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Are Foley catheters needed after minimally invasive repair of pectus excavatum?
ARTICLE IN PRESS Surgery ■■ (2017) ■■–■■
Contents lists available at ScienceDirect
Surgery j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / y m s y
Are Foley catheters needed after minimally invasive repair of pectus excavatum? Tyler C. Friske a, Richard Sola b, Yangyang R. Yu a,c, Abdur R. Jamal a, Eric Rosenfeld a,c, Huirong Zhu d, Mark V. Mazziotti a,c, Shawn D. St. Peter b, and Sohail R. Shah a,c,* a
Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX Division of Pediatric Surgery, Children’s Mercy Hospital, Kansas City, MO c Division of Pediatric Surgery, Texas Children’s Hospital, Houston, TX d Division of Outcomes and Impact Service, Texas Children’s Hospital, Houston, TX b
A R T I C L E
I N F O
Article history: Accepted 18 October 2017
A B S T R A C T
Background. High narcotic requirements after minimally invasive repair of pectus excavatum (MIRPE) can increase the risk of urinary retention. Placement of intraoperative Foley catheters to minimize this risk is variable. This study determines the rate of urinary retention in this population to guide future practice. Materials and Methods. We reviewed retrospectively all patients who underwent MIRPE from January 2012 to July 2016 at 2 academic children’s hospitals. Data collected included demographics, BMI, severity of the pectus defect, postoperative pain management, and the incidence of urinary retention and urinary tract infection (UTI). Results. Of 360 total patients who underwent MIRPE, 218 had an intraoperative Foley catheter. Patients with epidural pain control were more likely to receive a Foley catheter. The urinary retention rate was 34% for patients without an intraoperative Foley, and 1% in patients after removal of an intraoperatively placed Foley. Urinary retention was greater with an epidural compared with patient-controlled anesthesia (55% vs 26%, P = .002) in the no intraoperative Foley group. No urinary tract infections were identified. Epidural pain control was the only risk factor on multivariate analysis for retention in patients without an intraoperatively Foley catheter. Conclusion. Intraoperative Foley catheters obviate urinary retention without increasing the risk of urinary tract infection after MIRPE. These results will allow surgeons to better counsel patients regarding Foley placement. © 2017 Elsevier Inc. All rights reserved.
Pectus excavatum is a chest wall deformity characterized by inward depression of the sternum and adjacent costal cartilage. Pectus excavatum constitutes approximately 90% of all anterior chest wall deformities, with an estimated incidence of 1 in 400 to 1,000 live births.1 The most common techniques for operative repair of pectus excavatum include the Ravitch and Nuss procedures.2,3 The Nuss procedure or a modified version of the Nuss procedure is often the favored technique for many pediatric surgeons because of its minimally invasive approach. This minimally invasive repair of pectus excavatum (MIRPE) offers an advantage of improved incisional cosmesis with an average duration of stay of 4.6 days.3,4 The primary reason for an extended duration of stay for patients who undergo
Presented at the 12th Annual Academic Surgical Congress, February 7–9, 2017, Las Vegas, Nevada. The authors have no conflict of interests or financial funding in completing this study to report or disclose. * Corresponding author. Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin Suite 1210, Houston, TX 77030. E-mail address: [email protected] (S.R. Shah).
MIRPE is an increased intravenous narcotic requirement for postoperative pain control.5,6 The type of narcotic pain control varies between institutions but typically involves either regional thoracic epidural analgesia (epidural) or intravenous patient-controlled analgesia (PCA).7 The amount of narcotic requirements after MIRPE raise concern for urinary retention in this patient population. Intraoperative Foley catheters are often placed to minimize the risk of this complication; however, there is variation in this practice. Additionally, Foley catheterization has been found to increase the risk of urinary tract infection in certain populations.8,9 The purpose of this study was to determine the urinary retention rate of patients who undergo minimally invasive repair of pectus excavatum. We hypothesized that the rate of urinary retention after MIRPE may be high enough to support routine use of intraoperative Foley catheterization. Methods After Institutional Review Board approval at both institutions (H38983, 15060265), a retrospective review was performed of all
https://doi.org/10.1016/j.surg.2017.10.049 0039-6060/© 2017 Elsevier Inc. All rights reserved.
