A MULTIMODAL APPROACH TO PERIOPERATIVE PAIN MANAGEMENT FOR THE NUSS PROCEDURE IN THE ABSENCE OF THORACIC EPIDURAL ANALGESIA, A CASE REPORT
Taylor J. Cox, MD, Treniece Eubanks, MD, Preeti Sheth, MD, Rachel Meeks, MD, Stephan Klumpp, MD
University of Miami Miller School of Medicine Department of Anesthesiology, Perioperative Medicine, and Pain Management
The Nuss Procedure has been used for the treatment of Pectus Excavatum (PE) since 1987, which has largely replaced the original method known as Ravitch procedure. The NUSS procedure consists of placing a curved steel bar under the sternum through two small incisions on the sides of the chest using thorascopic guidance. Because the sternum is forced outward and held under great pressure, the Nuss procedure results in a great deal of pain and discomfort for the patient. One study suggests the postoperative pain to be similar to that of open thoracotomy (1). A combination of general and continuous thoracic epidural anesthesia (CTEA) has become a mainstay of therapy for patients undergoing the procedure; however, there are many instances in which CTEA cannot be utilized and an alternative multimodal pain management approach must be implemented.
The patient is a 13 -year -old male (48kg) with history of pectus excavatum since birth. The deformity had continued to worsen over time and he is electively scheduled to undergo the NUSS procedure for correction of his pectus excavatum for cosmetic purposes. The patient's mother does not consent to thoracic epidural anesthesia for the procedure. General endotracheal anesthesia was provided to the patient for the surgery which lasted approximately 2 hours.
Materials and Methods
Intraoperative pain modality:
- 200mcg (4.0mcg/kg) of IV fentanyl was given in 50mcg boluses over the first 90 minutes
- 1.2mg (25mcg/kg) of IV hydromorphone was given 45 minutes prior to emergence/extubation
- An infusion of dexmedetomidine at 0.3mcg/kg/hr was maintained throughout the case and was continued during transfer of the patient from the OR to the ICU
Postoperative pain modality:
- Hydromorphone PCA, 0.3mg Q15min, max dose 1.2mg/hr x24 hours
- Acetaminophen 650mg PO Q8hr scheduled
- Ketorolac 30mg IV x1
- Oxycodone/acetaminophen 5mg/325mg PO Q4hr PRN
- Ibuprofen 600mg PO Q8hr scheduled
- Home regimen: oxycodone/acetaminophen acetaminophen 5mg/325mg PO Q4hr PRN, Ibuprofen 600mg PO Q8hr scheduled x3 days, then PRN
Exceptional pain control was maintained throughout the perioperative period without the use of CTEA as exemplified by early transition to PO medications, self-reported numeric pain scores and Wong-Baker FACES pain rating scale consistently <6 (figure 2), the ability to maintain deep breathing, and early hospital discharge. The patient had a hospital stay of 4 days compared to the average of 5.5 days (4), which includes those who received thoracic epidural anesthesia.
This case illustrates that an alternative pain management approach can be effective when CTEA is either refused or contraindicated for the NUSS procedure. There is limited data comparing patient outcomes with CTEA vs. intravenous opioids (IVPCA) in this specific group; however, the literature has shown benefit of CTEA over IVPCA for other thoracic procedures in adult and pediatric populations and CTEA remains the standard of care. In the absence of CTEA, new challenges emerge. The key element to overcoming these challenges, as this case effectively demonstrates, is not only the effective use of IVPCA, but to focus on the multifaceted nature of pain, to use drugs synergistically to combat this, and to emphasize smooth transitions from one pain modality to another. The use of dexmedetomidine infusion was a key step in achieving these goals by targeting the anxiety that often accompanies and perpetuates pain, and by establishing a smooth transition from the OR to the ICU. It is imperative to have a safe and efficacious pain management strategy when CTEA cannot be utilized in these procedures, and this case exemplifies a potential ideal strategy not only for the Nuss procedure, but also for other thoracic procedures as well.
1. Nuss D, Kelly RE., Jr A 10-year review of minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg. 1998;33:545–52. 2. Walaszczyk M, Knapik P, Misiolek H, Korlacki W. Epidural and opioid analgesia following the Nuss procedure. Med Sci Monit. 2011;17:PH81–PH86. 3. 3.Ghionzoli M, Brandigi E, Messineo A, Messeri A. Pain and Anxiety Management in Minimally Invasive Repair of Pectus Excavatum. The Korean Journal of Pain. 2012;25(4):267-271. doi:10.3344/kjp.2012.25.4.267. 4. 4. Protopapas AD, Athanasiou T. Peri-operative data on the Nuss procedure in children with pectus excavatum: independent survey of the first 20 years’ data. J Cardiothorac Surg. 2008;3:40.