Introduction of a novel ultrasound-guided extrathoracic sub-paraspinal block for control of perioperative pain in Nuss procedure patients.
BACKGROUND
A safe and effective method of multilevel thoracic pain control remains an elusive goal in patients undergoing the Nuss procedure. The aim of our study was to develop a nonopioid centered approach using a novel regional technique as part of a quality improvement initiative.


METHODS
The proposed ultrasound-guided technique positions multi-perforated soaker catheter deep to the paraspinal muscles from T2 to T11. The project was conducted in two phases. First, a cadaveric dissection was performed to establish the pathway of spread of local anesthetic in vivo. Second, a pilot double blind randomized control project was conducted to evaluate effectiveness of the technique in ten patients and to derive parameters necessary for the definitive future study. Outcomes were evaluated based on the narcotic requirement, pain scores and functional measures.


RESULTS
Placement of the catheters in two cadavers demonstrated reliable positioning in the subparaspinal tissue plane, and multilevel dye spread along the intercostal nerve path. In addition, a potential route of spread toward the paravertebral space along the canal accommodating dorsal ramus of the thoracic nerve was demonstrated. The pilot trial demonstrated a trend in decreased cumulative hydromorphone requirement in comparison to the control group at both 24h (0.19±0.09mg/kg vs. 0.13±0.08mg/kg p=0.72) and 48h (0.37±0.2mg/kg vs. 0.3±0.12mg/kg p=0.37). Functional performance ability was higher in the treatment group on both POD#1 (6.7±1.8 vs. 4.8±1 p=0.0495) and POD#2 (8.9±0.8 vs. 6.5±1.2 p=0.04). Pain scores were similar among the two groups (p=0.96).


CONCLUSIONS
We describe a new technique to treat multilevel thoracic pain following the Nuss procedure that is reproducible, safe, allows diminished opioid use and enhances functional recovery.
Department of Anesthesiology, Nemours Children's Clinic, Jacksonville, FL, USA,. Electronic address: RBryskin@Nemours.org.
Robert B
RB
Bryskin
Department of Surgery, Nemours Children's Clinic, Jacksonville, FL, USA. Electronic address: drobie@nemours.org.
Daniel K
DK
Robie
Fellow Mayo School of Graduate Medical Education. Electronic address: FMansfield@gmail.com.
Frederick M
FM
Mansfield
Department of Anesthesiology, Nemours Children's Clinic, Jacksonville, FL, USA,. Electronic address: drfreid@jlrmed.com.
Eugene B
EB
Freid
Mayo School of Graduate Medical Education. Electronic address: sukumvanich.siam@gmail.com.
Siam
S
Sukumvanich
D000293:Adolescent; D000701:Analgesics, Opioid / Q000008:administration & dosage; D002102:Cadaver; D057785:Catheters; D004311:Double-Blind Method; D005260:Female; D005660:Funnel Chest / Q000601:surgery*; D006801:Humans; D004091:Hydromorphone / Q000008:administration & dosage; D007366:Intercostal Muscles / Q000033:anatomy & histology / Q000000981:diagnostic imaging; D007367:Intercostal Nerves; D008297:Male; D009407:Nerve Block / Q000379:methods*; D059408:Pain Management / Q000379:methods*; D010147:Pain Measurement / Q000379:methods*; D010149:Postoperative Pain / Q000517:prevention & control*; D010865:Pilot Projects; D013909:Thorax / Q000033:anatomy & histology; D018084:Ultrasonography, Interventional / Q000379:methods*
D000701:Analgesics, Opioid; D004091:Hydromorphone
Anesthesia; Chest pain; Nerve block; Pain; Pectus excavatum; Postoperative pain; Recovery period