Centel Sadai

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In our experience, the number of patients needing any IV opioid in the 1st 2 or 3 days when they have epidural is less than 5% now

quote · Pectus Carinatum

If a child is on 5 days in a row of oxycodone or any other opioid, the risk of dependence goes up significantly

quote · Pectus Carinatum

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.

clinical · Pectus Excavatum

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.

clinical · Pectus Excavatum

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Centel's statements about Pectus Carinatum 48 statements

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Pain Management: Pectus Innovations

Statement Nothing is as good as epidural analgesia for pectus patients; On-Q pumps come second to epidural. Open

Quotation nothing is as good as epidural analogies here for Pus patients. Onup pumps come second to epidural in our experience Open

Statement More than 95% of Cincinnati's pectus patients do not get a PCA along with epidural. Open

Quotation more than 95% of our patients do not get a PCA along with epidural, which says a lot about how we manage our epidural Open

Statement Older patients and young adults have more pain after pectus repair because of chest wall rigidity. Open

Statement Patients with Ehlers-Danlos syndrome have extensive pain and often have pain even before surgery. Open

Statement Most neurological risk with epidural in children is from hypoperfusion of spinal cord, not from traumatic placement. Open

Statement Exparel (liposomal bupivacaine) is safer than plain local anesthetic because the treatment for local anesthetic toxicity is intralipid, and Exparel is already in intralipid. Open

Statement In Cincinnati's donor nephrectomy experience with Exparel TAP blocks, patients go off PCA one day earlier, have less opioid-related adverse effects, and use less opioids. Open

Statement Exparel is not approved for pediatric use by the FDA. Open

Statement Cincinnati allows patients with epidurals to walk inside the room and outside with help; Foley catheters are removed the next day after surgery. Open

Statement Cincinnati's surgical pain service sees patients minimum 3 times daily (morning, afternoon, evening rounds) and is available 24/7. Open

Statement About 20-30% of pectus patients experience chronic persistent post-operative pain, defined as pain score of 3 or more two months after surgery. Open

Statement If a patient is on 5 days in a row of oxycodone or any other opioid, the risk of dependence goes up significantly. Open

Quotation If a child is on 5 days in a row of oxycodone or any other opioid, the risk of dependence goes up significantly Open

Statement Cincinnati takes 10-15 minutes to place an epidural and achieves more than 95% success rate. Open

Quotation 10 years ago or 15 years ago it was not heard of zero pain after a major Pal surgery Open

Statement With a good working epidural, Cincinnati sees zero pain scores immediately after surgery in the first 2-3 days, which was unheard of 10-15 years ago. Open

Statement Cincinnati uses local anesthetic-only epidural solution which does not cause urinary retention and is very dermatomal, blocking only thoracic dermatomes. Open

Statement Most Cincinnati pectus patients go home on the 3rd or 4th day after surgery. Open

Statement Cincinnati's epidural success rate is more than 95%, and the number of patients needing PCA on top of epidural is now less than 5% (was 14% in 2013). Open

Statement Cincinnati uses IV methadone at lower doses (5 mg max) than adults (15-20 mg) because higher doses caused too much sedation in teenage pectus patients. Open

Statement Methadone can cause prolongation of QT interval with reports of ventricular arrhythmias, so Cincinnati monitors with EKG to ensure QT doesn't exceed 480 milliseconds. Open

Statement The number of Cincinnati patients needing any IV opioid in the first 2-3 days when they have epidural is less than 5%. Open

Quotation In our experience, the number of patients needing any IV opioid in the 1st 2 or 3 days when they have epidural is less than 5% now Open

Statement Cincinnati stops epidurals at 6 AM on post-op day 3 without weaning (from 8 mL/hour to zero immediately). Open

Statement The advantage of not using opioids in epidural solution is minimal; opioids cause more problems (itching, urinary retention) than benefit. Clonidine can provide the same pain relief without those side effects. Open

Statement Cincinnati uses high concentration ropivacaine (0.2%) for epidural; lower concentrations (0.12% or 0.15%) don't provide adequate pain relief. Open

Statement About 50% of Cincinnati's pectus patients get constipation the moment oxycodone is started. Open

Statement Naloxegol is a medication similar to naloxone that doesn't cross the blood-brain barrier, so it relieves opioid-induced constipation without reversing analgesia. Open

Statement In spine surgery patients (equally or less painful than pectus) who get PCA instead of epidural, about 15% have respiratory depression (respiratory rate <8, oxygen saturation <90%) despite multimodal analgesia. Open

