title: Continuous chest wall ropivacaine infusion for analgesia in children undergoing Nuss procedure: a comparison with thoracic epidural.
abstract: Pain following Nuss procedure is severe and its management is challenging. Many different pain treatment modalities are currently being used, but none of them have been found to be ideal.
  
  
  
  In this retrospective review, we compare our current multimodal approach, which involves continuous ropivacaine infusion through chest wall catheters (CWC), intravenous patient-controlled analgesia (IV-PCA), and adjunctive medications (gabapentin and clonidine), with the technique that we used in the past, the thoracic epidural catheter (TEC).
  
  
  
  Following IRB approval, we performed a retrospective analysis of data on 32 patients who underwent the Nuss procedure at our institution. All children were divided into two groups: TEC group: 0.2% ropivacaine and hydromorphone 10 mcg·ml(-1) epidural infusion (n = 15) and CWC group (with IV-PCA and adjuncts [gabapentin + clonidine]): 0.2% ropivacaine infusion and hydromorphone PCA, oral gabapentin, and transdermal clonidine patch (n = 17).
  
  
  
  Both the groups were demographically similar. Average numeric pain scores were higher in the CWC group only on the day of surgery (mean ± sd: 3.79 ± 1.58 vs 2.68 ± 1.30; 95% CI: -2.16 to -0.05). Pain scores on postoperative day 1 (mean ± sd: 3.40 ± 1.59 vs 3.35 ± 1.32; 95% CI: -1.11 to 1.01), day 2 (mean± sd: 3.39 ± 1.79 vs 2.99 ± 1.06; 95% CI: -1.50 to 0.70), and on the day of discharge (DOD) (mean± sd: 3.25 ± 1.84 vs 3.99 ± 1.28; 95% CI: -0.42 to 1.89) were comparable between the groups. The CWC group needed fewer changes in the therapeutic regimen to maintain acceptable pain relief, had lower incidence of nausea and vomiting, had shorter anesthesia time, total OR time, and hospital length of stay.
  
  
  
  TEC provided better analgesia following the Nuss procedure only on the day of surgery. On the subsequent days until discharge, pain scores were comparable. However, CWC offered other advantages: it was less labor intensive and had fewer side effects, shorter OR time, and shorter hospital stay.
authors.affiliation: Department of Anesthesiology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.
authors.forename: Dinesh K
authors.initials: DK
authors.lastname: Choudhry
authors.affiliation: Department of Anesthesiology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.
authors.forename: B Randall
authors.initials: BR
authors.lastname: Brenn
authors.affiliation: Department of Anesthesiology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.
authors.forename: Karen
authors.initials: K
authors.lastname: Sacks
authors.affiliation: Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.
authors.forename: Kirk
authors.initials: K
authors.lastname: Reichard
mesh_terms: D000293:Adolescent; D000577:Amides / Q000008:administration & dosage*; D000588:Amines / Q000008:administration & dosage; D016058:Analgesia, Patient-Controlled / Q000379:methods; D000700:Analgesics / Q000008:administration & dosage; D000701:Analgesics, Opioid / Q000008:administration & dosage; D000767:Anesthesia, Epidural; D000779:Anesthetics, Local / Q000008:administration & dosage*; D003000:Clonidine / Q000008:administration & dosage; D003131:Combined Modality Therapy; D003509:Cyclohexanecarboxylic Acids / Q000008:administration & dosage; D005260:Female; D005660:Funnel Chest / Q000601:surgery*; D000077206:Gabapentin; D006801:Humans; D007263:Infusions, Parenteral; D008297:Male; D009020:Morphine / Q000008:administration & dosage; D010149:Postoperative Pain / Q000188:drug therapy*; D012189:Retrospective Studies; D000077212:Ropivacaine; D035441:Thoracic Wall / Q000187:drug effects; D005680:gamma-Aminobutyric Acid / Q000008:administration & dosage
chemical_list: D000577:Amides; D000588:Amines; D000700:Analgesics; D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D003509:Cyclohexanecarboxylic Acids; D005680:gamma-Aminobutyric Acid; D000077206:Gabapentin; D009020:Morphine; D000077212:Ropivacaine; D003000:Clonidine
keywords: multimodal approach; pain management; pectus repair; pediatric