Please cite this article in press as: Tyler C. Friske, et al., Are Foley catheters needed after minimally invasive repair of pectus excavatum?, Surgery (2017), doi: 10.1016/ j.surg.2017.10.049
ARTICLE IN PRESS T.C. Friske et al. / Surgery ■■ (2017) ■■–■■
2
patients who underwent MIRPE from January 2012 to July 2016 at 2 tertiary-care academic children’s hospitals. Patients who underwent an open operative procedure for pectus excavatum repair and patients older than 22 years were excluded. Data collected included patient characteristics and postoperative variables, including type of postoperative pain management, amount of narcotic administered, duration of hospitalization, and incidence of urinary tract infection. For comparative purposes, PCA and epidural narcotic doses were converted to parenteral morphine equivalents based on published equianalgesic charts.10 The study population was then divided into 2 cohorts to determine rate of urinary retention: patients with and without placement of an intraoperative Foley catheter. A comparative analysis of rates of urinary retention was then performed between the 2 cohorts. Urinary retention was defined as the inability to void spontaneously requiring straight catheterization or placement of a Foley catheter in the postoperative period. Statistical analysis was performed using SAS software (Version 9.3; SAS Institute, Inc, Cary, NC). Patient characteristics and outcomes are described descriptively using counts and proportions for categorical variables and as mean ± standard deviation for parametric continuous variables or median (interquartile ratio [IQR]) for nonparametric continuous variables. Comparative analysis was performed using the Wilcoxon Mann-Whitney test and Fisher exact test or χ2 square test, as appropriate. Additional univariate and multivariate logistic regression models were used to identify potential risk factors. Results During the study period, 360 patients underwent MIRPE and met the inclusion criteria for this study. The mean age at the time of operation was 15.7 ± 2.1 years, 84% of patients were male (n = 302), and the mean body mass index (BMI) was 19.0 ± 2.3. The mean reported Haller Index score was 4.5 ± 1.5. The mean intravenous morphine equivalent dose administered was 1.5 ± 1.2 mg/kg/day per patient with a mean duration of stay of 4.5 ± 1.1 days. Hospital 1 contributed 189 patients (53%) and hospital 2 contributed 171 patients (47%) to the total study population. Intraoperative Foley catheter use varied at the 2 institutions, with hospital 1 placing intraoperative Foley catheters in 39% of patients (74/189) and hospital 2 placing Foley catheters in 84% of patients (144/171) undergoing MIRPE (P < .01) (Fig). Median duration of Foley catheter use for the 218 patients with an intraoperatively placed Foley catheter was 55 hours (IQR 42–73 hours). Median duration of Foley catheter was less at hospital 1 compared with hospital 2 (28 hours [IQR 23–47 hours] vs 71 hours [IQR 52–75 hours]; P < .001). A comparative analysis of patients with and without intraoperative Foley catheter placement found no significant difference in sex, BMI, or Haller Index score. The postoperative regimen of pain control did, however, influence placement of an intraoperative Foley catheter. Of the 360 patients, 221 (61%) received a PCA exclusively, 114 (32%) received an epidural exclusively, and 25 (7%) received both for postoperative pain management. The average duration of epidural use in our cohort was 2.9 ± 1.1 days and the average duration of PCA use was 2.7 ± 0.8 days. Patients who had an epidural placed for immediate postoperative pain control were 2.2 times more likely to have had an intraoperative Foley catheter placed than those who received PCA pain control postoperatively (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.4–3.6, P < .01) (Table 1). The Foley catheter was removed before epidural discontinuation in 62% (63/ 102) of patients with an epidural and intraoperative Foley. Overall, the average time of Foley removal was 23 hours before epidural discontinuation in these patients; however, hospital 1 removed the Foley on average 51 hours before epidural discontinuation while hospi-
100% 27
90%
84%
80% 70%
115
60% 50%
39%
40%
144
30% 20%
74
10% 0%
Hospital 1 (n=189)
Hospital 2 (n=171) Foley
No Foley
Fig. Variation in practice of intraoperative Foley catheter placement: comparison of 2 tertiary-care academic pediatric hospitals.
