Epidural versus PCA Pain Management after Pectus Excavatum Repair: A Multi-Institutional Prospective Randomized Trial

Abstract

Introduction Postoperative pain control remains the primary reason for inpatient stay after minimally invasive repair of pectus excavatum. In a previous study, our group reported that early pain control was better in patients managed with a thoracic epidural, while late pain control was better in patients managed with patient-controlled analgesia (PCA). After revising our epidural transition and modifying the PCA protocol, we conducted a multi-institutional prospective randomized trial to evaluate these two pain control strategies.

Materials and Methods Patients were randomized to epidural or PCA following minimally invasive repair of pectus excavatum with standard protocols for each arm. Primary outcome was length of stay with secondary variables including mean patient pain scores, complications, and parental satisfaction. Scores were pooled for the two groups and reported as means with standard deviation. Results were compared using t-tests and one-way analysis of variance with p-value < 0.05 determining significance.

Results Sixty-five patients were enrolled, 32 epidural and 33 PCA. Enrollment was stopped early when we developed an alternative strategy for controlling these patients' pain. There was no difference in length of stay in hours between the two arms; epidural 111.3 ± 18.5 versus PCA 111.4 ± 51.4, p = 0.98. Longer operative time was found in the epidural group. Nine patients in the epidural group (28%) required a PCA in addition to epidural for adequate pain control. Mean pain scores were lower on postoperative day 0 in the epidural group compared with the PCA groups, but were otherwise similar.

Conclusion In our prospective randomized trial, PCA is just as effective as thoracic epidural in decreasing early postoperative pain scores after minimally invasive repair of pectus excavatum.

