Pain Management
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Thoracoscopic intercostal cryoanalgesia
Pain control has always been an Achilles point of pectus excavatum surgery, and it has traditionally required a number of pain medications that included among others non-steroid anti-inflammatory drugs, opioids such as morphine or oxycodone, and epidural analgesia.
In 2016, the first reports on the use of a novel pain control method were published. This method, called “Cryoanalgesia”, consists of freezing the intercostal nerves intrathoracically (from the third or fourth to the seventh or eighth intercostal nerves bilaterally) via thoracoscopic guidance. This freezing causes axonotmesis, or “Wallerian degeneration”, an astounding effect of selective nervous degeneration that interrupts postoperative chest wall pain signaling of the nerves to the Central Nervous System for approximately six weeks. After this period, the treated nerves grow back with complete restoration of their function.
Until now, many centers worldwide have begun implementing cryoanalgesia during minimally invasive repair of pectus excavatum with unparalleled results comprised of significant decrease in hospital stays and in opioid requirements, a critical outcome amid an opioid overdose epidemic. However, operation time is extended using this pain management but patients benefit from cryoanalgesia.
Figure 1
The intercostal neurovascular bundle runs along the inferior aspect of the ribs and the nerve is the most caudal element (yellow line). The cryoprobe used for cryoanalgesia is applied in the middle of the intercostal space and pushed upwards to get as close as possible to the nerve.
Figure 2
Cryoanalgesia of the 4to intercostal nerve on the right hemithorax. To perform cryoanalgesia effectively, the cryoprobe has to be applied at the posterior area of the intercostal spaces, lateral to the change in direction of the intercostal muscles.
Figure 3
The cryoprobe is easily introduced through the chest wall. Its 30-degree angle of the tip allows a correct location of the probe at the intercostal space with minimum force.
Author
Gaston Bellia-Munzon, M.D.
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References
Kim et al. J Thorac Cardiovasc Surg. 2016
Keller et al. J Ped Surg. 2016
Parrado et al. J Laparoendos Surg. 2019
Graves et al. J Ped Surg. 2019
Dekonenko et al. J Ped Surg. 2019
Cadaval Gallardo et al. Cir Ped. 2020
Di Fiore et al. J Ped Surg. 2022
Rettig et al. J Ped Surg. 2022
Arshad et al. Ann Surg. 2022
Lai et al. J Ped Surg. 2022
Ultrasound-Guided Percutaneous Bilaleral Intercostal Nerve Cyoanalgesia
Percutaneous thoracic cryoanalgesia can be performed under deep sedation or general anesthesia. It has been described on the same day of surgery or in the 24, 48, or 72 hours prior to surgery, as an outpatient procedure or with hospital admission. The patient is positioned in the prone position with the arms abducted above the head and chest elevation or in lateral decubitus position with a 45° inclination.
Percutaneous cryoanalgesia is performed as an aseptic technique with ultrasound control. The neurovascular bundle is in relation to the lower margin of the upper rib, with a cranial-caudal vein, artery and nerve arrangement.
Figure 1a-1b: Ultrasound of the vascular-nerve package between both ribs on the pleura
A 14G peripheral venous catheter is inserted under continuous ultrasound control searching for the intercostal nerve, starting from the upper edge of the lower rib in a caudo-cranial direction with an approximate angulation of 30-45°. Hydro dissection (0.2-0.5 ml physiological saline) is advisable to locate the catheter tip and to reject the pleura and reduce the risk of pneumothorax.
Once the tip of the catheter is located, the stylet is withdrawn, the blunt tip cryoanalgesia probe is introduced, and a simple 1-2.5-minute freeze cycle with -88°C nitrogen dioxide or -70°C carbon dioxide is applied, followed by 20 to 30 seconds of thawing.
Figure 2a-2b: Ultrasound image of the intercostal space, pleura and probe tip, as well as the ice ball itself
This same procedure is repeated in all desired intercostal spaces (T3 – T7) on both sides.
Once the procedure is finished, the absence of immediate complications such as pneumothorax and hematoma are confirmed by ultrasound.
Figure 3: Sequential technique performed with an assistant.
Patients who underwent percutaneous cryoanalgesia had lower pain scores
Figure 5. Sequential technique performed with an assistant. Note the adhesive mark that
ensures the correct passage of the probe through the catheter.
and a shorter hospital stay. The average duration needed to perform the ultrasound-guided subcutaneous cryoanalgesie ranges from 56-120 minutes.
Author
Manuel Lopez, M.D.
References
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Erector Spinae Plane Catheters in Multimodal Pain Management
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Erector spinae plane (ESP) blocks were first described by Forero in 2016 for acute and chronic thoracic pain.1 In the following years, ESP catheters have been successfully used in a multimodal approach to treat postoperative pain after Nuss procedure. ESP catheters are placed by the anesthesia pain team after induction of anesthesia for the Nuss procedure. The patient is positioned in the prone position and under ultrasound guidance, bilateral ESP catheters are placed in paraspinal fascial plane of the erector spinae muscles superficial to the tips of the transverse processes of the spine. Local anesthesia (0.25% ropivacaine) is given as a bolus and then continuously infused into this plane, diffusing anteriorly to the ventral and dorsal rami of the spinal nerves, resulting in a multi-dermatomal sensory block of the anterior, posterior, and lateral chest wall. Easier to perform than thoracic epidural or paravertebral blocks, the site of catheter placement is remote from the pleura, major blood vessels, and spinal cord, and therefore there are few complications or contraindications associated with this technique. Furthermore, the anesthetic effect is preemptive prior to the pain of the procedure and the numbing effect lasts only as long as the local anesthetic that is infusing. ESP catheter infusion is supplemented by bilateral intercostal nerve blocks at the end of the case and a multimodal pain management protocol postoperatively, including opioids only as needed, muscle relaxants, ibuprofen, and acetaminophen. Patients are routinely discharged home on postop day 2 with the catheters in place. The catheters are removed at home by the caregivers on postop day 5 with detailed instructions by the pain team. Compared with epidural use, ESP ambulatory catheters demonstrated expedited discharge from hospital in 2 versus 3 days, decreased opioid use, quicker attainment of PT goals, and increased patient satisfaction.2,3 Data was also collected in the outpatient setting including pain scores, opioid use, and return ED visits/admissions which demonstrated an advantage for ESP catheters (decreased pain scores and opioid use) with no differences in return ED visits/admissions.2,3 Almost all patients had discontinued opioids by postop day 5-6. Furthermore, while there were no significant or serious complications associated with the use of ESP catheters, there was a 17% incidence of leaking at the ESP catheter site (usually minor and treated with reinforcement) and 5% risk of dislodgment of at least one of the catheters.2,3 Similar findings have been reported by others as well. 4,5
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Author
Rebeccah L. Brown, M.D.
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References
Forero et al. Reg Anesth Pain Med. 2016
Walter et al. J Pediatr Surg. 2022
Abbasian et al. Regional Anesthesia and Pain Medicine 2022
Bliss et al. J Pediatr Surg. 2022
Santana et al. World J Pediatr Surg. 2022