Erector Spinae Plane Block With Liposomal Bupivacaine: Analgesic Adjunct in Adult Pectus Surgery.

INTRODUCTION: Pain management may be challenging in patients undergoing pectus excavatum (PE) bar removal surgery. To enhance recovery, opioid sparing strategies with regional anesthesia including ultrasound-guided erector spinae plane block (ESPB) have been implemented. The purpose of this study was to evaluate the safety and efficacy of bilateral ESPB with a liposomal bupivacaine/traditional bupivacaine mixture as part of an enhanced patient recovery pathway. MATERIALS AND METHODS: A retrospective review of adult patients who underwent PE bar removal from January 2019 to December 2020 was performed. Perioperative data were reviewed and recorded. Patients who received ESPB were compared to historical controls (non-ESPB patients). RESULTS: A total of 202 patients were included (non-ESPB: 124 patients; ESPB: 78 patients). No adverse events were attributed to ESPB. Non-ESPB patients received more intraoperative opioids (milligram morphine equivalents; 41.8 ± 17.0 mg versus 36.7 ± 17.1, P = 0.05) and were more likely to present to the emergency department within 7 d postoperatively (4.8% versus 0%, P = 0.05) when compared to ESPB patients. No significant difference in total perioperative milligram morphine equivalents, severe pain in postanesthesia care unit (PACU), time from PACU arrival to analgesic administration, PACU length of stay, or postprocedure admission rates between groups were observed. CONCLUSIONS: In patients undergoing PE bar removal surgery, bilateral ESPB with liposomal bupivacaine was performed without complications. ESPB with liposomal bupivacaine may be considered as an analgesic adjunct to enhance recovery in patients undergoing cardiothoracic procedures but further prospective randomized clinical trials comparing liposomal bupivacaine to traditional local anesthetics with and without indwelling nerve catheters are necessary.

Safety and feasibility of transesophageal echocardiography in patients with prior esophageal surgery.

BACKGROUND: Transesophageal echocardiography (TEE) is a specialized form of cardiac ultrasound and has been associated with rare but serious complications. In patients with prior esophageal surgery, the risk of esophageal damage or the inability to perform a comprehensive and successful TEE warrants further evaluation. METHODS: Retrospective study of patients with prior esophageal surgery who underwent TEE between June 21, 2002 and October 15, 2019. Medical and echocardiographic records were reviewed for image quality and procedural complications. Post-procedure complications and 30-day all-cause mortality were collected. Evaluation by gastroenterology (GI), otolaryngology/ear, nose, throat (ENT), or thoracic surgery (TS) within 30 days of TEE was reviewed in detail. RESULTS: Ninety-five patients with prior esophageal surgery underwent 145 TEEs. The most commonly performed esophageal procedures were anti-reflux operations (89%). TEE image quality was degraded in 16% while transgastric imaging was not completed in 37% of cases. A comprehensive TEE was completed in 57% of patients with diagnostic study goals achieved in 96% of cases. Comments describing procedural difficulty were reported in 6% while comments on procedural complications occurred in 1% of cases. Post-procedure complications occurred in 1% of patients including hypotension and unplanned hospital/ICU admission. CONCLUSIONS: Concern for esophageal damage and the inability to perform a comprehensive and diagnostic TEE may limit the usefulness of TEE in patients with prior esophageal surgery. While TEE-associated complications were rare in this series, a conservative approach with a thorough pre-procedure assessment, including multi-disciplinary evaluation when appropriate, is prudent in this complex cohort of patients.