Multi-modal pediatric pain management with continuous ... · Multi-modal pediatric pain management...
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2014 Mayo Foundation for Medical Education and Research Multi-modal pediatric pain management with continuous paravertebral block for Nuss procedure Minimally invasive pectus excavatum repair or Nuss surgery involves placement of a steel bar under the chest wall to correct deformity; it is associated with high pain scores and potentially lengthy hospital stays. Traditional pain control regimens included patient controlled analgesia (PCA) ± epidural analgesia and more recently paravertebral block catheters (PVBC). Some comparison studies reported improved analgesia with epidurals while other studies found no difference compared to PCA. More recently, BPVC has been compared as well and it has been shown to be superior to PCA and equivalent to epidurals, but required more opioid than epidural. Epidurals potentially can provide a dense sensory block, but: • Children often do not tolerate awake thoracic epidural • Thoracic epidurals placed without imaging may result in misplacement or failure, which has been reported as high as 35% • Serious injury has been reported with epidural placement under anesthesia Neuraxial catheters are not routinely managed as home-going infusions. Our institution initiated a standardized multi-modal pain management strategy for children undergoing Nuss procedure with ultra-sound guided bilateral paravertebral catheters (BPVC) continued as a home-going infusion. Background Objectives/Study Aim • Develop a multimodal strategy to reduce opioid consumption • ultrasound-guided BPVC placement with aim of achieving consistent analgesia • To evaluate if opioid consumption and LOS has been reduced without affecting pain scores Methods • IRB approved retrospective review of case series of pediatric patients who underwent Nuss surgery • 114 patients with BPVC • 18 patients with thoracic epidural • Outcomes measured: Length of stay (hours), morphine equivalence consumption 0 to 24 and 24 to 48 hours, average pain scores while hospitalized. • Wilcoxon/Kruskal-Wallis Tests nonparametric statistical analysis was used to compare the BPVC data between the years. Results From July 27, 2010 to June 9, 2015, we had 115 consecutive patient who had BPVC with Nuss operation. We did not remove any outliers from analysis. Length of stay • Average length of stay decreased after initiation of BPVC pain management strategy from median of 120 hours pre-BPVC to median of 80 hours. • We saw a gradual decrease from 2010 with a peak in 2013 p=0.0006 Opioid consumption • Opioid consumption decreased in 2010 and subsequently every year. Figure 1 and 2 show 1 st 24 hours and 24 -48 hours of median morphine equivalence used. Pre-PVBC median morphine equivalence was 80 mg and in 2015 it was 34 mg. • The incremental decrease in trend downwards from year to year was statistically significant with p = 0.004. • Clonidine was added at end of 2012 and resulted in a dramatic decrease in opioids in the 1 st 24 hours and subsequently. Pain scores • Pain scores initially decreased from median 5/10 from pre-BPVC to lowest median of 2.8. • Overall pain scores remained stable.ificant Discussion • Length of stay: LOS decreased dramatically after BVPC initiated strategy, and then remained stable. Outliers of LOS were not associated with poor pain scores . Recent study found LOS following Nuss to be shorter with BPVC compared to epidurals. The aim of this study was to improve our protocol and not a comparative study. We improved our protocol by maximizing non-opioid analgesics including BPVC strategy that included home-infusion system; the infusion continued 2 -5 days after discharge. There are potential non-measured barriers to discharge besides adequate postoperative pain control; however they were beyond the scope of this study. Patients were discharged according to parent/ home-care-giver’s level of comfort . Pain service followed for the duration of the BPVC, and it was rare that opioid consumption increased after discharge. • Opioid consumption: Opioid consumption decreased steadily over time, in contrast to other Loftus et al. Note the significant decrease in initial 24 hour opioid requirements with the addition of clonidine to the block. • Pain score: While opioid consumption decreased, pain scores remained consistently low. BPVC probably do not provide the density of epidural block; however, the level of analgesia seems consistent based on the similarity of the opioid consumed. Conclusions • Studies have been published showing PCA, epidural, and BPVC all providing satisfactory pain control following Nuss procedure • We chose BPVC as the core regional technique