Statement Thoracic surgery including pectus is considered high risk for persistent post-operative pain; about 20-30% of pectus patients develop chronic pain (pain score >3 at 2 months post-op). Open

Statement When pain is managed without regional anesthesia, the barrage of noxious stimuli to the brain precipitates neuroplasticity, causing the brain to remember pain long-term (6-12 months after surgery). Open

Statement Higher amounts of preoperative opioid use increase the risk for persistent pain; high opioid doses turn down opioid receptor genes, which is connected with persistent pain. Open

Statement Cincinnati performs preoperative CYP2D6 genetic testing; saliva or blood sample taken at surgical clinic, results available in EPIC within 2 days, covered by most insurance. Open

Statement CYP2D6 is the major liver enzyme that metabolizes most oral opioids including codeine, tramadol, oxycodone, and hydrocodone. Open

Statement Ultra-rapid metabolizers are not good candidates for codeine, tramadol, or hydrocodone, but they are okay with morphine and hydromorphone. Open

Statement Cincinnati can reliably predict who will have respiratory depression by looking at their genes and genetic signature. Open

Statement In Cincinnati population, only 1-2% are ultra-rapid metabolizers; in African American and especially Ethiopian populations, ultra-rapid metabolizers can be as high as 29%. Open

Statement The FDA has warned against use of codeine following tonsillectomy; tramadol and hydrocodone warnings are under FDA review. Open

Statement Among currently available opioids, oxycodone is the least affected by CYP2D6 metabolism. Open

Statement Even extensive metabolizers (normal population) are at high risk for sedation and respiratory depression if they have coexisting morbidity like asthma or sleep apnea. Open

Statement Sedation always precedes respiratory depression; Cincinnati nurses monitor sedation using Ramsay sedation scale every shift to prevent respiratory depression. Open

Statement Cincinnati has not used naloxone for any pain patients in more than 3 years despite using maximum opioid amounts, attributed to aggressive monitoring. Open

Statement The 50-gene genetic panel costs $50; CYP2D6 testing costs less than $1 per gene. Open

Statement One gene (fatty acid amide hydrolase) associated with nausea, vomiting, and prolonged PACU stay saves more than $100 per patient when used to guide dosing, exceeding the cost of genotyping. Open

Statement Intercostal blocks are still good and better than nothing for preemptive pain control, but may miss one or two intercostal nerves and don't provide pain relief as good as epidural. Open

Statement Higher concentration of local anesthetic is better for preemptive analgesia, which is why Cincinnati places epidurals before surgery with high-concentration ropivacaine. Open

Centel's statements about Pectus Excavatum 229 statements

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Pectus Excavatum Pain Management at Cincinnati Children's Hospital

Statement Nothing is as good as epidural analgesia for pectus patients; On-Q pumps come second to epidural in Cincinnati's experience. Open

Quotation nothing is as good as epidural analogiesia for Pus patients. Oncup pumps comes second to epidural in our experience Open

Statement Seattle Children's Hospital, which transitioned from epidural to On-Q pumps, is experiencing issues with pain management. Open

Quotation more than 95% of our patients do not get a PCA along with epidural, which says a lot about how we manage our epidural Open

Statement More than 95% of Cincinnati's pectus patients do not receive PCA along with epidural. Open

Statement The pain team sees pectus patients at least 3 times per day and tweaks epidural rate or position to optimize analgesia. Open

Statement More than 99% of Cincinnati's pectus patients receive epidural analgesia. Open

Statement Older patients and young adults have more pain after pectus repair due to chest wall rigidity. Open

Statement Patients with Ehlers-Danlos syndrome have extensive pain and may have pain even before surgery. Open

Statement Patients with psychological problems like depression and excessive anxiety benefit from On-Q pumps in addition to epidural. Open

Statement Patients with family history of substance abuse benefit from minimizing opioid use through epidural and On-Q pump. Open

Statement Pain catastrophization (anticipating negative outcomes) in children or parents is associated with more postoperative pain. Open

Statement Two major risks with epidural are injury during placement (including paraplegia) and infection (epidural abscess) if the catheter is left too long. Open

Statement Cincinnati places epidurals in awake patients with minimal sedation in sitting position to minimize risk of traumatic placement. Open

Statement Cincinnati removes epidural catheters on the 3rd day after surgery to prevent epidural abscess. Open