Keywords

PCA - epidural - pectus excavatum - postoperative pain control

• References

• 1 Nuss D, Kelly RE. Congenital chest wall deformities. In: Ashcraft KW, Holcomb GW, Murphy JP, Ostlie DJ. , eds. Ashcraft's Pediatric Surgery. 6th ed. London: Elsevier; 2014: 261-269
• 2 Croitoru DP, Kelly Jr RE, Goretsky MJ, Lawson ML, Swoveland B, Nuss D. Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients. J Pediatr Surg 2002; 37 (03) 437-445
• 3 Miller KA, Woods RK, Sharp RJ. , et al. Minimally invasive repair of pectus excavatum: a single institution's experience. Surgery 2001; 130 (04) 652-657
• 4 Molik KA, Engum SA, Rescorla FJ, West KW, Scherer LR, Grosfeld JL. Pectus excavatum repair: experience with standard and minimal invasive techniques. J Pediatr Surg 2001; 36 (02) 324-328
• 5 Park HJ, Lee SY, Lee CS, Youm W, Lee KR. The Nuss procedure for pectus excavatum: evolution of techniques and early results on 322 patients. Ann Thorac Surg 2004; 77 (01) 289-295
• 6 Swoveland B, Medvick C, Kirsh M, Thompson GK, Nuss D. The Nuss procedure for pectus excavatum correction. AORN J 2001; 74 (06) 828-841
• 7 Uemura S, Nakagawa Y, Yoshida A, Choda Y. Experience in 100 cases with the Nuss procedure using a technique for stabilization of the pectus bar. Pediatr Surg Int 2003; 19 (03) 186-189
• 8 Fonkalsrud EW. Current management of pectus excavatum. World J Surg 2003; 27 (05) 502-508
• 9 Cánovas Martínez L, Domínguez García M, Fernández Gil N, Montes Deza A, López Alonso D, Castro Méndez A. Thoracic epidural analgesia in the postoperative period of pediatric surgery for the repair of pectus excavatum and pectus carinatum [in Spanish]. Rev Esp Anestesiol Reanim 1998; 45 (04) 148-152
• 10 Futagawa K, Suwa I, Okuda T. , et al. Anesthetic management for the minimally invasive Nuss procedure in 21 patients with pectus excavatum. J Anesth 2006; 20 (01) 48-50
• 11 McBride WJ, Dicker R, Abajian JC, Vane DW. Continuous thoracic epidural infusions for postoperative analgesia after pectus deformity repair. J Pediatr Surg 1996; 31 (01) 105-107
• 12 Bohosiewicz J, Kudela G, Koszutski T. Results of Nuss procedures for the correction of pectus excavatum. Eur J Pediatr Surg 2005; 15 (01) 6-10
• 13 Cucchiaro G, Adzick SN, Rose JB, Maxwell L, Watcha M. A comparison of epidural bupivacaine-fentanyl and bupivacaine-clonidine in children undergoing the Nuss procedure. Anesth Analg 2006; 103 (02) 322-327
• 14 Gasior AC, Weesner KA, Knott EM, Poola A, St Peter SD. Long-term patient perception of pain control experience after participating in a trial between patient-controlled analgesia and epidural after pectus excavatum repair with bar placement. J Surg Res 2013; 185 (01) 12-14
• 15 St Peter SD, Weesner KA, Weissend EE. , et al. Epidural vs patient-controlled analgesia for postoperative pain after pectus excavatum repair: a prospective, randomized trial. J Pediatr Surg 2012; 47 (01) 148-153
• 16 St Peter SD, Sharp SW, Ostlie DJ, Snyder CL, Holcomb III GW, Sharp RJ. Use of a subxiphoid incision for pectus bar placement in the repair of pectus excavatum. J Pediatr Surg 2010; 45 (06) 1361-1364
• 17 Butkovic D, Kralik S, Matolic M, Kralik M, Toljan S, Radesic L. Postoperative analgesia with intravenous fentanyl PCA vs epidural block after thoracoscopic pectus excavatum repair in children. Br J Anaesth 2007; 98 (05) 677-681
• 18 St Peter SD, Weesner KA, Sharp RJ, Sharp SW, Ostlie DJ, Holcomb III GW. Is epidural anesthesia truly the best pain management strategy after minimally invasive pectus excavatum repair?. J Pediatr Surg 2008; 43 (01) 79-82
• 19 Meyer MJ, Krane EJ, Goldschneider KR, Klein NJ. Case report: neurological complications associated with epidural analgesia in children: a report of 4 cases of ambiguous etiologies. Anesth Analg 2012; 115 (06) 1365-1370
• 20 Morton NS, Errera A. APA national audit of pediatric opioid infusions. Paediatr Anaesth 2010; 20 (02) 119-125
• 21 Walker BJ, Long JB, Sathyamoorthy M. , et al; Pediatric Regional Anesthesia Network Investigators. Complications in pediatric regional anesthesia: an analysis of more than 100,000 blocks from the Pediatric Regional Anesthesia Network. Anesthesiology 2018; 129 (04) 721-732
• 22 Voepel-Lewis T, Caird MS, Tait AR. , et al. A high preoperative pain and symptom profile predicts worse pain outcomes for children after spine fusion surgery. Anesth Analg 2017; 124 (05) 1594-1602
• 23 Sujka J, Benedict LA, Fraser JD, Aguayo P, Millspaugh DL, St Peter SD. Outcomes using cryoablation for postoperative pain control in children following minimally invasive pectus excavatum repair. J Laparoendosc Adv Surg Tech A 2018; 28 (11) 1383-1386
• 24 Graves C, Idowu O, Lee S, Padilla B, Kim S. Intraoperative cryoanalgesia for managing pain after the Nuss procedure. J Pediatr Surg 2017; 52 (06) 920-924
• 25 Keller BA, Kabagambe SK, Becker JC. , et al. Intercostal nerve cryoablation versus thoracic epidural catheters for postoperative analgesia following pectus excavatum repair: preliminary outcomes in twenty-six cryoablation patients. J Pediatr Surg 2016; 51 (12) 2033-2038
• 26 Kim S, Idowu O, Palmer B, Lee SH. Use of transthoracic cryoanalgesia during the Nuss procedure. J Thorac Cardiovasc Surg 2016; 151 (03) 887-888