Reader response
Myron Yaster MD
From Jonathan Blank MD FAAA FAAPA, Pediatric Anesthesiologist, Robert Wood Johnson Barnabus Health, Newark Beth Israel Medical Center
It would be NICE, really great, to have a team to deal with small or large patients with autism spectrum disorders (ASD), however, in my world we don’t. Further, many of the patients with ASD that I see are too developmentally delayed to work with almost anyone. I have had to, uncomfortably, hold down these patients and induce anesthesia with Brutane. This requires massive human effort and risks physical and moral injury to myself, my colleagues, and the patient..
Further, this is not limited to patients with ASD. We have all taken a normal child who appears calm and loses it when in the OR even with parents present at induction and have had to quickly induce with Brutane. We are all confronted by this type of situation and until we have a fast transdermal scifi like agent, some patients will still require Brutane. A sad but real reality….
From Samuel Vanderhoek MD, Johns Hopkins University
Thank you for reviewing our group’s article in PAAD Combined erector spinae plane block with surgical intercostal nerve cryoablation for Nuss procedure. This study was conducted over a 17-month period from May 2021 through September 2022. Since then, our practice has evolved to a regimen similar to Dr. Boretsky’s at Boston Children’s, namely single-shot paravertebral blocks coupled with cryoablation. In our experience, we have found that the PVB is a reliable, dense block. Compared to an ESP, however, the PVB is technically more challenging to perform without prior training and experience. In addition to PVB and cryoablation, we have continued our "kitchen sink" multi-modal analgesic protocol including gabapentin, acetaminophen, ketorolac and diazepam as needed.
From Casey Stondell, M.D, Pediatric Anesthesiologist, Sundeep Tumber, D.O., Chief of Pediatric Anesthesia, Shriners Children’s Northern California
Thank you for the most recent PAAD highlighting the important topic of pain management in patients undergoing Nuss bar placement, known to be one of the most painful procedures performed in pediatric patients. Our institution has a busy Nuss procedure program and, over the years, we have continuously updated our perioperative protocol based on the literature and our outcomes. We clearly remember the days long ago when it was not uncommon for the length of stay to be five days or more, and when the mainstay of pain management was just a post-operative PCA; patients suffered greatly. Thoracic epidurals provided excellent pain control but came at a cost of immobilization, prolonged hospitalization, difficulty in weaning to oral analgesics, and risks inherent to epidural placement.
Our surgeons began performing cryoanalgesia for the Nuss procedure around 2015 and published their findings showing multiple benefits1. We quickly realized, however, that cryo alone was insufficient for post-operative pain management; patients still had extreme pain for the first 24 hours but did well thereafter. We initially managed this by adding multimodal analgesia and intrathecal opioid as an analgesic bridge; this worked well but also led to side effects such as nausea, itching, and sedation.
Once erector spinae plane blocks became popularized by Forero (amongst others) and we became facile with them, we began performing pre-incision thoracic ESP blocks followed by surgeon-performed intraoperative cryo. In 2020 we shared our experience in what we believe to be the first publication describing this combined technique.2 It was a small retrospective case series that admittedly had many flaws but nevertheless described the feasibility of combining ESP blocks with cryo for the Nuss procedure. We continued to use ESP blocks until 2 years ago, at which time we modified our protocol again in an attempt to achieve better/denser analgesia of the chest wall and sternum.
Our current protocol for patients undergoing the Nuss procedure includes preoperative acetaminophen, celecoxib, gabapentin (to theoretically decrease the risk of cryo-induced neuralgia, which we have seen in some patients), pre-incision single shot paravertebral blocks bilaterally at T4 utilizing a mixture of bupivacaine and liposomal bupivacaine (large volume of 20ml in each block to cover multiple levels), and intra-op cryo. We agree that PVBs are technically more challenging and may carry a higher risk of complications compared to ESP blocks but we also believe that PVBs provide denser, superior analgesia and are safe when performed or taught by those experienced in regional anesthesia. Patients continue multimodal analgesia post-operatively, and diazepam is used as a first-line breakthrough analgesic, as muscle spasms are common. Patients no longer require PCAs or scheduled opioids, and most patients use minimal PRN opioids post-operatively. Many patients go home on post-op day 1 and almost all patients are home by post-op day 2. At discharge, patients are prescribed 5 tabs of oxycodone 5mg and almost no patients request refills. We look forward to comparing outcomes between PVBs with cryo and ESP blocks with cryo in a publication in the near future. Progress truly is an amazing thing.
References
1. Keller BA, Kabagambe SK, Becker JC, Chen YJ, Goodman LF, Clark-Wronski JM, Furukawa K, Stark RA, Rahm AL, Hirose S, Raff GW. Intercostal nerve cryoablation versus thoracic epidural catheters for postoperative analgesia following pectus excavatum repair: Preliminary outcomes in twenty-six cryoablation patients. J Pediatr Surg. 2016 Dec;51(12):2033-2038. doi: 10.1016/j.jpedsurg.2016.09.034. Epub 2016 Sep 28. PMID: 27745867.
2. Stondell C, Tumber S, Raff G, et al. A Novel Approach to Pain Management for the Nuss Procedure using Erector Spinae Plane Blockade and Cryoanalgesia. Int J Anesth Res. 2020;7(4):584-588.