in our multi-modal strategy because of the potential safety of placing them asleep, predictability in analgesia, and capacity to send home with an infusion. • Our institution’s experience with BPVC over the past 5 years shows promising trends in terms of decreased length of hospital stay; decreased opioid consumption; and stable, low pain scores. References Natalie Dean 1 MD, Christopher Moir 2 MD, Dean D. Potter 2 MD and Dawit Haile 1 MD Department of Anesthesiology 1 , Mayo Clinic; Department of Pediatric Surgery 2 , Mayo Clinic, Rochester MN Multi-modal strategy BPVC technique—see illustration: • Load: 0.25% bupivacaine with 1:200,000 epinephrine +/- 2 mcg/kg clonidine • Infusion: Lidocaine 1% 1 -2 cc/h+ 2-4 cc bolus every 4 hours Pain medications • PCA for initial 24 -36 hours, while transitioning to oral opioid • Scheduled gabapentin, acetaminophen, NSAID Improvement over time • Bent needle tip: allows easier access to paravertebral space • Scheduled boluses of the infusion: thought to maintain patency of space and volume of medication • Clonidine was added to loading dose starting late 2012 MOS 4 mg :Morphine equivalence; LOS: Length of stay (hours); PVBC: Paravertebral catheter Figure 1. Decreasing opioid consumption MSO4) from 2010 to 2015, in the 1 st 24 hours (P = 0.004) and in the subsequent 24 -48 hours (p = 0001). Figure 2. After the initial decrease with PVBC initiation, the length of stay initially decreased to ~90 hours (~3.3 days) and stayed in ~70 hours. Pain score also did not increase despite decrease in opioid consumption (p = 0.04) Table 1. Summary data before starting multi-modal strategy (pre-PVBC) and subsequent years (2010, 2011…) after PVBC was started, and the associated reduction of opioid consumption, decreasing hospital length of stay while pain scores stayed about he same. • Loftus PD, Elder CT, et al. Paravertebral regional blocks decrease length of stay following surgery for pectus excavatum in children. J Pediatr Surg. 2016 Jan;51(1):149-53. • Stroud AM, Tulanont DD, et al 2014. Epidural analgesia versus intravenous patient- controlled analgesia following minimally invasive pectus excavatum repair: a systematic review and meta-analysis. J Pediatr Surg. 2014 May;49(5):798-806.
Transcript of Multi-modal pediatric pain management with continuous ... · Multi-modal pediatric pain management...
2014 Mayo Foundation for Medical Education and Research
Multi-modal pediatric pain management with continuous paravertebral block for Nuss procedure
Minimally invasive pectus excavatum repair or Nuss surgery involves placement of a steel bar under the chest wall to correct deformity; it is associated with high pain scores and potentially lengthy hospital stays. Traditional pain control regimens included patient controlled analgesia (PCA) ± epidural analgesia and more recently paravertebral block catheters (PVBC). Some comparison studies reported improved analgesia with epidurals while other studies found no difference compared to PCA. More recently, BPVC has been compared as well and it has been shown to be superior to PCA and equivalent to epidurals, but required more opioid than epidural. Epidurals potentially can provide a dense sensory block, but: • Children often do not tolerate awake thoracic epidural • Thoracic epidurals placed without imaging may result in misplacement or
failure, which has been reported as high as 35% • Serious injury has been reported with epidural placement under
anesthesia
Neuraxial catheters are not routinely managed as home-going infusions. Our institution initiated a standardized multi-modal pain management strategy for children undergoing Nuss procedure with ultra-sound guided bilateral paravertebral catheters (BPVC) continued as a home-going infusion.
Background
Objectives/Study Aim
• Develop a multimodal strategy to reduce opioid consumption • ultrasound-guided BPVC placement with aim of achieving consistent
analgesia • To evaluate if opioid consumption and LOS has been reduced without
affecting pain scores
Methods
• IRB approved retrospective review of case series of pediatric patients who underwent Nuss surgery • 114 patients with BPVC • 18 patients with thoracic epidural
• Outcomes measured: Length of stay (hours), morphine equivalence consumption 0 to 24 and 24 to 48 hours, average pain scores while hospitalized.
• Wilcoxon/Kruskal-Wallis Tests nonparametric statistical analysis was used to compare the BPVC data between the years.
Results
From July 27, 2010 to June 9, 2015, we had 115 consecutive patient who had
BPVC with Nuss operation. We did not remove any outliers from analysis.
Length of stay
• Average length of stay decreased after initiation of BPVC pain management strategy from median of 120 hours pre-BPVC to median of 80 hours.
