Randomized trial of epidural vs. subcutaneous catheters for managing pain after modified Nuss in adults

Dawn E. Jaroszewski, M'hamed Temkit, Mennat Allah M Ewais, Todd C. Luckritz, Joshua D. Stearns, Ryan C. Craner, Brantley D. Gaitan, Harish Ramakrishna, Christopher A. Thunberg, Ricardo A. Weis, Kelly M. Myers, Marianne V. Merritt, David M. Rosenfeld

Research output: Contribution to journalArticle

11 Citations (Scopus)

Abstract

Background: Minimally invasive repair of pectus excavatum (MIRPE) is now performed in adults. Managing adult patients' pain postoperatively has been challenging due to increased chest wall rigidity and the pressure required for supporting the elevated sternum. The optimal pain management regimen has not been determined. We designed this prospective, randomized trial to compare postoperative pain management and outcomes between thoracic epidural analgesia (TEA) and bilateral subcutaneous infusion pump catheters (On-Q). Methods: Patients undergoing MIRPE (modified Nuss) underwent random assignment to TEA or On-Q group. Both groups received intravenous, patient-controlled opioid analgesia, with concomitant delivery of local anesthetic. Primary outcomes were length of stay (LOS), opioid use, and pain scores. Results: Of 85 randomly assigned patients, 68 completed the study [52 men, 76.5%; mean (range) age, 32.2 (20.0-58.0) years; Haller index, 5.9 (range, 3.0-26.7)]. The groups were equally matched for preoperative variables; however, the On-Q arm had more patients (60.3%). No significant differences were found between groups in mean daily pain scores (P=0.52), morphine-equivalent opioid usage (P=0.28), or hospital stay 3.5 vs. 3.3 days (TEA vs. On-Q; P=0.55). Thirteen patients randomized to TEA refused the epidural and withdrew from the study because they perceived greater benefit of the On-Q system. Conclusions: Postoperative pain management in adults after MIRPE can be difficult. Both continuous local anesthetic delivery by TEA and On-Q catheters with concomitant, intravenous, patient-controlled anesthesia maintained acceptable analgesia with a reasonable LOS. In our cohort, there was preference for the On-Q system for pain management.

Original languageEnglish (US)
Pages (from-to)2102-2110
Number of pages9
JournalJournal of Thoracic Disease
Volume8
Issue number8
DOIs
StatePublished - 2016

Fingerprint

Epidural Analgesia
Catheters
Pain Management
Funnel Chest
Thorax
Pain
Opioid Analgesics
Length of Stay
Postoperative Pain
Local Anesthetics
Subcutaneous Infusions
Infusion Pumps
Patient-Controlled Analgesia
Sternum
Thoracic Wall
Analgesia
Morphine
Arm
Anesthesia
Pressure

Keywords

  • Funnel chest
  • Minimally invasive surgery
  • Pectus excavatum (PE)
  • Postoperative care
  • Postoperative pain

ASJC Scopus subject areas

  • Pulmonary and Respiratory Medicine

Cite this

Jaroszewski, D. E., Temkit, M., Ewais, M. A. M., Luckritz, T. C., Stearns, J. D., Craner, R. C., ... Rosenfeld, D. M. (2016). Randomized trial of epidural vs. subcutaneous catheters for managing pain after modified Nuss in adults. Journal of Thoracic Disease, 8(8), 2102-2110. https://doi.org/10.21037/jtd.2016.06.62

Randomized trial of epidural vs. subcutaneous catheters for managing pain after modified Nuss in adults. / Jaroszewski, Dawn E.; Temkit, M'hamed; Ewais, Mennat Allah M; Luckritz, Todd C.; Stearns, Joshua D.; Craner, Ryan C.; Gaitan, Brantley D.; Ramakrishna, Harish; Thunberg, Christopher A.; Weis, Ricardo A.; Myers, Kelly M.; Merritt, Marianne V.; Rosenfeld, David M.

In: Journal of Thoracic Disease, Vol. 8, No. 8, 2016, p. 2102-2110.

