Pain and Anxiety Management in Minimally Invasive Repair of Pectus Excavatum (original) (raw)
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Surgical Practice, 2013
The minimally-invasive Nuss procedure has become the preferred technique for pectus excavatum repair. This procedure is still associated with significant postoperative pain, and an optimal pain-management strategy is yet to be determined. The purpose of this study was to compare the efficacy of patient-controlled analgesia (PCA) to thoracic epidural analgesia (TEA). Patients and Methods: We retrospectively reviewed 112 charts from a single paediatric centre. Patients were grouped according to pain-management strategy: 90 patients received a PCA, and 22 patients received TEA. Outcomes included length of hospitalization and daily pain scores, operating room time and duration of Foley catheterization. Results: Demographic data were similar between the two groups. The daily pain scores were not statistically different between the groups. Length of hospitalization was similar (PCA: 4.6 days, epidural: 4.3 days, P = 0.33). The PCA group required less operating room time (2:44 vs 2:58, P = 0.04) and shorter Foley catheter duration (2.1 days vs 2.5 days, P = 0.04). Conclusion: In our patient population, TEA for the Nuss procedure does not offer an advantage over PCA-centred analgesia in terms of subjective daily pain scores or length of hospital stay. The potential risks of TEA need to be carefully considered in this patient population.
The Journal of Thoracic and Cardiovascular Surgery, 2007
Objective: Minimally invasive pectus excavatum repair is a common and painful surgical procedure in children and adolescents. Adequate postoperative pain therapy is important far beyond the immediate postoperative period because sensitization to painful stimuli can cause chronic pain or higher pain levels during subsequent surgical procedures. Although data in adults favor thoracic epidural anesthesia for pain control in thoracotomy, data for adolescents and children are scarce. We tested the hypothesis that pain relief with thoracic epidural analgesia was superior to that with intravenous patient-controlled analgesia after minimally invasive pectus excavatum repair in children and adolescents. Methods: We performed a prospective randomized trial with adolescents who had undergone minimally invasive pectus excavatum repair to compare postoperative pain using two different postoperative pain therapy settings: intravenous patientcontrolled analgesia (n ϭ 20) with morphine versus continuous thoracic epidural analgesia (n ϭ 20) with 0.2% ropivacain containing 2 g/mL fentanyl.
Anesthesiology and Pain Medicine
Background: Pain is a major concern in the early postoperative phase after correction of pectus excavatum. Most studies only focus on pain management in the first days after surgery and describe methods to alleviate the pain immediately postoperatively. The severity of postoperative pain may be influenced by anxiety. So far, few studies have looked into the relationship between anxiety and postoperative pain after pectus excavatum correction. Objectives: This study aimed to investigate the correlation between preoperative anxiety and late postoperative pain scores. Methods: This was a prospective cohort study. Anxiety was assessed with the State and Trait Anxiety Inventory questionnaire. Visual analogue scale (VAS) for pain scores assessed the pain at rest and activity. Anxiety was measured before surgery and pain scores six weeks after surgery. A hierarchical linear regression analysis was performed to investigate the correlation between baseline anxiety and pain measurements six weeks after surgery. Results: In this study, 136 patients were included. State anxiety was not associated with postoperative pain (mean of pain on activity and in rest), only with pain on activity after six weeks. Age and sex were not effect modifiers in any of the models. Relevant confounding factors, although not significant, consisted of trait, sex, minor complications, epidural duration, major complications, and the number of stabilizer plates. The explained variance of state anxiety on VAS for pain scores was minimum after 6 weeks. Conclusions: Preoperative anxiety does not appear to influence postoperative pain after PE correction.
Journal of Pediatric Surgery, 2014
The minimally invasive pectus excavatum repair (MIPER) is a painful procedure. The ideal approach to postoperative analgesia is debated. We performed a systematic review and meta-analysis to assess the efficacy and safety of epidural analgesia compared to intravenous Patient Controlled Analgesia (PCA) following MIPER. We searched MEDLINE (1946-2012) and the Cochrane Library (inception-2012) for randomized controlled trials (RCT) and cohort studies comparing epidural analgesia to PCA for postoperative pain management in children following MIPER. We calculated weighted mean differences (WMD) for numeric pain scores and summarized secondary outcomes qualitatively. Of 699 studies, 3 RCTs and 3 retrospective cohorts met inclusion criteria. Compared to PCA, mean pain scores were modestly lower with epidural immediately (WMD -1.04, 95% CI -2.11 to 0.03, p=0.06), 12 hours (WMD -1.12; 95% CI -1.61 to -0.62, p<0.001), 24 hours (WMD -0.51, 95%CI -1.05 to 0.02, p=0.06), and 48 hours (WMD -0.85, 95% CI -1.62 to -0.07, p=0.03) after surgery. We found no statistically significant differences between secondary outcomes. Epidural analgesia may provide superior pain control but was comparable with PCA for secondary outcomes. Better designed studies are needed. Currently the analgesic technique should be based on patient preference and institutional resources.
