Epidural analgesia versus intravenous patient-controlled analgesia following minimally invasive pectus excavatum repair: a systematic review and meta-analysis

Abstract

Background/Purpose The minimally invasive pectus excavatum repair (MIPER) is a painful procedure. The ideal approach to postoperative analgesia is debated. We performed a systematic review and meta-analysis to assess the efficacy and safety of epidural analgesia compared to intravenous Patient Controlled Analgesia (PCA) following MIPER. Methods We searched MEDLINE (1946–2012) and the Cochrane Library (inception–2012) for randomized controlled trials (RCT) and cohort studies comparing epidural analgesia to PCA for postoperative pain management in children following MIPER. We calculated weighted mean differences (WMD) for numeric pain scores and summarized secondary outcomes qualitatively. Results Of 699 studies, 3 RCTs and 3 retrospective cohorts met inclusion criteria. Compared to PCA, mean pain scores were modestly lower with epidural immediately (WMD −1.04, 95% CI −2.11 to 0.03, p = 0.06), 12 hours (WMD −1.12; 95% CI −1.61 to −0.62, p < 0.001), 24 hours (WMD −0.51, 95%CI −1.05 to 0.02, p = 0.06), and 48 hours (WMD −0.85, 95% CI −1.62 to −0.07, p = 0.03) after surgery. We found no statistically significant differences between secondary outcomes. Conclusions Epidural analgesia may provide superior pain control but was comparable with PCA for secondary outcomes. Better designed studies are needed. Currently the analgesic technique should be based on patient preference and institutional resources.

A review of anesthetic techniques and outcomes following minimally invasive repair of pectus excavatum (Nuss procedure)

“…The prospective randomized trials compared continuous epidural analgesia alone vs intravenous opioids (IVPCA) after the Nuss procedure and demonstrated epidural superiority with pain control better immediately, at 12 h, and at 24 h . A subsequent meta‐analysis of six studies confirmed that epidural analgesia is associated with a small improvement in pain scores through to 48 h after surgery, without significant differences in secondary outcomes . Two of the papers reviewed provided 73% of the cohort and confounded comparison between groups because of the high epidural failure rates (22 and 35%).…”

Continuous chest wall ropivacaine infusion for analgesia in children undergoing Nuss procedure: a comparison with thoracic epidural

“…The management of these adolescents has traditionally focused on the use of TEC and narcotic analgesics to manage pain . In a recent retrospective study of 20 adolescent males undergoing the Nuss procedure, Hall Burton et al .…”

Utilization of paravertebral nerve blocks as part of a multimodal analgesic regimen in a patient with Bernard-Soulier syndrome undergoing a Nuss procedure

“…Anesthetic concerns with the Nuss procedure include significant postoperative pain of the anterior chest wall, which may impede the patient's respiratory efforts. A thoracic epidural is routinely placed for patients undergoing the procedure for perioperative pain control, and such practice is widely supported [3,12]. Other regional analgesic techniques included bilateral PVB catheters, which have been shown to be non-inferior to a thoracic epidural for postoperative analgesia in pediatric patients undergoing the Nuss procedure [13].…”