tal 2 removed the Foley on average 19 hours after epidural discontinuation. The urinary retention rate of patients who had an intraoperative Foley catheter placed was 1.4% (3/218) compared with 34% (48/142) in patients without an intraoperatively placed Foley catheter (P < .01). There were no urinary tract infections in the entire study population. A multivariable analysis was then performed to identify risk factors that may increase the likelihood of urinary retention in patients without intraoperative placement of a Foley catheter. After adjusting for sex, age at time of operation, BMI, Haller index, and pain control regimen, only epidural pain control was a risk factor for urinary retention. Patients with epidural pain control were 3.7 times more likely to have urinary retention than those with a PCA (OR 3.7, 95% CI 1.6–8.5, P < .01) (Table 2). In patients without an intraoperative Foley catheter, the rate of urinary retention with an epidural (55%, 18/33) was greater (P = .002) compared with PCA (26%, 27/105). Discussion The Nuss procedure or a modified Nuss procedure is a common approach for the repair of pectus excavatum by pediatric sur-
Table 1 Comparison of children with intraoperative Foley catheter placed and those children without an intraoperative Foley catheter placed. Overall (n = 360)
Intraoperative Foley catheter (n = 218)
Demographic characteristics Sex, % male 84% 85% BMI, 19.0 ± 2.3 18.9 ± 2.2 mean ± SD Haller Index, 4.5 ± 1.5 4.5 ± 1.5 mean ± SD Immediate postoperative pain control regimen PCA 221 (61%) 116 (52%) Epidural 114 (32%) 81 (71%) Both 25 (7%) 21 (84%)
No Intraoperative Foley catheter (n = 142)
P value
82% 19.2 ± 2.5
.53 .43
4.4 ± 1.5
.64
105 (48%) 33 (29%) 4 (16%)
<.01
PCA, patient controlled analgesia; SD, standard deviation.
Please cite this article in press as: Tyler C. Friske, et al., Are Foley catheters needed after minimally invasive repair of pectus excavatum?, Surgery (2017), doi: 10.1016/ j.surg.2017.10.049
ARTICLE IN PRESS T.C. Friske et al. / Surgery ■■ (2017) ■■–■■
Table 2 Multivariate analysis of risk factors that may increase the likelihood of urinary retention in children without an intraoperative Foley catheter placed. Variable
Odds Ratio (95% CI)
P value
Female versus male Age at operation BMI Haller Index Immediate postoperative pain control regimen: epidural versus PCA
0.53 (0.18, 1.52) 0.95 (0.79, 1.15) 1.11 (0.95, 1.31) 1.21 (0.92, 1.58) 3.66 (1.58, 8.46)
.23 .58 .18 .18 <.01
geons. These less invasive techniques are often more appealing to patients and families but still necessitate the need for substantial pain control with narcotics in the immediate postoperative period. One of the theoretic adverse effects of the increased narcotic requirements is the potential for urinary retention in this mostly adolescent population. The sacral parasympathetic nervous system controls detrusor emptying, and systemic opioids have been found to inhibit acetylcholine release from these nerves.11 In this study, we evaluated the postoperative rate of urinary retention in this population to determine the need for routine postoperative placement of a Foley catheter. Our data from 2, tertiary-care, academic children’s hospitals indicates that there is substantial variation in practice in the use of routine postoperative Foley catheters after MIRPE. Patient characteristics did not seem to influence the decision for intraoperative placement of a Foley catheter at either institution; however, patients who received an epidural in the operating room were 2.2 times more likely to have an intraoperative Foley catheter placed than patients to be treated with PCA pain control. As we analyzed the cohort of patients who did not have an intraoperative Foley catheter placed, we determined that the urinary retention rate was 34% in this population compared with just 1.4% in patients who did have an intraoperatively placed Foley catheter. Further multivariable analysis indicated that the only risk factor for increasing the likelihood of urinary retention was epidural pain control. Although patients with epidural pain control were 3.7 times more likely to have urinary retention compared with those who had PCA pain control, there was still