Eubanks Alicia L, Grabski David F, Pollack Jessica, Levin Daniel E, McGahren Eugene, Martin Linda W, Gander Jeffrey
Department of Surgery, University of Virginia, Charlottesville, VA, USA.
J Thorac Dis. 2021 Nov;13(11):6363-6372. doi: 10.21037/jtd-21-1314.
A major challenge associated with the Nuss procedure for pectus excavatum repair is postoperative pain control. Early Recovery Program (ERP) protocols for the Nuss procedure are becoming common, but there is a paucity of experience using liposomal bupivacaine (LB), a long-acting local anesthetic, for rib blocks in this setting. We investigated whether a protocol utilizing LB rib blocks decreased opioid use after the Nuss procedure while achieving equivalent pain control.
All adolescent patients undergoing the Nuss procedure at our institution between January 2013 and January 2021 were included. Patients were divided into a pre-intervention cohort (n=15), a transition cohort (n=4), and a post-intervention cohort (n=13). Patients in all groups received scheduled acetaminophen and non-steroidals postoperatively. The pre-intervention cohort received an opioid patient-controlled analgesia (PCA) pump postoperatively, with a transition to oral opiates. The transition and post-intervention cohorts received scheduled gabapentin in addition to intraoperative bilateral rib blocks with longer-acting local anesthetic. Rib blocks were performed using 0.25% Bupivacaine in the pre-intervention group. In the transition group, epinephrine (1 mg/kg) was added to 0.25% bupivacaine for the rib block. Following approval in patients aged 13-18 years, 1.3% LB (2.25 mg/kg) was given for a rib block in the post-intervention cohort.
Demographic and clinical variables were equivalent in all groups. Post-intervention patients received 90% fewer opioids [median morphine equivalent (MME) mg/kg] compared to the pre-intervention cohort (0.8 8.2 MME mg/kg, P<0.0001), with no significant difference in pain scores between groups. Hospital length of stay was decreased among the intervention cohort (3 4 days, P=0.002).
Significant decreases in opioid use and length of stay after the Nuss procedure were achieved by the implementation of a multimodal ERP for pain management, without increase in patient-reported pain scores.
漏斗胸修复术的努斯手术面临的一个主要挑战是术后疼痛控制。努斯手术的早期恢复计划（ERP）方案正变得越来越普遍，但在这种情况下，使用长效局部麻醉剂脂质体布比卡因（LB）进行肋骨阻滞的经验却很少。我们研究了一种利用LB肋骨阻滞的方案是否能在努斯手术后减少阿片类药物的使用，同时实现等效的疼痛控制。
纳入2013年1月至2021年1月在我院接受努斯手术的所有青少年患者。患者分为干预前队列（n = 15）、过渡队列（n = 4）和干预后队列（n = 13）。所有组的患者术后均接受定期对乙酰氨基酚和非甾体类药物治疗。干预前队列术后接受阿片类药物患者自控镇痛（PCA）泵治疗，然后过渡到口服阿片类药物。过渡队列和干预后队列除术中双侧肋骨阻滞使用长效局部麻醉剂外，还接受定期加巴喷丁治疗。干预前组使用0.25%布比卡因进行肋骨阻滞。在过渡组中，将肾上腺素（1 mg/kg）加入0.25%布比卡因中用于肋骨阻滞。在13 - 18岁患者获得批准后，干预后队列使用1.3% LB（2.25 mg/kg）进行肋骨阻滞。
所有组的人口统计学和临床变量相当。与干预前队列相比，干预后患者的阿片类药物使用量减少了90%[吗啡当量中位数（MME）mg/kg]（0.8对8.2 MME mg/kg，P < 0.0001），各组之间的疼痛评分无显著差异。干预队列的住院时间缩短（3对4天，P = 0.002）。
通过实施多模式ERP进行疼痛管理，努斯手术后阿片类药物使用量和住院时间显著减少，且患者报告的疼痛评分没有增加。
