漏斗胸修复六年质量改进：肋间神经冷冻消融术及加速康复外科方案在接受努斯手术患者中的实施
Six Years of Quality Improvement in Pectus Excavatum Repair: Implementation of Intercostal Nerve Cryoablation and ERAS Protocols for Patients Undergoing Nuss Procedure.
作者信息
Rook Jordan M, Lee Lisa K, Wagner Justin P, Sullins Veronica F, Lee Steven L, Shekherdimian Shant, DeUgarte Daniel A, Dichter Christine E, Jen Howard C
机构信息
Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Greater Los Angeles Veterans Administration Healthcare System, Los Angeles, CA, USA; UCLA National Clinician Scholars Program, Los Angeles, CA, USA; Department of Health Policy & Management, UCLA Fielding School of Public Health, USA.
Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
出版信息
J Pediatr Surg. 2025 Feb;60(2):161634. doi: 10.1016/j.jpedsurg.2024.07.019. Epub 2024 Jul 20.
BACKGROUND
The Nuss procedure for pectus excavatum is associated with prolonged hospitalizations due to pain. We evaluated implementation of intercostal nerve cryoablation and enhanced recovery after surgery (ERAS) protocols on outcomes of Nuss procedures performed over six years at a single institution.
METHODS
This retrospective cohort study included patients who underwent Nuss procedure from 10/2017 to 09/2023. Patients received epidurals prior to 06/2019, cryoablation from 06/2019 to 07/2021, and ERAS with cryoablation and intraoperative methadone administration after 07/2021. We used multivariable linear regression to evaluate length of stay (LOS), inpatient morphine milligram equivalents (MMEs), and discharge opioids. We assessed the balancing measures of operative time, postoperative pain scores, and complications.
RESULTS
We identified 62 patients; 15 who received epidurals, 18 cryoablation, and 29 cryoablation with ERAS. Cryoablation was associated with a 62.3% (p < 0.001) decrease in length of stay, an 86.6% (p < 0.001) decrease in inpatient MMEs, and a 72.9% (p < 0.001) decrease in discharge opioids. Cryoablation was additionally associated with 24.5% (p = 0.02) longer operative times and 46.4% (p = 0.04) higher postoperative day one pain scores. Subsequent implementation of an ERAS protocol was associated with a further 82.8% (p = 0.04) decrease in discharge opioids and a 25.0% (p = 0.04) decrease in postoperative day one pain scores.
CONCLUSIONS
Over six years of quality improvement efforts, we found the implementation of cryoablation and ERAS protocols to be associated with a significant decrease in length of stay and opioid exposures. Protocolized pain management and cryoablation may work synergistically to improve outcomes without compromising patient experience.
LEVEL OF EVIDENCE
Level III - Retrospective comparative study.
背景
漏斗胸的努斯手术因疼痛导致住院时间延长。我们评估了在单一机构进行的六年努斯手术中肋间神经冷冻消融和术后加速康复（ERAS）方案的实施对手术结果的影响。
方法
这项回顾性队列研究纳入了2017年10月至2023年9月期间接受努斯手术的患者。2019年6月之前的患者接受硬膜外麻醉，2019年6月至2021年7月的患者接受冷冻消融，2021年7月之后的患者接受冷冻消融联合术中使用美沙酮的ERAS方案。我们使用多变量线性回归来评估住院时间（LOS）、住院期间吗啡毫克当量（MMEs）和出院时的阿片类药物使用量。我们评估了手术时间、术后疼痛评分和并发症等平衡指标。
结果
我们确定了62例患者；15例接受硬膜外麻醉，18例接受冷冻消融，29例接受冷冻消融联合ERAS方案。冷冻消融与住院时间减少62.3%（p < 0.001）、住院期间MMEs减少86.6%（p < 0.001）以及出院时阿片类药物使用量减少72.9%（p < 0.001）相关。冷冻消融还与手术时间延长24.5%（p = 0.02）和术后第1天疼痛评分升高46.4%（p = 0.04）相关。随后实施的ERAS方案与出院时阿片类药物使用量进一步减少82.8%（p = 0.04）和术后第1天疼痛评分降低25.0%（p = 0.04）相关。
结论
经过六年的质量改进努力，我们发现冷冻消融和ERAS方案的实施与住院时间和阿片类药物暴露量的显著减少相关。规范化的疼痛管理和冷冻消融可能协同作用以改善手术结果，而不影响患者体验。
证据水平
III级——回顾性比较研究。
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