Pain management following the Nuss procedure: a survey of practice and review.

BACKGROUND: Pectus excavatum is the most common congenital chest wall deformity. The Nuss procedure is frequently used for surgical correction and this technique has been associated with severe and prolonged post-operative pain. At the present time, the optimal analgesic strategy for managing patients following this procedure has not been determined. METHODS: A web-based survey was sent to representatives from 108 primarily pediatric hospitals in North America, Europe, Asia and Australia. One individual per institution was contacted to complete the survey on behalf of their department. RESULTS: Survey response rate was 54% and 55 institutions reported using the Nuss procedure for correction of pectus excavatum. Annual case volume is less than or equal to 25 cases in 57% of institutions, and the most common age of patients is 14 to 17 years old. A clinical protocol for patient post-operative pain management is used in 45% of institutions. Thoracic epidural is utilized as a primary analgesic modality by 91% of institutions. Concomitant use of intravenous patient-controlled analgesia is reported by 27% of institutions. Nine respondents (16%) reported that they had recently stopped performing epidurals because of surgeon preference. Referral of one or more patients annually for chronic pain management was reported in 22% of surveys. CONCLUSIONS: Post-operative pain management following the Nuss procedure is variable and poorly characterized. Clinical trials or large observational registries comparing the safety and efficacy of primary modalities and long-term outcomes are needed to enable evidence-based decision-making for the management of these patients.

Same patients, same critical events--different systems of care, different outcomes: description of a human factors approach aimed at improving the efficacy and safety of sedation/analgesia care.

The practice of sedating pediatric patients undergoing diagnostic and therapeutic procedures represents an ideal model for evaluating systems of health care delivery. We present detailed evidence of how different systems acting on the same patient under similar conditions result in very different outcomes. In contrast to epidemiological methods, our research follows a Human Factors approach of observing a small number of representative cases in great detail to characterize the critical components and processes of ideal sedation care. In this descriptive article we present a framework by which this work domain can be codified and evaluated. We conclude with a demonstration of how a patient simulator can be used to quantify responses to sedation emergencies. These data constitute the basis for innovating novel sedation care systems and strategies that will optimize safety and efficacy.

Emergence characteristics of sevoflurane compared to halothane in pediatric patients undergoing bilateral pressure equalization tube insertion.

STUDY OBJECTIVE: To compare the emergence characteristics of sevoflurane with halothane in pediatric patients having bilateral myringotomy and pressure equalization tube insertion using a highly standardized and common anesthetic technique. DESIGN: Prospective, randomized, double-blind study. SETTING: University hospital. PATIENTS: 43 ASA physical status I and II healthy pediatric outpatients scheduled for initial ear tube placement by one surgeon. INTERVENTIONS: Patients were randomized to receive either halothane or sevoflurane as their sole anesthetic drug for ear tube insertion. All patients as well as the research nurse grading emergence agitation were blinded to group assignment. No premedication was administered, and all patients received a standard dose of rectal acetaminophen for postoperative pain control. MEASUREMENT AND MAIN RESULTS: The primary outcome was the percentage of patients with emergence agitation, defined as thrashing behavior requiring physical restraint for greater than three minutes. Time to discharge from the postanesthesia care unit (PACU) and from the hospital were also compared. Sevoflurane patients had a greater incidence of emergence delirium: 57% versus 27% [95% CI (1.7%-58.1%) p = 0.047]. Time to discharge from the PACU and the hospital were longer for patients who received sevoflurane: 62 versus 50 min [95% CI (1.4-23.6) p = 0.02] and 102 versus 79 mins [95% CI (9.6-37.1) p = 0.003]. CONCLUSION: In our institution there is a trend toward greater emergence agitation in ear tube placement patients given sevoflurane versus halothane anesthesia. Further, (with our discharge criteria) patients are actually discharged from the PACU and the hospital faster when given halothane as a sole anesthetic when compared to sevoflurane.

Emergence agitation in paediatric patients after sevoflurane anaesthesia and no surgery: a comparison with halothane.

This study was designed to compare the emergence characteristics of sevoflurane with halothane anaesthesia in paediatric patients having no surgical intervention. We randomized 32 ASA I or II paediatric outpatients scheduled for magnetic resonance imaging scans to receive either halothane or sevoflurane anaesthesia. The primary outcome measure was the percentage of patients with emergence agitation, as defined by two different criteria. Time to discharge from the postanaesthesia care unit (PACU) and the secondary recovery unit (SRU) were compared. Sevoflurane patients had a greater incidence of emergence delirium when a high threshold for agitation was defined (33% vs. 0%, P = 0.010) and a lower threshold for agitation was applied (80% vs. 12%, P<0.0001). Discharge times from the PACU and the SRU were not different. We conclude that there is an increased incidence of emergence agitation with sevoflurane anaesthesia compared to halothane independent of any painful stimulus.