Bilateral erector spinae catheters as a component of a multimodal analgesic protocol for the Nuss procedure – another possible solution to a painful conundrum
Lynne Maxwell MD and Myron Yaster MD
Over the last several years, a proliferation of regional anesthetic techniques have been described for the severe and frequently prolonged pain endured by patients who have undergone the Nuss procedure.1 Among these are thoracic epidural, submuscular wound soaking catheters, paravertebral blocks, and cryoablation of intercostal nerves, all of which have been reported in small case series. Indeed, the proliferation of these blocks were featured in several lectures at the recent Society for Pediatric Pain Medicine and the Society for Pediatric Anesthesia meetings held last month in Tampa. In today’s PAAD we will discuss the use of bilateral erector spinae catheters, next week we will discuss cryoablation. Ideally, the efficacy and safety of these various techniques would be compared with each other through randomized controlled trials, but institutional clinical practice habits as well as culture commonly present barriers to willingness to compare the new technique (“best thing since sliced bread”) with a technique that had previously been discarded because of dissatisfaction of anesthesiologists, patients, or surgeons. These biases and difference in institutional culture have also interfered with aspirations to undertake such randomized studies on a multi-institutional basis. These barriers were what led a group of pain/regional pediatric anesthesiologists to undertake a multi-institutional registry study of perioperative analgesic interventions for Nuss procedure as well as other “rare” procedures under the auspices of the Society for Pediatric Anesthesia (SPAIN – Society for Pediatric Anesthesia Improvement Network).
At the recent SPA meeting in Tampa, Paul Stricker gave a master class on “leveraging multi-center data to define and improve practices and outcomes”. In his lecture, which in my (MY) opinion was one of the best of the meeting, Paul discussed how these collaborative networks through the development of registries have helped define best practice for a myriad of pediatric anesthetic practices, like the use of antifibrinolytics in complex cranial vault reconstructions, perioperative cardiac arrest, complications from pediatric regional anesthesia, to name just a few. Indeed, I (MY) would urge all of you to review his lecture slides when you have a moment. I know many of the SPA meeting lectures were hybrid with a virtual as well as live component. As the videos become available, I (MY) will ask the PAAD writer/reviewers to summarize them for you in forthcoming PAADs (or should I say Pediatric Anesthesia Videos of the Day?).
But I digress and back to today’s PAAD. Nuss procedures are incredibly painful with long painful recoveries. One of us (LM) participated in an investigation and publication,2 which showed minimal difference in pain control among the various techniques, albeit none included erector spinae (ESP) blocks or cryoablation. Because of the institutional and clinical difficulties (not to mention IRB and consent issues), many recent studies, such as that in today’s PAAD, have been performed under the umbrella of quality improvement, with parameters such as pain scores, supplemental analgesic intake, and length of stay (LOS) being tracked and compared with the historically recent technique performed at the same institution, with the outcomes frequently being reported in the form of run charts. Lynn Martin, at the Children’s Hospital of Seattle and former SPA president has advocated this type of research for years and made an informal presentation of using these techniques at the recent SPA meeting as well. Some of the confounders of this method may be changes in other components of the multimodal analgesic regimen from the historical time period to the intervention time period. The authors of today’s PAAD were careful to thoroughly describe all elements of their multimodal regimen, but do not detail whether any of these components changed from the historical time period. It is therefore unknown what role these changes may have played in the outcome described.
Original article
Niekoo Abbasian, Smokey J Clay, Meenu Batra, Charlotte M Walter, Vanessa A Olbrecht, Marc Mecoli, Christopher S Lee, Manu Nair, Abraar Huq, Blair E Simpson, Rebeccah L Brown, Victor F Garcia, Vidya Chidambaran. Multimodal continuous ambulatory erector spinae catheter pain protocol for early recovery following Nuss procedure: a retrospective cohort study. Reg Anesth Pain Med 2022; Jan 27 Online ahead of print. PMID: 35086901
The authors describe their institutional adoption and use over a one year period of bilateral erector spinae catheters (ultrasound-guided at T5) in 104 patients for both intraoperative and postoperative analgesia after Nuss procedure, comparing pain scores both in hospital and after discharge, supplemental opioid intake, ED visits and readmission within 30 days, and LOS with a prior period during which thoracic epidural catheters were used for analgesia.3 The authors state that the change in regional approach was motivated in part by the difficult, frequently painful transition from epidural to oral analgesia in the prior patient group.
Although the authors do not report the time for epidural placement in the prior group, time for bilateral ESP catheters was 21 minutes. Catheters were dosed with bolus 0.2% ropivacaine with dexmedetomidine (0.25 mcg/kg to max of 20 mcg) followed by an infusion of ropivacaine 0.15% with 0.5 mcg/mL clonidine at 6-8 mL/hr. After surgery, 0.15% ropivacaine was infused at 6 mL/hr with patient demand bolus of 4 mL every 6 hours. Over the time of the study, length of stay (LOS) decreased from 3.5 to 2 days. LOS with epidural had been 4 days. Very little supplemental intravenous opioid was required as well as little oral opioid, both in hospital and after discharge. Catheters were removed at home on day 5, after which there was not an increase in pain. The catheter leakage/removal rate (17.1/4.8%) was significantly higher than that previously reported for peripheral nerve catheters (1.1/1.9%).4
In an appendix to the article, the authors provide an exhaustive description of the numerous elements of the multimodal regimen, the combination of which probably contributed to the excellent outcomes in the studied patients. The complexity of this regimen and the institution’s ability to provide continued ESP catheter infusion for 3 days after discharge, are elements which require close attention in order to reproduce their results elsewhere.
We will discuss cryoablation for the Nuss procedure next week.
Lynne Maxwell MD and Myron Yaster MD
References
1. Harbaugh CM, Lee JS, Hu HM, McCabe SE, Voepel-Lewis T, Englesbe MJ, Brummett CM, Waljee JF: Persistent Opioid Use Among Pediatric Patients After Surgery. Pediatrics 2018; 141
2. Muhly WT, Beltran RJ, Bielsky A, Bryskin RB, Chinn C, Choudhry DK, Cucchiaro G, Fernandez A, Glover CD, Haile DT, Kost-Byerly S, Schnepper GD, Zurakowski D, Agarwal R, Bhalla T, Eisdorfer S, Huang H, Maxwell LG, Thomas JJ, Tjia I, Wilder RT, Cravero JP: Perioperative Management and In-Hospital Outcomes After Minimally Invasive Repair of Pectus Excavatum: A Multicenter Registry Report From the Society for Pediatric Anesthesia Improvement Network. Anesth Analg 2019; 128: 315-327
3. Abbasian N, Clay SJ, Batra M, Walter CM, Olbrecht VA, Mecoli M, Lee CS, Nair M, Huq A, Simpson BE, Brown RL, Garcia VF, Chidambaran V: Multimodal continuous ambulatory erector spinae catheter pain protocol for early recovery following Nuss procedure: a retrospective cohort study. Reg Anesth Pain Med 2022
4. Gurnaney H, Kraemer FW, Maxwell L, Muhly WT, Schleelein L, Ganesh A: Ambulatory continuous peripheral nerve blocks in children and adolescents: a longitudinal 8-year single center study. Anesth Analg 2014; 118: 621-7