a high rate of urinary retention in the PCA group. Ultimately, our study demonstrated that 55% of patients with epidural pain control and 26% of patients with PCA pain control have urinary retention after MIRPE if an intraoperative Foley catheter is not placed. Frawley et al12 reported their experience recently with postoperative pain management after a minimally invasive repair of pectus excavatum in children. Mean duration of PCA for their patients was 3.8 days and was associated with a urinary retention rate of 18%.12 Our PCA duration was less at a mean of 2.7 days, and although their total average morphine equivalent daily dose was 2.2 mg/kg/day, ours was less at 1.5 mg/kg/day. In the literature, morphine equivalent daily doses reported after pectus excavatum repair range from 0.6 to 5 mg/kg/day.13-16 With the relatively high urinary retention rate after MIRPE in patients without an intraoperative Foley catheter (34%), regardless of postoperative pain control regimen, and no urinary tract infections in the entire study population, some may suggest that routine placement of a Foley catheter and continuation should be considered during MIRPE. The added fact that the treatment for urinary retention in this population resulted in straight catheterization or Foley catheter placement in an awake population of adolescents may influence some surgical and pain management teams. Although the potential for urinary retention after epidural catheter placement is routinely recognized by most providers, these data also suggest that
3
the potential for urinary retention should be considered with PCA pain control after minimally invasive repair of pectus excavatum. This study had several limitations. As a retrospective review, the rates of urinary retention and urinary tract infections may be underrepresentative because of the limitations of the accuracy of the medical charts and completeness of documentation. Also, the lack of monitoring of pain control does not permit us to comment on the appropriateness of epidural vs PCA for pain control which may in itself help to suggest whether epidural and/or PCA should be used to control pain. Additionally, although we analyzed 2 institutions with different practices regarding placement of Foley catheters in patients undergoing MIRPE, the sample size of this study may not be sufficiently large to detect all differences, especially for urinary retention, a complication that is relatively rare. Conclusions Intraoperative Foley catheter placement obviates the risk of urinary retention without increasing the risk of urinary tract infection in children and young adults after a minimally invasive repair of pectus excavatum. These results will allow surgeons to better counsel patients and families regarding placement of Foley catheter during minimally invasive repair of pectus excavatum. References 1. Fokin AA, Steuerwald NM, Ahrens WA, Allen KE. Anatomical, histologic, and genetic characteristics of congenital chest wall deformities. Semin Thorac Cardiovasc Surg 2009;21:44-57. 2. Nuss D, Kelly RE Jr, Croitoru DP, Katz ME. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998;33:545-52. 3. Kanagaratnam A, Phan S, Tchantchaleishvili V, Phan K. Ravitch versus Nuss procedure for pectus excavatum: systematic review and meta-analysis. Ann Cardiothorac Surg 2016;5:409-21. 4. Weissler EH, Sanati-Mehrizy P, Massenburg B, Jenny H, Taub PJ, Midulla PS. Abstract: complications, length of stay, and economic burden among children undergoing pectus excavatum repair. Plast Reconstruct Surg Glob Open 2016;4:198-9. 5. Molik KA, Engum SA, Rescorla FJ, West KW, Scherer LR, Grosfeld JL. Pectus excavatum repair: experience with standard and minimal invasive techniques. J Pediatr Surg 2001;36:324-8. 6. Fonkalsrud EW. Current management of pectus excavatum. World J Surg 2003;27:502-8. 7. St Peter SD, Weesner KA, Sharp RJ, Sharp SW, Ostlie DJ, Holcomb GW 3rd. Is epidural anesthesia truly the best pain management strategy after minimally invasive pectus excavatum repair? J Pediatr Surg 2008;43:79-82, discussion 82. 8. Sedor J, Mulholland SG. Hospital-acquired urinary tract infections associated with the indwelling catheter. Urol Clin North Am 1999;26:821-8. 