Continuous thoracic paravertebral analgesia after minimally invasive atrial septal defect closure surgery in pediatric population: Effectiveness and safety analysis.

INTRODUCTION: Lateral thoracotomy is replacing traditional median sternotomy for atrial septal defect (ASD) closure in children in order to improve cosmetic outcomes. Continuous paravertebral block has been described as an effective and safe analgesic technique in children. The aim of this study is to assess pain management by continuous perfusion of local anesthetic through a thoracic paravertebral catheter (PVC) in a pediatric population after thoracotomy closure of ASD, and its effectiveness in a fast-track program. METHODS: Descriptive cross-sectional study. Analgesic effectiveness, perioperative and safety-related data were analyzed in 21 patients who underwent thoracotomy closure of ASD with PVC. In the postoperative period, patients received continuous perfusion of bupivacaine 0.125% and fentanyl (1 mcg.ml-1) at 0.2 ml.kg-1.h-1 through the PVC. RESULTS: The median of mean pain scale score for each patient was 1.5. All patients were extubated in the operating theatre. No patient with PVC required opioid rescue. The median length of stay in the Pediatric Intensive Care Unit was 48 hours. There were 3 adverse events related to PVC: 1 due to malposition and 2 due to accidental removal. No other complications or cases of local anesthetic toxicity were recorded. CONCLUSIONS: PVC provides effective, safe, opioid-saving analgesia in the postoperative period of ASD closure by thoracotomy in the context of a fast-track protocol.

Analgesia paravertebral torácica continua tras cirugía mínimamente invasiva de cierre de comunicación interauricular en población pediátrica: análisis de eficacia y seguridad / Continuous thoracic paravertebral analgesia after minimally invasive atrial septal defect closure surgery in pediatric population: Effectiveness and safety analysis

Introducción: La toracotomía lateral está sustituyendo la esternotomía media clásica para el cierre de la comunicación interauricular (CIA) en niños con objetivo de obtener un menor impacto estético. El bloqueo paravertebral continuo se ha descrito como una técnica analgésica efectiva y segura en niños. El objetivo del estudio es valorar el control analgésico tras el cierre de CIA por toracotomía, mediante la administración de anestésico local en perfusión continua a través de un catéter paravertebral torácico (CPV) en población pediátrica, y su efectividad en un programa fast-track. Métodos: Estudio transversal descriptivo. Se analizaron datos de efectividad analgésica, datos perioperatorios y relacionados con la seguridad en 21 pacientes intervenidos de cierre de CIA mediante toracotomía con CPV. En el periodo postoperatorio se empleó una perfusión continua a través del CPV de bupivacaína al 0,125% y fentanilo (1μg.ml-1) a 0,2ml.kg-1.h-1. Resultados: La mediana de las puntuaciones medias en las escalas de dolor de cada paciente fue 1,5. Todos los pacientes se extubaron en quirófano. Ningún paciente con CPV requirió rescate con opioides. La mediana de tiempo de estancia en la unidad de cuidados intensivos pediátricos fue de 48h. Se objetivaron 3 eventos adversos relacionados con el CPV: uno debido a mala posición y 2 por salida accidental. No se registraron otras complicaciones ni casos de toxicidad por anestésicos locales. Conclusiones: El CPV proporciona una analgesia efectiva y segura en el postoperatorio de cierre de CIA mediante toracotomía en el contexto de un protocolo fast-track disminuyendo el consumo postoperatorio de opioides.(AU)

Introduction: Lateral thoracotomy is replacing traditional median sternotomy for atrial septal defect (ASD) closure in children in order to improve cosmetic outcomes. Continuous paravertebral block has been described as an effective and safe analgesic technique in children. The aim of this study is to assess pain management by continuous perfusion of local anesthetic through a thoracic paravertebral catheter (PVC) in a pediatric population after thoracotomy closure of ASD, and its effectiveness in a fast-track program. Methods: Descriptive cross-sectional study. Analgesic effectiveness, perioperative and safety-related data were analyzed in 21 patients who underwent thoracotomy closure of ASD with PVC. In the postoperative period, patients received continuous perfusion of bupivacaine 0.125% and fentanyl (1 μg.ml-1) at 0.2ml.kg-1.h-1 through the PVC. Results: The median of mean pain scale score for each patient was 1.5. All patients were extubated in the operating theatre. No patient with PVC required opioid rescue. The median length of stay in the Pediatric Intensive Care Unit was 48hours. There were 3 adverse events related to PVC: 1 due to malposition and 2 due to accidental removal. No other complications or cases of local anesthetic toxicity were recorded. Conclusions: PVC provides effective, safe, opioid-saving analgesia in the postoperative period of ASD closure by thoracotomy in the context of a fast-track protocol.(AU)