• We saw a gradual decrease from 2010 with a peak in 2013 p=0.0006
Opioid consumption • Opioid consumption decreased in 2010 and subsequently every year.
Figure 1 and 2 show 1st 24 hours and 24 -48 hours of median morphine equivalence used. Pre-PVBC median morphine equivalence was 80 mg and in 2015 it was 34 mg.
• The incremental decrease in trend downwards from year to year was statistically significant with p = 0.004.
• Clonidine was added at end of 2012 and resulted in a dramatic decrease in opioids in the 1st 24 hours and subsequently.
Pain scores • Pain scores initially decreased from median 5/10 from pre-BPVC to
lowest median of 2.8. • Overall pain scores remained stable.ificant
Discussion
• Length of stay: LOS decreased dramatically after BVPC initiated strategy, and then remained stable. Outliers of LOS were not associated with poor pain scores. Recent study found LOS following Nuss to be shorter with BPVC compared to epidurals. The aim of this study was to improve our protocol and not a comparative study. We improved our protocol by maximizing non-opioid analgesics including BPVC strategy that included home-infusion system; the infusion continued 2 -5 days after discharge. There are potential non-measured barriers to discharge besides adequate postoperative pain control; however they were beyond the scope of this study. Patients were discharged according to parent/ home-care-giver’s level of comfort . Pain service followed for the duration of the BPVC, and it was rare that opioid consumption increased after discharge.
• Opioid consumption: Opioid consumption decreased steadily over time, in contrast to other Loftus et al. Note the significant decrease in initial 24 hour opioid requirements with the addition of clonidine to the block.
• Pain score: While opioid consumption decreased, pain scores remained consistently low. BPVC probably do not provide the density of epidural block; however, the level of analgesia seems consistent based on the similarity of the opioid consumed.
Conclusions
• Studies have been published showing PCA, epidural, and BPVC all providing satisfactory pain control following Nuss procedure
• We chose BPVC as the core regional technique in our multi-modal strategy because of the potential safety of placing them asleep, predictability in analgesia, and capacity to send home with an infusion.
• Our institution’s experience with BPVC over the past 5 years shows promising trends in terms of decreased length of hospital stay; decreased opioid consumption; and stable, low pain scores.
References
Natalie Dean1MD, Christopher Moir2 MD, Dean D. Potter2 MD and Dawit Haile1 MD
Department of Anesthesiology1, Mayo Clinic; Department of Pediatric Surgery2, Mayo Clinic, Rochester MN
Multi-modal strategy
BPVC technique—see illustration: • Load: 0.25% bupivacaine with 1:200,000 epinephrine +/- 2 mcg/kg
clonidine • Infusion: Lidocaine 1% 1 -2 cc/h+ 2-4 cc bolus every 4 hours
Pain medications • PCA for initial 24 -36 hours, while transitioning to oral opioid • Scheduled gabapentin, acetaminophen, NSAID
Improvement over time • Bent needle tip: allows easier access to paravertebral space • Scheduled boluses of the infusion: thought to maintain patency of
space and volume of medication • Clonidine was added to loading dose starting late 2012
MOS4mg:Morphine equivalence; LOS: Length of stay (hours);
PVBC: Paravertebral catheter
Figure 1. Decreasing opioid consumption MSO4) from 2010 to 2015, in the 1st 24 hours (P = 0.004) and in the subsequent 24 -48 hours (p = 0001).
Figure 2. After the initial decrease with PVBC initiation, the length of stay initially decreased to ~90 hours (~3.3 days) and stayed in ~70 hours. Pain score also did not increase despite decrease in opioid consumption (p = 0.04)
Table 1. Summary data before starting multi-modal strategy (pre-PVBC) and subsequent years (2010, 2011…) after PVBC was started, and the associated reduction of opioid consumption, decreasing hospital length of stay while pain scores stayed about he same.
• Loftus PD, Elder CT, et al. Paravertebral regional blocks decrease length of stay following surgery for pectus excavatum in children. J Pediatr Surg. 2016 Jan;51(1):149-53.
• Stroud AM, Tulanont DD, et al 2014. Epidural analgesia versus intravenous patient-controlled analgesia following minimally invasive pectus excavatum repair: a systematic review and meta-analysis. J Pediatr Surg. 2014 May;49(5):798-806.
2014 Mayo Foundation for Medical Education and Research
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