Randomized trial of epidural vs. subcutaneous catheters for managing pain after modified Nuss in adults

Abstract

Background: Minimally invasive repair of pectus excavatum (MIRPE) is now performed in adults. Managing adult patients' pain postoperatively has been challenging due to increased chest wall rigidity and the pressure required for supporting the elevated sternum. The optimal pain management regimen has not been determined. We designed this prospective, randomized trial to compare postoperative pain management and outcomes between thoracic epidural analgesia (TEA) and bilateral subcutaneous infusion pump catheters (On-Q).

Methods: Patients undergoing MIRPE (modified Nuss) underwent random assignment to TEA or On-Q group. Both groups received intravenous, patient-controlled opioid analgesia, with concomitant delivery of local anesthetic. Primary outcomes were length of stay (LOS), opioid use, and pain scores.

Results: Of 85 randomly assigned patients, 68 completed the study [52 men, 76.5%; mean (range) age, 32.2 (20.0-58.0) years; Haller index, 5.9 (range, 3.0-26.7)]. The groups were equally matched for preoperative variables; however, the On-Q arm had more patients (60.3%). No significant differences were found between groups in mean daily pain scores (P=0.52), morphine-equivalent opioid usage (P=0.28), or hospital stay 3.5 vs. 3.3 days (TEA vs. On-Q; P=0.55). Thirteen patients randomized to TEA refused the epidural and withdrew from the study because they perceived greater benefit of the On-Q system.

Conclusions: Postoperative pain management in adults after MIRPE can be difficult. Both continuous local anesthetic delivery by TEA and On-Q catheters with concomitant, intravenous, patient-controlled anesthesia maintained acceptable analgesia with a reasonable LOS. In our cohort, there was preference for the On-Q system for pain management.

Keywords: Minimally invasive surgery; funnel chest; pectus excavatum (PE); postoperative care; postoperative pain.

Conflict of interest statement

Dawn E. Jaroszewski discloses consulting relationship with Zimmer Biomet. The other authors have no conflicts of interest to declare.

Figures

Figure 1

Study protocol for the two groups of patients (TEA and On-Q). Both groups received only infusion of local anesthetic and standardized protocol pain regimen described in the Box 1. On-Q indicates On-Q pain relief system; TEA, thoracic epidural analgesia.

Figure 2

On-Q catheters placed by using disposable 17-gauge × 8-inch tunneling system (Model T17X8, Halyard Health) to place 7.5-cm soaker catheters (MP050-A, Halyard Health) bilaterally in the subcutaneous tissues along the anterior axilla, lateral to surgical site.

Figure 3

Mean daily pain scores of TEA and On-Q groups. There was a day effect (increasing pain over time) (P

Figure 4

Morphine-equivalent opioid use of TEA and On-Q groups. There was a day effect (increasing pain over time) (P