Analgesic Quality Improvement in Paravertebral Blocks for Pediatric Nuss Procedure: An Exploratory Report on the Effects of Perineural Combined Glucocorticoids.

Purpose: Pectus excavatum repair using the Nuss procedure is associated with significant postoperative opioid consumption even in the presence of a continuous thoracic paravertebral block. Patients and Methods: A CQI project was initiated by adding combined glucocorticoids as perineural adjuvants to continuous thoracic paravertebral block. An electronic health record review of patients undergoing Nuss procedures by a single surgeon at a major academic children's hospital from June 2013 to December 2021 was performed with no patients excluded. The patients received pre-incision continuous bilateral T4 paravertebral blocks preoperatively either with plain ropivacaine (standard group, N = 34) or with a combination of dexamethasone sodium phosphate (DXP) and methylprednisolone acetate (MPA) in addition to ropivacaine (experimental group, N = 10). The primary outcome studied was postoperative opioid consumption measured by oral morphine milligram equivalents (MME). Results: A total of 44 patients were included in the final analysis. The experimental group had 72% lower postoperative opioid usage than the standard group during the hospitalization (p < 0.001) with comparable pain scores and hospital length of stay and no increase in wound dehiscence or other complications. Conclusion: The addition of dexamethasone sodium phosphate and methylprednisolone acetate to continuous paravertebral blocks significantly decreased postoperative opioid consumption while maintaining comfort pain scores.