A Novel Approach to Pain Management for the Nuss Procedure using Erector Spinae Plane Blockade and Cryoanalgesia

Purpose: Nuss bar placement results in severe and prolonged postoperative pain [1, 2]. Cryoanalgesia (cryo) is a promising new approach for managing thoracic pain which involves freezing intercostal nerves, resulting in analgesia of the chest wall for months [3, 4]. However, the analgesic effect of cryo is delayed for 24 hours or more [5, 6]. Erector Spinae Plane Blockade (ESPB) provides immediate analgesia to the chest wall and can act as an analgesic bridge until cryo reaches peak effect [7, 8]. Methods: We reviewed the charts of all patients who underwent Nuss bar placement between June and July of 2018. Patients received multimodal and preemptive analgesia as well as bilateral thoracic ESPB and cryo. Patient demographics, analgesic techniques, opioid consumption, pain scores, length of stay (LOS), and antiemetic administration were recorded. Results: Analysis included 1 female and 6 male patients. Mean age was 14.9 +/- 1.9 years and mean Haller index was 3.60 +/- 0.73. Mean LOS was 1.34 +/- 0.56 days. Mean intraoperative fentanyl administration was 5.3 +/- 1.25 mcg/kg. Mean long-acting opioid consumption was 0.43 +/- 0.38 mg/kg PO morphine equivalents on POD 0 and 0.51 +/- 0.73 mg/kg PO morphine equivalents on POD 1. Mean visual analog scale (VAS) pain scores were 2.5 +/- 2.3 and 3.0 +/- 0.97 for POD 0 and 1, respectively. Two patients (28.6%) required antiemetic treatment. Conclusions: This small historical cohort study shows that it is possible to have short LOS and good pain control after the Nuss procedure by using a combination of ESPB, cryo and multimodal analgesia.