Intercostal nerve cryoablation versus thoracic epidural catheters for postoperative analgesia following pectus excavatum repair: Preliminary outcomes in twenty-six cryoablation patients.

BACKGROUND: Multimodal pain management strategies are used for analgesia following pectus excavatum repair. However, the optimal regimen has not been identified. We describe our early experience with intercostal cryoablation for pain management in children undergoing the Nuss procedure and compare early cryoablation outcomes to our prior outcomes using thoracic epidural analgesia. METHODS: A multi-institutional, retrospective review of fifty-two patients undergoing Nuss bar placement with either intercostal cryoablation (n=26) or thoracic epidural analgesia (n=26) from March 2013 to January 2016 was conducted. The primary outcome was hospital length of stay. Secondary outcomes included telemetry unit monitoring time, total intravenous narcotic use, duration of intravenous narcotic use, and postoperative complications. RESULTS: Patients who underwent intercostal cryoablation had a significant reduction in the mean hospital length of stay, time in a monitored telemetry bed, total use of intravenous narcotics, and the duration of intravenous narcotic administration when compared to thoracic epidural patients. Cryoablation patients had a slightly higher rate of postoperative complications. CONCLUSION: Intercostal cryoablation is a promising technique for postoperative pain management in children undergoing repair of pectus excavatum. This therapy results in reduced time to hospital discharge, decreased intravenous narcotic utilization, and has eliminated epidurals from our practice. LEVEL OF EVIDENCE: Retrospective study - level III.

Regional techniques as an adjunct to general anesthesia for pediatric extremity and spine surgery.

The purpose of this review is to evaluate the safety of regional anesthesia techniques performed for postoperative analgesia in anesthetized children. Pediatric regional anesthesia techniques, such as nerve blocks and neuraxial injections of either local anesthetics or narcotics, can potentially reduce postoperative pain for all children undergoing surgery. However, children may react differently to anesthesia than adults, and they usually cannot tolerate the administration of regional anesthesia unless they are under general anesthesia. During a 5-year period (1999-2004) at the Shriners Hospitals for Children Northern California, 2236 regional anesthetic procedures were performed in 1809 patients. All of the regional procedures were performed with patients under general anesthesia. Ninety-one percent (1641) of patients were for orthopaedic extremity or spine surgeries. Patients ranged from 2 months to 20 years old, with 65% (1169) between the ages of 6 months and 12 years. One thousand eleven procedures were lower extremity blocks, 646 were upper extremity blocks, and 579 were neuraxial injections. Four hundred fifty-four peripheral nerve blocks were performed in patients aged 3 years or younger. Two self-limiting complications possibly related to peripheral nerve blocks were noted. No complications were noted in patients who received neuraxial injections. This retrospective review indicates that regional anesthesia techniques performed 'under general anesthesia have a low rate of complications in children. A prospective trial is recommended to establish the efficacy and safety of this practice.