Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States.
Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States.
J Pediatr Surg. 2023 Mar;58(3):397-404. doi: 10.1016/j.jpedsurg.2022.06.017. Epub 2022 Jul 6.
There are no optimal postoperative analgesia regimens for Nuss procedures. We compared the effectiveness of thoracic epidurals (EPI) and novel ambulatory erector spinae plane (ESP) catheters as part of multimodal pain protocols after Nuss surgery.
Data on demographics, comorbidities, perioperative details, length of stay (LOS), in hospital and post discharge pain/opioid use, side effects, and emergency department (ED) visits were collected retrospectively in children who underwent Nuss repair with EPI (N = 114) and ESP protocols (N = 97). Association of the group with length of stay (LOS), in hospital opioid use (intravenous morphine equivalents (MEq)/kg over postoperative day (POD) 0-2), and oral opioid use beyond POD7 was analyzed using inverse probability of treatment weighting (IPTW) with propensity scores, followed by multivariable regression.
Groups had similar demographics. Compared to EPI, ESP had longer block time and higher rate of ketamine and dexmedetomidine use. LOS for ESP was 2 days IQR (2, 2) compared to 3 days IQR (3, 4) for EPI (p < 0.01). Compared to EPI, ESP group had higher opioid use (in MEq/kg) intraoperatively (0.32 (IQR 0.27, 0.36) vs. 0.28 (0.24, 0.32); p < 0.01) but lower opioid use on POD 0 (0.09 (IQR 0.04, 0.17) vs. 0.11 (0.08, 0.17); p = 0.03) and POD2 (0.00 (IQR 0.00, 0.00) vs. 0.04 (0.00, 0.06) ; p < 0.01). ESP group also had lower total in hospital opioid use (0.57 (IQR 0.42, 0.73) vs.0.82 (0.71, 0.91); p < 0.01), and shorter duration of post discharge opioid use (6 days (IQR 5,8) vs. 9 days (IQR 7,12) (p < 0.01). After IPTW adjustment, ESP continued to be associated with shorter LOS (difference -1.20, 95% CI: -1.38, -1.01, p < 0.01) and decreased odds for opioid use beyond POD7 (OR 0.11, 95% CI: 0.05, 0.24); p < 0.01). However, total in hospital opioid use in MEq/kg (POD0-2) was now similar between groups (difference -0.02 (95% CI: -0.09, -0.04); p = 0.50). The EPI group had higher incidence of emesis (29% v 4%, p < 0.01), while ESP had higher catheter malfunction rates (23% v 0%; p < 0.01) but both groups had comparable ED visits/readmissions.
DISCUSSION/CONCLUSION: Compared to EPI, multimodal ambulatory ESP protocol decreased LOS and postoperative opioid use, with comparable ED visits/readmissions. Disadvantages included higher postoperative pain scores, longer block times and higher catheter leakage/malfunction.
Level III.
Nuss 手术后没有最佳的术后镇痛方案。我们比较了胸椎硬膜外镇痛（EPI）和新型门诊竖脊肌平面（ESP）导管作为 Nuss 手术后多模式镇痛方案的一部分的效果。
回顾性收集接受 EPI（N=114）和 ESP 方案（N=97）修复的儿童的人口统计学、合并症、围手术期详细信息、住院时间（LOS）、住院和出院后疼痛/阿片类药物使用、副作用和急诊就诊数据。使用倾向评分的逆概率治疗加权（IPTW）分析组与 LOS、术后第 0-2 天静脉吗啡等效物（MEq）/kg 内阿片类药物使用和术后第 7 天以上口服阿片类药物使用的相关性，然后进行多变量回归。
两组的人口统计学特征相似。与 EPI 相比，ESP 的阻滞时间更长，使用氯胺酮和右美托咪定的比例更高。ESP 的 LOS 为 2 天 IQR（2，2），而 EPI 为 3 天 IQR（3，4）（p<0.01）。与 EPI 相比，ESP 组术中阿片类药物使用（MEq/kg）更高（0.32（IQR 0.27，0.36）比 0.28（0.24，0.32）；p<0.01），但术后第 0 天（0.09（IQR 0.04，0.17）比 0.11（0.08，0.17）；p=0.03）和第 2 天（0.00（IQR 0.00，0.00）比 0.04（IQR 0.00，0.06）；p<0.01）的阿片类药物使用量较低。ESP 组住院期间阿片类药物总用量（0.57（IQR 0.42，0.73）比 0.82（0.71，0.91）；p<0.01）和出院后阿片类药物使用时间（6 天（IQR 5，8）比 9 天（IQR 7，12）；p<0.01）也较短。IPTW 调整后，ESP 与 LOS 缩短（差异-1.20，95%CI：-1.38，-1.01，p<0.01）和术后第 7 天以上阿片类药物使用减少的几率降低（OR 0.11，95%CI：0.05，0.24）；p<0.01）相关。然而，MEq/kg（POD0-2）的住院期间阿片类药物总用量现在在两组之间相似（差异-0.02（95%CI：-0.09，-0.04）；p=0.50）。EPI 组呕吐发生率（29%比 4%，p<0.01）较高，而 ESP 组导管故障发生率（23%比 0%；p<0.01）较高，但两组的急诊就诊/再入院率相似。
讨论/结论：与 EPI 相比，多模式门诊 ESP 方案可减少 LOS 和术后阿片类药物使用，且急诊就诊/再入院率相当。缺点包括术后疼痛评分较高、阻滞时间较长和导管渗漏/故障较高。
III 级。