Statement Most neurological injury from epidural in children is from hypoperfusion of the spinal cord, not traumatic placement. Open

Statement Cincinnati aggressively manages blood pressure to maintain spinal cord perfusion, reducing epidural rate and removing clonidine if blood pressure is low. Open

Statement Exparel (liposomal bupivacaine) is safer than plain local anesthetic because the treatment for local anesthetic toxicity is intralipid, which Exparel already contains. Open

Quotation The treatment for a local anesthetic toxicity is intralipid. This medication is in the intralipid, so it is safer Open

Statement In Cincinnati's donor nephrectomy experience with Exparel TAP blocks, patients discontinue PCA one day earlier and use fewer opioids with fewer side effects. Open

Statement Exparel is not FDA-approved for pediatric use. Open

Statement Cincinnati allows patients with epidurals to walk inside the room and even outside with help because there are no narcotics in the epidural solution. Open

Statement Cincinnati removes Foley catheters the day after surgery and allows ambulation, which epidural facilitates. Open

Statement Cincinnati's preoperative preparation includes mandatory pain education by a pain nurse 2-3 months before surgery and optional genetic research for opioid risk. Open

Statement Medical literature shows meditation benefits include minimizing pain, anxiety, and improving immune function after surgery. Open

Statement About 20-30% of pectus patients experience chronic persistent post-operative pain, defined as pain score of 3 or more two months after surgery. Open

Statement Opioids have a narrow therapeutic index: beyond a certain dose they will not relieve pain but can cause significant side effects. Open

Statement Strong adult literature shows that regional analgesia (epidural or On-Q pump) reduces persistent post-operative pain, including after thoracotomy. Open

Statement If a child is on 5 consecutive days of oxycodone or any other opioid, the risk of dependence increases significantly. Open

Statement A 2023 meta-analysis of 6 studies comparing epidural to PCA for pectus repair found epidural provided better pain control in the first 2 days. Open

Statement Two studies from Kansas had epidural failure rates of 22% and 35%, likely explaining why epidural didn't provide superior pain relief in those studies. Open

Statement 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. Open

Statement Cincinnati uses local anesthetic-only epidural solution (no opioids), which does not cause urinary retention and is very dermatomal, blocking only thoracic dermatomes. Open

Statement Most Cincinnati pectus patients are discharged on the 3rd or 4th day after surgery. Open

Statement 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). Open

Statement 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. Open

Statement Cincinnati uses pregabalin preoperatively; literature shows that giving pregabalin or gabapentin one hour before surgery significantly decreases postoperative pain and opioid need. Open

Statement 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. Open

Statement Cincinnati uses IV methocarbamol routinely for muscle spasms after pectus surgery, which reduces the need for IV diazepam. Open

Statement 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. Open

Statement Cincinnati alternates IV ketorolac every 6 hours with IV acetaminophen to minimize opioid use. Open

Statement Less than 5% of Cincinnati's pectus patients need any IV opioid in the first 2-3 days when they have epidural. Open

Statement Cincinnati delays starting oxycodone until post-op day 2 when possible to minimize opioid exposure. Open

Statement 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. Open

Statement Cincinnati stops epidural abruptly at 6 AM on post-op day 3 without weaning. Open

Statement 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. Open

Statement 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. Open

Statement About 50% of patients on oxycodone develop opioid-induced constipation. Open

Statement Naloxegol is similar to naloxone but doesn't cross the blood-brain barrier, so it relieves opioid-induced constipation without reversing analgesia. Open

Statement Naloxegol is FDA-approved for opioid-induced constipation but not yet approved for pediatric use; Cincinnati uses it off-label. Open

Statement 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%. Open

Statement 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. Open

Statement In Ethiopian populations, ultra-rapid metabolizers can be as high as 29%, compared to 1-2% in Cincinnati's population. Open

Statement The FDA has warned against use of codeine following tonsillectomy; warnings for tramadol and hydrocodone are under FDA review. Open

Statement Among currently available opioids, oxycodone is the least affected by CYP2D6 metabolism. Open

Statement Cincinnati avoids oxycodone in ultra-rapid metabolizers and uses oral hydromorphone (Dilaudid) instead. Open

Statement 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. Open

Statement Sedation always precedes respiratory depression; Cincinnati nurses monitor sedation using Ramsay sedation scale every shift to prevent respiratory depression. Open

Statement Cincinnati monitors end-tidal carbon dioxide continuously for the first 24 hours after pectus surgery. Open