9. Tambyah PA, Maki DG. Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients. Arch Intern Med 2000;160:678-82. 10. Shaheen PE, Walsh D, Lasheen W, Davis MP, Lagman RL. Opioid equianalgesic tables: are they all equally dangerous? J Pain Symptom Manage 2009;38:409-17. 11. Baldini G, Bagry H, Aprikian A, Carli F. Postoperative urinary retention: anesthetic and perioperative considerations. Anesthesiology 2009;110:1139-57. 12. Frawley G, Frawley J, Crameri J. A review of anesthetic techniques and outcomes following minimally invasive repair of pectus excavatum (Nuss procedure). Paediatr Anaesth 2016;26:1082-90. 13. Papic JC, Finnell SM, Howenstein AM, Breckler F, Leys CM. Postoperative opioid analgesic use after Nuss versus Ravitch pectus excavatum repair. J Pediatr Surg 2014;49:919-23, discussion 23. 14. Sacco Casamassima MG, Goldstein SD, Salazar JH, McIltrot KH, Abdullah F, Colombani PM. Perioperative strategies and technical modifications to the Nuss repair for pectus excavatum in pediatric patients: a large volume, single institution experience. J Pediatr Surg 2014;49:575-82. 15. Grosen K, Pfeiffer-Jensen M, Pilegaard HK. Postoperative consumption of opioid analgesics following correction of pectus excavatum is influenced by pectus severity: a single-centre study of 236 patients undergoing minimally invasive correction of pectus excavatum. Eur J Cardiothorac Surg 2010;37:833-9. 16. Singhal NR, Jones J, Semenova J, et al. Multimodal anesthesia with the addition of methadone is superior to epidural analgesia: a retrospective comparison of intraoperative anesthetic techniques and pain management for 124 pediatric patients undergoing the Nuss procedure. J Pediatr Surg 2016;51:612-6.
Please cite this article in press as: Tyler C. Friske, et al., Are Foley catheters needed after minimally invasive repair of pectus excavatum?, Surgery (2017), doi: 10.1016/ j.surg.2017.10.049
Contents lists available at ScienceDirect
Surgery j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / y m s y
Are Foley catheters needed after minimally invasive repair of pectus excavatum? Tyler C. Friske a, Richard Sola b, Yangyang R. Yu a,c, Abdur R. Jamal a, Eric Rosenfeld a,c, Huirong Zhu d, Mark V. Mazziotti a,c, Shawn D. St. Peter b, and Sohail R. Shah a,c,* a
Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX Division of Pediatric Surgery, Children’s Mercy Hospital, Kansas City, MO c Division of Pediatric Surgery, Texas Children’s Hospital, Houston, TX d Division of Outcomes and Impact Service, Texas Children’s Hospital, Houston, TX b
A R T I C L E
I N F O
Article history: Accepted 18 October 2017
A B S T R A C T
Background. High narcotic requirements after minimally invasive repair of pectus excavatum (MIRPE) can increase the risk of urinary retention. Placement of intraoperative Foley catheters to minimize this risk is variable. This study determines the rate of urinary retention in this population to guide future practice. Materials and Methods. We reviewed retrospectively all patients who underwent MIRPE from January 2012 to July 2016 at 2 academic children’s hospitals. Data collected included demographics, BMI, severity of the pectus defect, postoperative pain management, and the incidence of urinary retention and urinary tract infection (UTI). Results. Of 360 total patients who underwent MIRPE, 218 had an intraoperative Foley catheter. Patients with epidural pain control were more likely to receive a Foley catheter. The urinary retention rate was 34% for patients without an intraoperative Foley, and 1% in patients after removal of an intraoperatively placed Foley. Urinary retention was greater with an epidural compared with patient-controlled anesthesia (55% vs 26%, P = .002) in the no intraoperative Foley group. No urinary tract infections were identified. Epidural pain control was the only risk factor on multivariate analysis for retention in patients without an intraoperatively Foley catheter. Conclusion. Intraoperative Foley catheters obviate urinary retention without increasing the risk of urinary tract infection after MIRPE. These results will allow surgeons to better counsel patients regarding Foley placement. © 2017 Elsevier Inc. All rights reserved.
