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Perioperative Management and In-Hospital Outcomes After Minimally Invasive Repair of Pectus Excavatum

A Multicenter Registry Report From the Society for Pediatric Anesthesia Improvement Network

Muhly, Wallis T., MD*; Beltran, Ralph J., MD; Bielsky, Alan, MD; Bryskin, Robert B., MD§; Chinn, Christopher, MD; Choudhry, Dinesh K., MD; Cucchiaro, Giovanni, MD#; Fernandez, Allison, MD**; Glover, Chris D., MD††; Haile, Dawit T., MD‡‡; Kost-Byerly, Sabine, MD§§; Schnepper, Gregory D., MD‖‖; Zurakowski, David, MS, PhD¶¶; Agarwal, Rita, MD##; Bhalla, Tarun, MD; Eisdorfer, Seth, MD; Huang, Henry, MD††; Maxwell, Lynne G., MD*; Thomas, James J., MD; Tjia, Imelda, MD††; Wilder, Robert T., MD, PhD‡‡; Cravero, Joseph P., MD¶¶

doi: 10.1213/ANE.0000000000003829
Pediatric Anesthesiology: Original Clinical Research Report

BACKGROUND: There are few comparative data on the analgesic options used to manage patients undergoing minimally invasive repair of pectus excavatum (MIRPE). The Society for Pediatric Anesthesia Improvement Network was established to investigate outcomes for procedures where there is significant management variability. For our first study, we established a multicenter observational database to characterize the analgesic strategies used to manage pediatric patients undergoing MIRPE. Outcome data from the participating centers were used to assess the association between analgesic strategy and pain outcomes.

METHODS: Fourteen institutions enrolled patients from June 2014 through August 2015. Network members agreed to an observational methodology where each institution managed patients based on their institutional standards and protocols. There was no requirement to standardize care. Patients were categorized based on analgesic strategy: epidural catheter (EC), paravertebral catheter (PVC), wound catheter (WC), no regional (NR) analgesia, and intrathecal morphine techniques. Primary outcomes, pain score and opioid consumption by postoperative day (POD), for each technique were compared while adjusting for confounders using multivariable modeling that included 5 covariates: age, sex, number of bars, Haller index, and use of preoperative pain medication. Pain scores were analyzed using repeated-measures analysis of variance with Bonferroni correction. Opioid consumption was analyzed using a multivariable quantile regression.

RESULTS: Data were collected on 348 patients and categorized based on primary analgesic strategy: EC (122), PVC (57), WC (41), NR (120), and intrathecal morphine (8). Compared to EC, daily median pain scores were higher in patients managed with PVC (POD 0), WC (POD 0, 1, 2, 3), and NR (POD 0, 1, 2), respectively (P < .001–.024 depending on group). Daily opioid requirements were higher in patients managed with PVC (POD 0, 1), WC (POD 0, 1, 2), and NR (POD 0, 1, 2) when compared to patients managed with EC (P < .001).

CONCLUSIONS: Our data indicate variation in pain management strategies for patients undergoing MIRPE within our network. The results indicate that most patients have mild-to-moderate pain postoperatively regardless of analgesic management. Patients managed with EC had lower pain scores and opioid consumption in the early recovery period compared to other treatment strategies.

From the *Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania

Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Ohio State University School of Medicine and Public Health, Columbus, Ohio

Department of Anesthesiology, Children’s Hospital of Colorado, University of Colorado School of Medicine, Denver, Colorado

§Department of Anesthesiology, Wolfson Children’s Hospital, Nemours Children’s Specialty Care, Jacksonville, Florida

Department of Anesthesiology, Children’s Hospital at Dartmouth-Hitchcock, Geisel School of Medicine Dartmouth College, Lebanon, New Hampshire

Department of Anesthesiology and Critical Care, Nemours A.I. DuPont Hospital for Children, Thomas Jefferson University School of Medicine, Wilmington, Delaware

#Department of Anesthesiology and Critical Care, Children’s Hospital Los Angeles, Los Angeles, California

**Department of Anesthesia, Perioperative and Pain Medicine, Johns Hopkins All Children’s Hospital, Johns Hopkins University School of Medicine, St Petersburg, Florida

††Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas

‡‡Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minneapolis

§§Department of Anesthesiology and Critical Care, Johns Hopkins Charlotte R. Bloomberg Children’s Center, Johns Hopkins School of Medicine, Baltimore, Maryland

‖‖Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina

¶¶Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts

##Department of Anesthesiology, Perioperative and Pain Medicine, Lucile Packard Children’s Hospital Stanford, Stanford University School of Medicine, Stanford, California.

Published ahead of print 23 August 2018.

Accepted for publication August 23, 2018.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Wallis T. Muhly, MD, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, Perelman School of Medicine of the University of Pennsylvania, 3401 Civic Center Blvd, Suite 9329, Philadelphia, PA 19104. Address e-mail to

© 2019 International Anesthesia Research Society
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