Derrame pleural unilateral tras perforación vascular por catéter venoso central de inserción periférica: utilidad del verde de indocianina en el diagnóstico / Unilateral pleural effusion caused by vessel perforation due to peripherally inserted central catheter: Indocyanine green as a diagnostic tool

Varón de 44 años con desnutrición calórico-proteica grave en el contexto de una estenosis pilórica benigna, a quien se decidió colocar un catéter central de inserción periférica (CCIP) para tratamiento con nutrición parenteral. Al quinto día de la inserción del catéter, presentó un derrame pleural derecho masivo de color blanco e insuficiencia respiratoria tras la realización de una endoscopia digestiva alta para el tratamiento de la estenosis pilórica. Ante la sospecha inicial de quilotórax el paciente ingresó en la Unidad de Reanimación. Se administró verde de indocianina a través del CCIP, obteniendo a los 30 min una coloración verdosa del contenido del derrame pleural; este resultado nos hizo sospechar que el derrame pleural era secundario a una perforación vascular por el CCIP con extravasación de la nutrición parenteral al espacio pleural. Se realizó una tomografía computarizada toracoabdominal, que confirmó la existencia de una perforación a nivel de la vena innominada. La colocación de un CCIP puede asociarse a complicaciones graves, como la perforación de una vena central, por tanto, la correcta posición de un catéter central debe ser siempre comprobada. La prueba diagnóstica de elección de perforación vascular a nivel central es la tomografía computarizada con contraste; sin embargo, ante la existencia de derrame pleural en este contexto, es posible emplear un colorante que, administrado de forma intravenosa, oriente su diagnóstico in situ. En este caso se empleó el verde de indocianina con este objetivo (AU)

A peripherally inserted central catheter (PICC) was inserted into a 44-year-old man to provide parenteral nutrition in a protein-calorie malnutrition secondary to a benign pyloric stenosis. On the fifth day while monitoring the catheter, the patient presented with a massive whitish pleural effusion after undergoing gastric endoscopy in order to treat pyloric stenosis. Chylothorax was initially suspected, and the patient was admitted to a recovery unit. Indocyanine green was administered through the PICC, obtaining a greenish discoloration in the pleural effusion 30 min later. This led to the diagnosis of a pleural effusion caused by a vessel perforation due to the PICC, leading to parenteral nutrition extravasation. Thoraco-abdominal computed tomography was performed, which confirmed an innominate vein perforation due to the PICC. PICC insertion may be associated with severe complications, such as central vessel perforation, and therefore the correct position of a central catheter should be always checked. Intravenous computed tomography contrast is the gold standard for central vascular perforation diagnosis. However if a pleural effusion occurs in this context, it is possible to use a dye, which administered intravenously can lead us to the correct diagnosis in situ. Indocyanine green was used for this purpose in this case (AU)

[Unilateral pleural effusion caused by vessel perforation due to peripherally inserted central catheter: Indocyanine green as a diagnostic tool]. / Derrame pleural unilateral tras perforación vascular por catéter venoso central de inserción periférica: utilidad del verde de indocianina en el diagnóstico.

A peripherally inserted central catheter (PICC) was inserted into a 44-year-old man to provide parenteral nutrition in a protein-calorie malnutrition secondary to a benign pyloric stenosis. On the fifth day while monitoring the catheter, the patient presented with a massive whitish pleural effusion after undergoing gastric endoscopy in order to treat pyloric stenosis. Chylothorax was initially suspected, and the patient was admitted to a recovery unit. Indocyanine green was administered through the PICC, obtaining a greenish discoloration in the pleural effusion 30 min later. This led to the diagnosis of a pleural effusion caused by a vessel perforation due to the PICC, leading to parenteral nutrition extravasation. Thoraco-abdominal computed tomography was performed, which confirmed an innominate vein perforation due to the PICC. PICC insertion may be associated with severe complications, such as central vessel perforation, and therefore the correct position of a central catheter should be always checked. Intravenous computed tomography contrast is the gold standard for central vascular perforation diagnosis. However if a pleural effusion occurs in this context, it is possible to use a dye, which administered intravenously can lead us to the correct diagnosis in situ. Indocyanine green was used for this purpose in this case.