Research output: Contribution to journalArticle

Jaroszewski, DE, Temkit, M, Ewais, MAM, Luckritz, TC, Stearns, JD, Craner, RC, Gaitan, BD, Ramakrishna, H, Thunberg, CA, Weis, RA, Myers, KM, Merritt, MV & Rosenfeld, DM 2016, 'Randomized trial of epidural vs. subcutaneous catheters for managing pain after modified Nuss in adults', Journal of Thoracic Disease, vol. 8, no. 8, pp. 2102-2110. https://doi.org/10.21037/jtd.2016.06.62
Jaroszewski, Dawn E. ; Temkit, M'hamed ; Ewais, Mennat Allah M ; Luckritz, Todd C. ; Stearns, Joshua D. ; Craner, Ryan C. ; Gaitan, Brantley D. ; Ramakrishna, Harish ; Thunberg, Christopher A. ; Weis, Ricardo A. ; Myers, Kelly M. ; Merritt, Marianne V. ; Rosenfeld, David M. / Randomized trial of epidural vs. subcutaneous catheters for managing pain after modified Nuss in adults. In: Journal of Thoracic Disease. 2016 ; Vol. 8, No. 8. pp. 2102-2110.
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abstract = "Background: Minimally invasive repair of pectus excavatum (MIRPE) is now performed in adults. Managing adult patients' pain postoperatively has been challenging due to increased chest wall rigidity and the pressure required for supporting the elevated sternum. The optimal pain management regimen has not been determined. We designed this prospective, randomized trial to compare postoperative pain management and outcomes between thoracic epidural analgesia (TEA) and bilateral subcutaneous infusion pump catheters (On-Q). Methods: Patients undergoing MIRPE (modified Nuss) underwent random assignment to TEA or On-Q group. Both groups received intravenous, patient-controlled opioid analgesia, with concomitant delivery of local anesthetic. Primary outcomes were length of stay (LOS), opioid use, and pain scores. Results: Of 85 randomly assigned patients, 68 completed the study [52 men, 76.5{\%}; mean (range) age, 32.2 (20.0-58.0) years; Haller index, 5.9 (range, 3.0-26.7)]. The groups were equally matched for preoperative variables; however, the On-Q arm had more patients (60.3{\%}). No significant differences were found between groups in mean daily pain scores (P=0.52), morphine-equivalent opioid usage (P=0.28), or hospital stay 3.5 vs. 3.3 days (TEA vs. On-Q; P=0.55). Thirteen patients randomized to TEA refused the epidural and withdrew from the study because they perceived greater benefit of the On-Q system. Conclusions: Postoperative pain management in adults after MIRPE can be difficult. Both continuous local anesthetic delivery by TEA and On-Q catheters with concomitant, intravenous, patient-controlled anesthesia maintained acceptable analgesia with a reasonable LOS. In our cohort, there was preference for the On-Q system for pain management.",
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T1 - Randomized trial of epidural vs. subcutaneous catheters for managing pain after modified Nuss in adults

AU - Jaroszewski, Dawn E.

AU - Temkit, M'hamed

AU - Ewais, Mennat Allah M

AU - Luckritz, Todd C.

AU - Stearns, Joshua D.

AU - Craner, Ryan C.

AU - Gaitan, Brantley D.

AU - Ramakrishna, Harish

AU - Thunberg, Christopher A.

AU - Weis, Ricardo A.

AU - Myers, Kelly M.

AU - Merritt, Marianne V.

AU - Rosenfeld, David M.

PY - 2016

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N2 - Background: Minimally invasive repair of pectus excavatum (MIRPE) is now performed in adults. Managing adult patients' pain postoperatively has been challenging due to increased chest wall rigidity and the pressure required for supporting the elevated sternum. The optimal pain management regimen has not been determined. We designed this prospective, randomized trial to compare postoperative pain management and outcomes between thoracic epidural analgesia (TEA) and bilateral subcutaneous infusion pump catheters (On-Q). Methods: Patients undergoing MIRPE (modified Nuss) underwent random assignment to TEA or On-Q group. Both groups received intravenous, patient-controlled opioid analgesia, with concomitant delivery of local anesthetic. Primary outcomes were length of stay (LOS), opioid use, and pain scores. Results: Of 85 randomly assigned patients, 68 completed the study [52 men, 76.5%; mean (range) age, 32.2 (20.0-58.0) years; Haller index, 5.9 (range, 3.0-26.7)]. The groups were equally matched for preoperative variables; however, the On-Q arm had more patients (60.3%). No significant differences were found between groups in mean daily pain scores (P=0.52), morphine-equivalent opioid usage (P=0.28), or hospital stay 3.5 vs. 3.3 days (TEA vs. On-Q; P=0.55). Thirteen patients randomized to TEA refused the epidural and withdrew from the study because they perceived greater benefit of the On-Q system. Conclusions: Postoperative pain management in adults after MIRPE can be difficult. Both continuous local anesthetic delivery by TEA and On-Q catheters with concomitant, intravenous, patient-controlled anesthesia maintained acceptable analgesia with a reasonable LOS. In our cohort, there was preference for the On-Q system for pain management.

AB - Background: Minimally invasive repair of pectus excavatum (MIRPE) is now performed in adults. Managing adult patients' pain postoperatively has been challenging due to increased chest wall rigidity and the pressure required for supporting the elevated sternum. The optimal pain management regimen has not been determined. We designed this prospective, randomized trial to compare postoperative pain management and outcomes between thoracic epidural analgesia (TEA) and bilateral subcutaneous infusion pump catheters (On-Q). Methods: Patients undergoing MIRPE (modified Nuss) underwent random assignment to TEA or On-Q group. Both groups received intravenous, patient-controlled opioid analgesia, with concomitant delivery of local anesthetic. Primary outcomes were length of stay (LOS), opioid use, and pain scores. Results: Of 85 randomly assigned patients, 68 completed the study [52 men, 76.5%; mean (range) age, 32.2 (20.0-58.0) years; Haller index, 5.9 (range, 3.0-26.7)]. The groups were equally matched for preoperative variables; however, the On-Q arm had more patients (60.3%). No significant differences were found between groups in mean daily pain scores (P=0.52), morphine-equivalent opioid usage (P=0.28), or hospital stay 3.5 vs. 3.3 days (TEA vs. On-Q; P=0.55). Thirteen patients randomized to TEA refused the epidural and withdrew from the study because they perceived greater benefit of the On-Q system. Conclusions: Postoperative pain management in adults after MIRPE can be difficult. Both continuous local anesthetic delivery by TEA and On-Q catheters with concomitant, intravenous, patient-controlled anesthesia maintained acceptable analgesia with a reasonable LOS. In our cohort, there was preference for the On-Q system for pain management.

KW - Funnel chest

KW - Minimally invasive surgery

KW - Pectus excavatum (PE)

KW - Postoperative care

KW - Postoperative pain

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