusion, intraoperative cell saver, drain clamping, pneumatic tourniquet application, and the use of tranexamic acid. For practical and clinical reasons we will try to classify these strategies in three main stages/pillars: Pre-operative optimization, intra-operative and post-operative protocols. The aim of this work is review the strategies currently in use and reports our experience regarding the perioperative blood management strategies in TKR.     

Tricuspid atresia: Where are we now?

Tricuspid atresia (TA) is a complex congenital heart disease that presents with cyanosis in the neonatal period. It is invariably fatal if left untreated and requires multiple stages of palliation. Early recognition and timely surgical intervention are therefore pivotal in the management of these infants. This literature review considers the pathophysiology, presentation, investigations, and classification of TA. Moreover, it discusses the evidence upon which the latest medical and surgical treatments are based, as well as numerous recent case reports. Further work is needed to elucidate the etiology of TA, clarify the role of pharmacotherapy, and optimize the surgical management that these patients receive.     

Calcaneal fractures: Where are we now?

This review article on the current management for calcaneal fractures discusses the advantages and disadvantages of different treatment options including the problems encountered. Controversies are described and the evidence reviewed. The management of some types of displaced intra-articular calcaneal fractures remains contentious; is there a preferred stabilisation method for each type of calcaneal fracture? How constant is the “constant fragment” in an intra-articular calcaneal fracture and what is the evidence for primary arthrodesis and what is its place in these fractures?     

Xenogeneic orthotopic heart transplantation: Where are we now?

Cardiac xenotransplantation is a promising option for satisfying the unmet need for cardiac replacement. Mechanical hearts have been in development for over 40 years and only one device is currently available “off the shelf” for implantation in the United States. It took 39 years for this first approved device to be available. This device approval arose from outcomes from the rematch trial (2001) when survival in the ventricular assist device group was fifty‐two percent and twenty‐three percent at 1 and 2 years, compared with twenty‐five percent and eight percent in the medically treated group. Quality of life was significantly improved at 1 year in the ventricular assist device group. While mechanical support continues to improve, intrinsic disadvantages remain, such as thromboembolism, the need for careful anticoagulation, infection, lack of physiological response, durability and power supply. Pursuit of cardiac xenotransplantation therefore remains a potentially important contributor to the treatment of heart failure clinically. With the addition of human complement regulating proteins to the pig genome using a micro‐injection technique and the subsequent development of Gal knockout pigs using cloning technology, pre‐clinical median survival of heterotopic cardiac xenotransplants is now in excess of 3 months. A three months median survival of orthotopic cardiac xenotransplants has been proposed as a possible threshold for a clinical trial. Attention has therefore focused on the orthotopic cardiac xenotransplant pig to baboon model. There have been six operative survivors ranging from 2 to 57 days. Immunosuppression in these recipients consisted of ATG induction, tacrolimus, sirolimus, anti‐CD20 and a steroid taper. No anticoagulation was used. None of the animals died of rejection. The causes of failure largely related to the challenges of the model system. In four of the six cases rejection was minimal and the remaining two mild to moderate. Recipients were healthy and well during the post‐operative period. Biochemistry was stable. Challenges encountered during these studies have included early peri‐operative heart failure which has markedly improved with peri‐operative management. These studies have shown maintenance of normal cardiac function for up to 2 months following pig to baboon transplantation. In addition, hearts from the recipients who survived showed peri‐operative myocardial dysfunction that completely recovered post‐operatively within a few days. Outcomes of pre‐clinical orthotopic cardiac xenotransplantation continue to improve with this report describing the longest survivors to date. Porcine hearts can function normally in primates for at least 2 months. Peri‐operative cardiac dysfunction is likely avoidable and is recoverable. Reparative processes are intact in the xenotransplant setting. Cardiac xenograft rejection is well controlled on tolerable immunosuppressants. Model limitations remain a serious challenge. The powerful advantage of biologic cardiac replacement (complete implantability, intrinsic power supply, lack of need for anticoagulation and physiological responsiveness) justifies continued pre‐clinical studies. In the first instance the goal of clinical cardiac xenotransplantation will be to provide additional treatment alternatives for patients with end‐stage organ failure. The comparison on outcomes will be with other available treatments and not allotransplantation in the first instance. Research programme supported by NIH Grant A166310.     

Immunosuppression for kidney transplantation: Where are we now and where are we going?

Advances in immunosuppression have propelled kidney transplantation from a scientific curiosity to the optimal treatment for patients with end stage kidney disease. Declining rates of acute rejection have led to improvements in short term kidney transplant survival, culminating in incrementally better long term patient and allograft outcomes. Contextualized around established immune-suppressing drug targets, this review summarizes the history of the clinical science and highlights the pivotal trials that have led to present-day treatment standards at the level of both individual agents and multidrug regimens for kidney recipients. Finally, recently approved and emerging therapies are discussed, with an emphasis on challenges faced by clinicians managing this increasingly complex patient population.     

Subacromial balloon spacer – Where are we now?

IntroductionRotator cuff tears are a common cause of disability and pain. The ideal treatment for truly irreparable rotator cuffs is still debated, and one recent surgical advance is the development of the subacromial balloon spacer. This review aims to clarify the current evidence and indications for this device.MethodsA comprehensive literature search was undertaken using the MeSH search terms combining “balloon spacer” and “irreparable cuff tear”. A total of 20 studies using the balloon spacer as a treatment modality in more than two patients, were analysed.ResultsA total of 513 patients were analysed, representing 83% of those initially identified as meeting the inclusion criteria. The majority of studies recommended the device, with only four suggesting it was not recommended based on their results. Notable bias was present in the studies analysed, and there were no papers providing greater than level III evidence.ConclusionThe subacromial balloon spacer is one possible treatment option for older, low-demand patients with a full thickness rotator cuff tear involving only the supraspinatus tendon, who also have no arthritis and have preserved active elevation beyond 90°. However, the results of two large randomised prospective trials are awaited to provide satisfactory evidence regarding the use of the balloon spacer.