Anesthesia & Analgesia, 2018
What are the postoperative analgesic strategies used to manage patients after minimally invasive pectus excavatum repair and how do their recoveries compare? • Findings: Patients managed with an epidural catheter had lower pain scores and opioid consumption compared to other treatment strategies in the early recovery period, but other goals, including mobilization and discharge, were achieved earlier in nonepidural analgesic strategies. • Meaning: Our data indicate that most patients undergoing the minimally invasive repair of pectus excavatum generally tolerate the procedure well and have mild-to-moderate pain postoperatively regardless of analgesic strategy. BACKGROUND: There are few comparative data on the analgesic options used to manage patients undergoing minimally invasive repair of pectus excavatum (MIRPE). The Society for Pediatric Anesthesia Improvement Network was established to investigate outcomes for procedures where there is significant management variability. For our first study, we established a multicenter observational database to characterize the analgesic strategies used to manage pediatric patients undergoing MIRPE. Outcome data from the participating centers were used to assess the association between analgesic strategy and pain outcomes. METHODS: Fourteen institutions enrolled patients from June 2014 through August 2015. Network members agreed to an observational methodology where each institution managed patients based on their institutional standards and protocols. There was no requirement to standardize care. Patients were categorized based on analgesic strategy: epidural catheter (EC), paravertebral catheter (PVC), wound catheter (WC), no regional (NR) analgesia, and intrathecal morphine techniques. Primary outcomes, pain score and opioid consumption by postoperative day (POD), for each technique were compared while adjusting for confounders using multivariable modeling that included 5 covariates: age, sex, number of bars, Haller index, and use of preoperative pain medication. Pain scores were analyzed using repeated-measures analysis of variance with Bonferroni correction. Opioid consumption was analyzed using a multivariable quantile regression. RESULTS: Data were collected on 348 patients and categorized based on primary analgesic strategy: EC (122), PVC (57), WC (41), NR (120), and intrathecal morphine (8). Compared to EC, daily median pain scores were higher in patients managed with PVC (POD 0), WC (POD 0, 1, 2, 3), and NR (POD 0, 1, 2), respectively (P < .001-.024 depending on group). Daily opioid requirements were higher in patients managed with PVC (POD 0, 1), WC (POD 0, 1, 2), and NR (POD 0, 1, 2) when compared to patients managed with EC (P < .001). CONCLUSIONS: Our data indicate variation in pain management strategies for patients undergoing MIRPE within our network. The results indicate that most patients have mild-to-moderate pain postoperatively regardless of analgesic management. Patients managed with EC had lower pain scores and opioid consumption in the early recovery period compared to other treatment strategies.
Pediatric Surgery International
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 decrea...
The Influence of Pain: Quality of Life after Pectus excavatum Correction
Introduction: The main indication for surgery of thoracic wall deformities (TWD) is psychological due to cosmetic complaints. The assumption is that appearances have a negative effect on self-esteem and quality of life (QoL). Correction should result in improvement. Methods: Prospective trial. QoL was assessed using the CHQ and the WHOQOL-bref. Measurements were taken before surgery (T1) and 6 weeks thereafter (T2). Results: Forty-two patients were included. WHOQOL-bref showed differences between pre-operative and six weeks past surgery on facet body image (p = 0.003). Self-esteem (CHQ) did not show a significant improvement at T2. Concerning the scores on the single step questionnaire (SSQ), 33 patients were “very” to “extremely satisfied” with appearance and increased self-esteem (p < 0.001). Concerning the domain “pain and physical complaints”, CHQ did show a significant change (p < 0.001) with more complaints at T2. Conclusion: Six weeks after surgical correction of a TWD satisfaction with the “new” chest is good; pain seems to be a problem with possible negative influence on self-esteem.