Statement Cincinnati has not used naloxone for any pain patients in more than 3 years. Open

Statement Cincinnati's 50-gene panel costs $50 (less than $1 per gene) and is covered by most insurance companies. Open

Statement 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. Open

Statement Intercostal blocks are better than nothing for preemptive analgesia but may miss one or two intercostal nerves, making them less effective than epidural. Open

Statement Cincinnati places all epidurals before surgical incision using high-concentration local anesthetic (0.2% ropivacaine) for optimal preemptive analgesia, balancing efficacy against hypotension risk. Open

Pain Management: Pectus Innovations

Statement Nothing is as good as epidural analgesia for pectus patients; On-Q pumps come second to epidural. Open

Quotation nothing is as good as epidural analogies here for Pus patients. Onup pumps come second to epidural in our experience Open

Statement Nothing is as good as epidural analgesia for pectus patients; On-Q pumps come second to epidural. Open

Statement Seattle Children's Hospital has gone from epidural to On-Q pump recently and is having some issues. Open

Statement More than 95% of Cincinnati's pectus patients do not get a PCA along with epidural. Open

Quotation more than 95% of our patients do not get a PCA along with epidural, which says a lot about how we manage our epidural Open

Statement More than 95% of Cincinnati's pectus patients do not get a PCA along with epidural. Open

Statement Older patients and young adults have more pain after pectus repair because of chest wall rigidity. Open

Statement Patients with Ehlers-Danlos syndrome have extensive pain and often have pain even before surgery. Open

Statement Recent literature shows that if a child and their parent have pain catastrophization (anticipating negative outcomes), they are more likely to have more pain after surgery. Open

Statement Most neurological risk with epidural in children is from hypoperfusion of spinal cord, not from traumatic placement. Open

Statement Exparel (liposomal bupivacaine) is safer than plain local anesthetic because the treatment for local anesthetic toxicity is intralipid, and Exparel is already in intralipid. Open

Statement In Cincinnati's donor nephrectomy experience with Exparel TAP blocks, patients go off PCA one day earlier, have less opioid-related adverse effects, and use less opioids. Open

Statement Exparel is not approved for pediatric use by the FDA. Open

Statement Cincinnati allows patients with epidurals to walk inside the room and outside with help; Foley catheters are removed the next day after surgery. Open

Statement Cincinnati's surgical pain service sees patients minimum 3 times daily (morning, afternoon, evening rounds) and is available 24/7. Open

Statement There is evidence in medical literature that meditation benefits include minimizing pain, anxiety, and improving immune function after surgery. Open

Statement About 20-30% of pectus patients experience chronic persistent post-operative pain, defined as pain score of 3 or more two months after surgery. Open

Quotation If a child is on 5 days in a row of oxycodone or any other opioid, the risk of dependence goes up significantly Open

Statement If a patient is on 5 days in a row of oxycodone or any other opioid, the risk of dependence goes up significantly. Open

Quotation If a child is on 5 days in a row of oxycodone or any other opioid, the risk of dependence goes up significantly Open

Statement If a patient is on 5 days in a row of oxycodone or any other opioid, the risk of dependence goes up significantly. Open

Statement A meta-analysis of 6 studies published last year found that compared to PCA, epidural provided better pain control the first 2 days after pectus repair. Open

Statement Two studies from Kansas with 22% and 35% epidural failure rates showed epidural didn't help relieve pain as well as PCA, likely due to poor epidural placement success. Open

Statement Cincinnati takes 10-15 minutes to place an epidural and achieves more than 95% success rate. Open

Statement With a good working epidural, Cincinnati sees zero pain scores immediately after surgery in the first 2-3 days, which was unheard of 10-15 years ago. Open

Quotation 10 years ago or 15 years ago it was not heard of zero pain after a major Pal surgery Open

Statement With a good working epidural, Cincinnati sees zero pain scores immediately after surgery in the first 2-3 days, which was unheard of 10-15 years ago. Open

Statement Cincinnati uses local anesthetic-only epidural solution which does not cause urinary retention and is very dermatomal, blocking only thoracic dermatomes. Open

Statement Most Cincinnati pectus patients go home on the 3rd or 4th day after surgery. Open

Statement Cincinnati's epidural success rate is more than 95%, and the number of patients needing PCA on top of epidural is now less than 5% (was 14% in 2013). Open

Statement There is evidence that if you give pregabalin or gabapentin one hour before surgery, it decreases pain after surgery significantly and need for opioid is significantly less. Open