Basic monitoring was used in the operating room (non-invasive blood pressure monitoring, continuous electrocardiogram, and pulse oximetry). A peripheral 18-G catheter was inserted and the induction of anesthesia was administered with 100 μg of fentanyl, 120 mg of propofol, 35 mg of atracurium, and 8 mg of dexamethasone. The patient was intubated with a first attempt grade 1 laryngoscopy. The maintenance of anesthesia was provided with sevoflurane at a minimun alveolar concentration of 1.0.
Following the induction of anesthesia, the patient was placed in lateral decubitus for the ESP block. Asepsis of the dorsal thoracic region was conducted followed by ultrasound-guided exploration (using a 13–16 MHz lineal ultrasound probe, Sonosite Inc., Bothewell, WA). The bilateral transverse vertebral processes were identified in a longitudinal section at the level of T6, the rhomboid major muscle, the erector muscles of the spine, and the fascia between the latter and the pulmonary pleura (Fig. 3). The puncture was performed at this level with a 22 G × 50 mm faceted tip echogenic needle, in cephalic-caudal direction. The infiltration of the local anesthetic was performed between the erector muscle of the spine and the T6 transverse process, injecting 30 mL of bupivacaine 0.25% on each side, with no associated complications.
The patient was placed in decubitus supine position and the surgical procedure began, which lasted for 1 hour. The bar was removed and the findings indicated that it was partially ossified on both sides, with right margin prevalence. The patient remained stable throughout the procedure and 30 minutes before completion of surgery, a 100 mL elastomeric pump was placed with 12.5 g of metamizole and 300 mg of diclofenac sodium, at a rate of infusion of 2 mL/hour, programed for 48 to 50 hours. No opioids were used as analgesics or during the trans/postoperative period. The neuromuscular block was reversed with 0.5 mg of atropine and 1 mg of neostigmine; the patient was then extubated free of complications.
During the immediate postoperative period and follow-up until discharge after 30 hours, the patient was assessed using the verbal analog scale (VAS) and reported pain of 0/10. During the telephone follow-up 48 hours later, the patient said he had no pain, but reported having used paracetamol (Table 1). After 2 hours in the recovery room, the pinprick test was conducted on the anterior and posterior aspect of the thorax, documenting reduced bilateral sensitivity from T2 to T11 on the anterior and posterior thoracic walls; at the left para-sternal level, the patient still had 1/3 of the sensitivity, while on the right para-sternal level, the patient reported total absence of sensitivity.
The procedure to place and remove the Ness bar is associated with several complications. In accordance with the level of deformity, pulmonary restriction, cardiac compression, and associated alterations should be considered; however, its management is invariable linked to significant postoperative pain.11 Placement and removal of the Ness bar can be extremely painful surgeries, and hence diverse anesthetic and analgesic methods have been reported in the literature, among which the most frequent one is general anesthesia using the thoracic epidural catheter.12
The thoracic epidural catheter for the management of Nuss procedures is considered the method of choice. The catheter may be in place for up to 3 days to facilitate pain management, and while the levels of analgesia are comparable with the intravenous techniques, it may take half of the time.11–13 Nonetheless, the catheter presents several frequent technical and clinical complications, that occasionally may be disastrous. The incidence of failure is up to 3.6%,14 with the possibility of sympathetic block, dural puncture, nerve and spinal cord injury,11 as well as failed placement because technically it is more difficult. Moreover, its use has been associated with extended hospital stays and higher use of opioids.13 The use of opioids is also associated with adverse effects, including nausea, vomiting, urinary retention, and constipation.15,16
Managing pain after a Nuss procedure, using only intravenous (IV) analgesic agents, has not offered clear benefits. The cases reported are usually few and contradictory, and it is not considered a reasonable option when other analgesic approaches are available.17
Multimodal pain management has recently experienced a boom in the literature, with a view to providing the most reasonable option for patient analgesia.18 This management includes the use of non-steroidal anti-inflammatory agents (NSAIDs), paracetamol, oral opiates, ketamine, gabapentin-like agents, incisional catheters, and the use of regional anesthesia.19–21 There are no reports on the removal of the Nuss bar using these techniques.
The key contribution of this case involves the high analgesic effectiveness of the ESP block, even 48 hours postop; the possibility to avoid the use of opioids; the low probability of complications, and the easy implementation of the procedure. There is limited literature describing the management of pain in Nuss procedures with the ESP block.
The multimodal approach herein described is consistent with the approach by Sánchez et al,11 that reported a case on the correction of pectus excavatum using an epidural catheter, NSAIDs, and metamizole, that resulted in satisfactory analgesia.
Nardiello and Herlitz10 is the only report using the ESP block as the primary analgesic method in the context of multimodal analgesia associated with the Nuss procedure, where satisfactory levels of analgesia were accomplished using a bilateral ESP block, in addition to metamizole, paracetamol, and IV ketoprofen, in 2 pediatric cases for the correction of pectus excavatum and pectus carinatum.
