A comparison of paravertebral nerve block catheters and thoracic epidural catheters for postoperative analgesia following the Nuss procedure for pectus excavatum repair.

INTRODUCTION: Thoracic epidurals (TE) have been advocated as a superior method for controlling postoperative pain after repair of pectus excavatum with a Nuss procedure. However, three recent reports of permanent neurologic injury after the Nuss procedure with concurrent TE analgesia have raised concerns about the safety of this combination. Paravertebral nerve blocks (PVNB) are used successfully for analgesia of the chest, but no studies are available comparing TE and PVNB catheters for postoperative analgesia in this patient population. This study was conducted to compare the efficacy of PVNB catheters with TE catheters for postoperative analgesia in pediatric patients undergoing the Nuss procedure. METHODS: We retrospectively reviewed the medical records of 20 adolescent males undergoing a thoracoscopic Nuss procedure with either bilateral PVNB catheters (n = 10) or TE catheter (n = 10) and compared postoperative opiate consumption and pain scores. RESULTS: There were no statistically significant differences between the groups with respect to demographics, opiate consumption measured in morphine equivalents, and pain scores. DISCUSSION: In this small series, bilateral PVNB catheters resulted in equivalent opioid consumption and pain scores when compared to TE for postoperative pain management in pediatric patients undergoing the Nuss procedure. Large prospective studies are needed to further compare the efficacy, incidence of side effects, and complications of TE and PVNB catheters for postoperative analgesia in this pediatric population.

Change in Eustachian Tube Function With Balloon Dilation in Adults With Ventilation Tubes.

OBJECTIVE: Assess the changes in Eustachian tube (ET) function (ETF) with balloon dilation of Eustachian tube (BDET). STUDY DESIGN: Prospective cohort for repeated testing measures. SETTING: Clinical research center. PATIENTS: Eleven adults with at least one patent ventilation tube (VT) inserted for chronic ET dysfunction (ETD) and history of otitis media with effusion. INTERVENTIONS: Subjects with evidence of moderate to severe ETD on the side with a VT underwent unilateral BDET. MAIN OUTCOME MEASURES: Changes in ETF parameters after BDET measured by Forced Response Test (FRT), Inflation Deflation Test (IDT), and Pressure Chamber test. RESULTS: With the FRT at 11 ml/min, opening pressure (OP) decreased from 458 ±â€Š160 to 308 ±â€Š173 daPa and closing pressure (CP) from 115 ±â€Š83 to 72 ±â€Š81 daPa at the 3-month post-BDET visit. The IDT and Pressure Chamber test showed that the percentage of middle ear (ME) pressure gradient equilibrated with swallows improved from 28 ±â€Š34 to 53 ±â€Š5% for positive and from 20 ±â€Š28 to 38 ±â€Š43% for negative ME pressure. Images from the pre- and post-BDET functional CT scans did not show apparent changes in the anatomy. Comparisons of ETF test parameters pre- and post-BDET suggested that the ET was easier to open and stayed open longer after the procedure. However, during the limited duration of follow-up most subjects continued to have ETD, some requiring VT re-insertion after the study period. CONCLUSIONS: Adults with severe ETD may benefit from BDET, however ETD may not be completely resolved and patients may continue to need VTs.

Regional Anesthesia Is Cost-Effective in Preventing Unanticipated Hospital Admission in Pediatric Patients Having Anterior Cruciate Ligament Reconstruction.

BACKGROUND AND OBJECTIVES: Published studies have shown a benefit of regional anesthesia (RA) in preventing unplanned hospital admissions (UHAs) and decreasing hospital costs after orthopedic surgeries in adults but not pediatric patients. We performed a retrospective analysis to assess the effect of converting from an opioid to RA-based approach to pain management after pediatric anterior cruciate ligament (ACL) reconstruction. METHODS: The records of patients having ACL reconstruction were reviewed. Two groups, those with (n = 115) and without (n = 39) nerve blocks, were identified. Single-shot blocks or indwelling catheters were performed in the operating room (OR) or a block room. Time to discharge readiness, postoperative opiate and antiemetic consumption, hospital admission or discharge, and complications were recorded. The cost of providing RA, the change in UHA and postanesthesia care unit utilization, and subsequent financial impact were calculated. RESULTS: Regional anesthesia-based pain management was associated with a lower rate of UHA (P = 0.045), less time in postanesthesia care unit phase II (P = 0.013), and a reduction in opioid consumption (P < 0.001). Use of a dedicated RA team with a dedicated block room resulted in cost savings or neutrality, whereas RA catheters placed in the OR were associated with increased direct hospital costs. CONCLUSIONS: Regional anesthesia for pain after ACL repair in pediatric patients facilitated reliable same-day surgery discharge and significantly reduced UHAs. Single-shot blocks and blocks performed outside the OR were the most cost-effective. In addition, nerve block patients required less opioids and were ready for discharge sooner.