Pectus Excavatum Pain Management at Cincinnati Children's Hospital
With Dr. Centel Sadai · StayCurrentMD
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Pectus Excavatum 58 items
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Nothing is as good as epidural analgesia for pectus patients; On-Q pumps come second to epidural in Cincinnati's experience.
More than 95% of Cincinnati's pectus patients do not receive PCA along with epidural.
The pain team sees pectus patients at least 3 times per day and tweaks epidural rate or position to optimize analgesia.
More than 99% of Cincinnati's pectus patients receive epidural analgesia.
Older patients and young adults have more pain after pectus repair due to chest wall rigidity.
Patients with Ehlers-Danlos syndrome have extensive pain and may have pain even before surgery.
Patients with psychological problems like depression and excessive anxiety benefit from On-Q pumps in addition to epidural.
Patients with family history of substance abuse benefit from minimizing opioid use through epidural and On-Q pump.
Pain catastrophization (anticipating negative outcomes) in children or parents is associated with more postoperative pain.
Two major risks with epidural are injury during placement (including paraplegia) and infection (epidural abscess) if the catheter is left too long.
Cincinnati places epidurals in awake patients with minimal sedation in sitting position to minimize risk of traumatic placement.
Cincinnati removes epidural catheters on the 3rd day after surgery to prevent epidural abscess.
Most neurological injury from epidural in children is from hypoperfusion of the spinal cord, not traumatic placement.
Cincinnati aggressively manages blood pressure to maintain spinal cord perfusion, reducing epidural rate and removing clonidine if blood pressure is low.
On-Q pump effectiveness depends on multiple factors: delivery amount, delivery location, catheter size and length, and introducer size relative to track.
The 5 cm On-Q catheter is too short to cover the pectus repair area; the 7.5 cm catheter is much better.
Most On-Q data in thoracic surgery is from thoracotomy with subpleural tunneling, making it difficult to extrapolate to pectus repair.
Exparel (liposomal bupivacaine) is safer than plain local anesthetic because the treatment for local anesthetic toxicity is intralipid, which Exparel already contains.
In Cincinnati's donor nephrectomy experience with Exparel TAP blocks, patients discontinue PCA one day earlier and use fewer opioids with fewer side effects.
Exparel is not FDA-approved for pediatric use.
Some patients have localized reactions to Exparel severe enough to require steroids, with reactions lasting 3 days.
Cincinnati allows patients with epidurals to walk inside the room and even outside with help because there are no narcotics in the epidural solution.
Cincinnati removes Foley catheters the day after surgery and allows ambulation, which epidural facilitates.
Cincinnati's preoperative preparation includes mandatory pain education by a pain nurse 2-3 months before surgery and optional genetic research for opioid risk.
About 20-30% of pectus patients experience chronic persistent post-operative pain, defined as pain score of 3 or more two months after surgery.
Opioids have a narrow therapeutic index: beyond a certain dose they will not relieve pain but can cause significant side effects.
If a child is on 5 consecutive days of oxycodone or any other opioid, the risk of dependence increases significantly.
With good epidural function, Cincinnati achieves zero pain scores immediately after pectus surgery in the first 2-3 days, which was unheard of 10-15 years ago.
Cincinnati uses local anesthetic-only epidural solution (no opioids), which does not cause urinary retention and is very dermatomal, blocking only thoracic dermatomes.
Most Cincinnati pectus patients are discharged on the 3rd or 4th day after surgery.
Cincinnati's epidural success rate is more than 95%, with less than 5% of patients needing PCA on top of epidural (down from 14% in 2013).
Cincinnati uses IV methadone intraoperatively and for the first 2 days; literature shows even one intraoperative dose significantly decreases pain and opioid use for 2 days.
Cincinnati uses pregabalin preoperatively; literature shows that giving pregabalin or gabapentin one hour before surgery significantly decreases postoperative pain and opioid need.
Cincinnati reduced methadone dose from 15-20 mg (adult dose) to 5 mg maximum in teenagers due to excessive sedation with higher doses combined with pregabalin and anesthesia.
Cincinnati uses IV methocarbamol routinely for muscle spasms after pectus surgery, which reduces the need for IV diazepam.
Methadone can cause QT interval prolongation; Cincinnati performs baseline EKG preoperatively and post-op day 1 EKG to ensure QT doesn't exceed 480 milliseconds.
Cincinnati alternates IV ketorolac every 6 hours with IV acetaminophen to minimize opioid use.
Less than 5% of Cincinnati's pectus patients need any IV opioid in the first 2-3 days when they have epidural.
Cincinnati delays starting oxycodone until post-op day 2 when possible to minimize opioid exposure.
For selected high-risk patients, Cincinnati places subcutaneous intercostal On-Q catheters, starting at 1 mL/hour per side with epidural, then increasing to 4-6 mL/hour per side after epidural removal.
Cincinnati stops epidural abruptly at 6 AM on post-op day 3 without weaning.
The advantage of not using opioids in epidural solution is minimal; opioids cause more problems (itching, urinary retention) than benefits. Clonidine provides the same pain relief benefits without these side effects.
Cincinnati uses high concentration ropivacaine (0.2%) in epidural solution for good pain control; lower concentrations (0.12% or 0.15%) don't provide adequate pain relief.
About 50% of patients on oxycodone develop opioid-induced constipation.
Naloxegol is similar to naloxone but doesn't cross the blood-brain barrier, so it relieves opioid-induced constipation without reversing analgesia.
Naloxegol is FDA-approved for opioid-induced constipation but not yet approved for pediatric use; Cincinnati uses it off-label.
In spine surgery patients receiving PCA (without epidural), about 15% experience respiratory depression defined as respiratory rate less than 8 breaths per minute and oxygen saturation less than 90%.
Tramadol is similar to codeine; about 80-85% of the population are intermediate or extensive metabolizers with good pain control, 10-12% are poor metabolizers with inadequate pain relief, and 1-2% are ultra-rapid metabolizers at risk for respiratory depression and death.
In Ethiopian populations, ultra-rapid metabolizers can be as high as 29%, compared to 1-2% in Cincinnati's population.
The FDA has warned against use of codeine following tonsillectomy; warnings for tramadol and hydrocodone are under FDA review.
Among currently available opioids, oxycodone is the least affected by CYP2D6 metabolism.
Cincinnati avoids oxycodone in ultra-rapid metabolizers and uses oral hydromorphone (Dilaudid) instead.
Even extensive metabolizers (normal population) with comorbidities like asthma or sleep apnea are at high risk for sedation and respiratory depression, so Cincinnati reduces oxycodone doses in these patients.
Sedation always precedes respiratory depression; Cincinnati nurses monitor sedation using Ramsay sedation scale every shift to prevent respiratory depression.
Cincinnati monitors end-tidal carbon dioxide continuously for the first 24 hours after pectus surgery.
Cincinnati has not used naloxone for any pain patients in more than 3 years.
Cincinnati's 50-gene panel costs $50 (less than $1 per gene) and is covered by most insurance companies.
Cost-benefit analysis for one gene (fatty acid amide hydrolase) associated with nausea, vomiting, and prolonged PACU stay shows savings of more than $100 per patient when genotype-guided dosing is used.
Intercostal blocks are better than nothing for preemptive analgesia but may miss one or two intercostal nerves, making them less effective than epidural.
Cincinnati places all epidurals before surgical incision using high-concentration local anesthetic (0.2% ropivacaine) for optimal preemptive analgesia, balancing efficacy against hypotension risk.