However, there are no reports on the use of the technique for the removal of the Nuss bar, which represents an additional novelty of our report.
This study may have some limitations since it is just 1 case. Though it may be logical to assume that the trauma generated by the removal of the Nuss bar is similar to the trauma resulting from the placement of the bar, this is just an assumption and not a fact. Moreover, the 48-hour follow-up was indirect, via telephone.
Notwithstanding the limitations, it may be concluded that this case points to the strong applicability of the ESP block as an element of postoperative analgesia, in the context of opioid-free multimodal analgesia in thoracic surgery, and represents an interesting field for future studies.
Protection of persons and animals. The authors declare that no experiments in human beings or animals were conducted for this research.
Confidentiality of the data. The authors declare that they have followed the protocols at their worksite on the disclosure of patient information.
Right to privacy and informed consent. The authors have obtained the informed consent of the patient described in the article and the informed consent of the mother. These documents are in the hands of the corresponding author.
The authors did not receive any sponsorship for this article.
Conflict of interests
The authors have no conflict of interests to disclose.
1. Forero M, Adhikary SD, Lopez H, et al. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain
. Reg Anesth Pain Med
2. Chin KJ, Malhas L, Perlas A. The erector spinae plane block provides visceral abdominal analgesia in bariatric surgery. A report of 3 cases. Reg Anesth Pain Med
3. Varela P. Pectus excavatum: history, and new proposals for diagnosis and treatment. Rev Med Clin Condes
4. Nuss D, Kelly R, Croitoru D, et al. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg
5. Nuss D, Obermeyer RJ, Kelly RE. Nuss bar procedure: past, present and future. Ann Cardiothorac Surg
6. Park HJ, Kim KS. Pectus bar removal: surgical technique and strategy to avoid complications. J Vis Surg
7. Nyboe C, Knudsen M, Pilegaard H. Elective pectus bar removal following Nuss procedure for pectus excavatum: a single-institution experience. Eur J Cardiothorac Surg
8. Shah SB, Hariharan U, Bhargava AK, et al. Anesthesia for minimally invasive chest wall reconstructive surgeries: our experience and review of literature. Saudi J Anaesth
9. Ladenhauf HN, Stundner O, Likar R, et al. Successful treatment of persistent pain
after pectus excavatum repair using paravertebral nerve radiofrequency thermoablation. A A Case Rep
10. Nardiello MA, Herlitz M. Bilateral single shot erector spinae plane block for pectus excavatum and pectus carinatum surgery in 2 pediatric patients. Rev Esp Anestesiol Reanim
11. Sánchez N, Lima J, Selman E, et al. Anesthetic management of pediatric patients with pectus excavatum. Rev Cuba Anestesiol Reanim
12. Patvardhan C. Anaesthetic considerations for pectus repair surgery. Review article on thoracic surgery. J Vis Surg
13. Soliman IE, Apuya JS, Fertal KM. Intravenous versus epidural analgesia after surgical repair of pectus excavatum. Am J Ther
14. Densmore J, Peterson D, Stahovic LL, et al. Initial surgical and pain
management outcomes after Nuss procedure. J Pediatr Surg
15. Muhly WT, Maxwell LG, Cravero JP. Pain
management following the Nuss procedure: a survey of practice and review. Acta Anaesthesiol Scand
16. Kolvekar S, Pilegaard H, Ashley E, et al. Pain
management using patient controlled anaesthesia in adults post Nuss procedure: an analysis with respect to patient satisfaction. J Vis Surg
17. Reinoso-Barbero F, Fernández A, Durán P, et al. Thoracic epidural analgesia vs patient-controlled analgesia with intravenous fentanyl in children treated for pectus excavatum with the Nuss procedure. Rev Esp Anestesiol Reanim
18. López-García JC, Castejón J, Moreno M, et al. Anestesia multimodal infantil: analgesia epidural. Rev Soc Esp Dolor
19. Singhal N, Jones J, Semenova J, et al. Multimodal anesthesia with the addition of methadone is superior to epidural analgesia: a retrospective comparison of intraoperative anesthetic techniques and pain
management for 124 pediatric patients undergoing the Nuss procedure. J Pediatr Surg
20. Manworren R, Anderson M, Girard ED, et al. Postoperative pain
outcomes after Nuss procedures: comparison of epidural analgesia, continuous infusion of local
anesthetic, and preoperative self-hypnosis training. J Laparoendosc Adv Surg Tech A
21. Kabagambe SK, Goodman LF, Chen YJ, et al. Subcutaneous local
anesthetic infusion could eliminate use of epidural analgesia after the Nuss procedure. Pain Manag
Funnel Chest; Nerve Block; Pain; Postoperative; Paraspinal Muscles; Anesthetics; Local; Palabras clave; Tórax en Embudo; Bloqueo Nervioso; Dolor Posoperatorio; Músculos Paraespinales; Anestésicos Locales
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