In the present study, UG-ICNBs provided superior postoperative analgesia compared with the PCIA regimen for pediatric patients undergoing the Nuss procedure. Postoperative FPS-R scores were reduced for the first 6 hours and opioid consumption decreased during the first 24 hours in the UG-ICNBs group. The patients in the UG-ICNBs group also showed a decrease in postoperative opioid-related adverse effects and length of PACU stay.
Besides conventional PCIA regimens, epidural analgesia is also effective in controlling pain after the Nuss procedure. However, for many practitioners, the risk of potential permanent neurological injury may outweigh these benefits.15,16 The addition of thoracic epidural analgesia is considered an independent risk factor for permanent neurological injury.17 Of the 5 reported cases of permanent neurological injury associated with thoracic epidural analgesia in pediatric patients, 3 were undergoing Nuss repair.18,19 In addition, epidural analgesia is associated with side effects such as pulmonary complications, urinary retention, nausea and vomiting, hypotension, and technique failure.6,7 These observations have raised concerns about the safety of thoracic epidural analgesia in combination with the Nuss procedure, particularly in children.
We compared FPS-R scores obtained at defined intervals. This scale shows a close linear relationship with the visual analog pain scales used and has been validated for children aged 4 to 16 years.13,33 Accordingly, we used this age range as an inclusion criterion and compared the efficacy of 2 different analgesia regimens. Furthermore, pain after the Nuss procedure is determined by several factors, such as deformity severity1 and patient age.1,34 A single injection may not cover all nerve segments and may be inadequate for inhibiting the noxious stimuli of the Nuss procedure. We administered bilateral multiple ICNBs, which can inhibit noxious stimuli more effectively. Moreover, we administered local anesthesia before initiation of the Nuss procedure. The patient may benefit from pre-emptive analgesia and be spared from the noxious stimuli of surgery.
Ropivacaine, a relatively long-acting local anesthetic with superior postoperative analgesic effects compared with those of lidocaine, has been used for pediatric ilioinguinal nerve blocks,35 and is a well-tolerated regional anesthetic with an efficacy that is broadly similar to that of bupivacaine. However, it may be a preferred option for the management of postoperative acute pain because of a lower propensity for motor blockade, and less neurotoxicity and cardiotoxicity.36 Compared with bupivacaine and lidocaine, ropivacaine is likely to provide a longer duration of anesthesia in digital nerve blocks.37 Further studies are required to clarify whether similar findings could be obtained for ICNBs. In the present study, UG-ICNBs decreased FPS-R scores for up to 6 hours and opioid consumption for up to 24 hours after surgery as compared with PCIA. To provide more satisfactory postoperative analgesia, the feasibility of applying longer-acting local anesthetics such as neosaxitoxin or adding epinephrine to ropivacaine for UG-ICNBs should be further investigated.
In conclusion, the present study suggests that UG-ICNBs are more effective than PCIA for postoperative analgesia in children who undergo the Nuss procedure for PE during the acute postoperative period.
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