Year : 2012  |  Volume : 15  |  Issue : 1  |  Page : 87--88

Lumbar epidural analgesia in pain management of Nuss procedures: Paediatric case

Handan Birbicer, Nurcan Doruk, Yücel Uguz, Türkan Altun 
 Department of Anaesthesiology and Reanimation, Medical Faculty, Mersin University, Mersin, Turkey

Correspondence Address:
Handan Birbicer
Department of Anaesthesiology and Reanimation, Faculty of Medicine, Mersin University, 33079, Mersin

How to cite this article:
Birbicer H, Doruk N, Uguz Y, Altun T. Lumbar epidural analgesia in pain management of Nuss procedures: Paediatric case.Ann Card Anaesth 2012;15:87-88

How to cite this URL:
Birbicer H, Doruk N, Uguz Y, Altun T. Lumbar epidural analgesia in pain management of Nuss procedures: Paediatric case. Ann Card Anaesth [serial online] 2012 [cited 2020 Feb 29 ];15:87-88
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Full Text

The Editor,

The Nuss operation is a minimally invasive technique for repair of pectus excavatum. Postoperative pain is the major problem. [1] Especially, satisfactory postoperative analgesia is essential to enable the pediatric patients to maintain bed rest.

In this study, we aimed to present two pediatricpediatriccases of Nuss procedure in which effective analgesia was achieved by lumbar bolus dose of an epidural opioid and continuous local anesthetic + opioid infüsion.

The pectus index for our two male cases (5 and 6 years old) were 3.5 and 5.8 (normal, <3.25). After standard monitors attached, anesthesia was induced with 5 mg/kg of thiopental + 0.1 mg/kg vecuronium. A single-lumen endotracheal tube was used for intubation. The patients were turned onto left lateral position, and the epidural catheter was easily inserted by median approach at the level of L 3 -L 4 interspinous space. Prior to the surgical incision, a bolus dose of 10 cc 30 μg/kg morphine was delivered through the epidural catheter which was followed by the continuous epidural infusion of 3 μg/kg/h morphine and 0.0625% bupivacaine (3 ml kg/h). Vital parameters, pain levels, and sedation scores were checked every 2 hours during the first day. Infupediatricsion dose was reduced by 30% if the sedation score was ≥ 2 in cases. Complications as well as need for additional drugs were noted. For both of the patients, the mean VAS value within the first 24 hours was 3-4, whereas the mean sedation score was 0-1. Epidural infusion was decreased to 2 ml/kg in the second hour in case I and in the 6th hour in case 2, followed by a reduction to 1 ml/kg in both patients at 16 hours. None of the cases required additional analgesics. Epidural infusion was continued during the first 2 days of the postoperative period. One of the cases exhibited nausea (twice) and constipation. The other case demonstrated no complication.

Initial postoperative hours of the Nuss operation are characterized by severe pain associated with the direct compression of the pectus bar over the posterior surface of the sternum. We succeeded to achieve an effective analgesic level by epidural anesthesia in both of our patients.

The level of epidural catheter placement and choice of epidural agent are very important. In Nuss procedures, local anesthetic agents and thoracic epidural anesthesia are commonly used for pain management. [1] However, hypotension and other complications that might be caused by high-dose local anesthetics are the limitations of local anesthetic use. Therefore, an adjuvant can be employed in order to reduce the incidence of complications. In Nuss procedures, pain is effective over T1-10 dermatomes and therefore achievement of an efficient analgesia requires successful pain management comprising an adequate number of those dermatomes. Another reason why we preferred morphine in our cases was that because we used the lumbar region instead of the thoracal region as the area of epidural intervention, it enabled us to affect an adequate number of dermatomes. In our cases, we applied the same morphine dose used by Kariya et al., 30 μg/kg/h, and proceeded with the same continuous infusion of morphine, 3 μg/kg/h. [2] However, considering the fact that they failed to achieve effective analgesia after the first postoperative day, we delivered an additional local anesthetic, 0.0625% bupivacaine (3 ml/kg/h).

We believe that by choosing the appropriate adjuvant and local anesthetic dose, lumbar epidural analgesia can be successfully performed in these cases.


1Nuss D, Kelly RE Jr, Croitoru DP, Katz ME. A 10- year review of a minimally invasive technique fort he correction of pectus excavatum. J Pediatr Surg 1998;33:545-52.
2Kariya N, Inoue Y, Minami W, Ikeda Y, Nishi S, Nishikawa K, et al. Lumbar epidural morphine for postoperative analgesia in children undergoing Nuss procedure. Masui 2005;54:496-9.