Pectus excavatum is a chest wall deformity characterized by inward depression of the sternum and adjacent costal cartilage. Pectus excavatum constitutes approximately 90% of all anterior chest wall deformities, with an estimated incidence of 1 in 400 to 1,000 live births.1 The most common techniques for operative repair of pectus excavatum include the Ravitch and Nuss procedures.2,3 The Nuss procedure or a modified version of the Nuss procedure is often the favored technique for many pediatric surgeons because of its minimally invasive approach. This minimally invasive repair of pectus excavatum (MIRPE) offers an advantage of improved incisional cosmesis with an average duration of stay of 4.6 days.3,4 The primary reason for an extended duration of stay for patients who undergo
Presented at the 12th Annual Academic Surgical Congress, February 7–9, 2017, Las Vegas, Nevada. The authors have no conflict of interests or financial funding in completing this study to report or disclose. * Corresponding author. Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin Suite 1210, Houston, TX 77030. E-mail address: [email protected] (S.R. Shah).
MIRPE is an increased intravenous narcotic requirement for postoperative pain control.5,6 The type of narcotic pain control varies between institutions but typically involves either regional thoracic epidural analgesia (epidural) or intravenous patient-controlled analgesia (PCA).7 The amount of narcotic requirements after MIRPE raise concern for urinary retention in this patient population. Intraoperative Foley catheters are often placed to minimize the risk of this complication; however, there is variation in this practice. Additionally, Foley catheterization has been found to increase the risk of urinary tract infection in certain populations.8,9 The purpose of this study was to determine the urinary retention rate of patients who undergo minimally invasive repair of pectus excavatum. We hypothesized that the rate of urinary retention after MIRPE may be high enough to support routine use of intraoperative Foley catheterization. Methods After Institutional Review Board approval at both institutions (H38983, 15060265), a retrospective review was performed of all
https://doi.org/10.1016/j.surg.2017.10.049 0039-6060/© 2017 Elsevier Inc. All rights reserved.
Please cite this article in press as: Tyler C. Friske, et al., Are Foley catheters needed after minimally invasive repair of pectus excavatum?, Surgery (2017), doi: 10.1016/ j.surg.2017.10.049
ARTICLE IN PRESS T.C. Friske et al. / Surgery ■■ (2017) ■■–■■
2
patients who underwent MIRPE from January 2012 to July 2016 at 2 tertiary-care academic children’s hospitals. Patients who underwent an open operative procedure for pectus excavatum repair and patients older than 22 years were excluded. Data collected included patient characteristics and postoperative variables, including type of postoperative pain management, amount of narcotic administered, duration of hospitalization, and incidence of urinary tract infection. For comparative purposes, PCA and epidural narcotic doses were converted to parenteral morphine equivalents based on published equianalgesic charts.10 The study population was then divided into 2 cohorts to determine rate of urinary retention: patients with and without placement of an intraoperative Foley catheter. A comparative analysis of rates of urinary retention was then performed between the 2 cohorts. Urinary retention was defined as the inability to void spontaneously requiring straight catheterization or placement of a Foley catheter in the postoperative period. Statistical analysis was performed using SAS software (Version 9.3; SAS Institute, Inc, Cary, NC). Patient characteristics and outcomes are described descriptively using counts and proportions for categorical variables and as mean ± standard deviation for parametric continuous variables or median (interquartile ratio [IQR]) for nonparametric continuous variables. Comparative analysis was performed using the Wilcoxon Mann-Whitney test and Fisher exact test or χ2 square test, as appropriate. Additional univariate and multivariate logistic regression models were used to identify potential risk factors. Results During the study period, 360 patients underwent MIRPE and met the inclusion criteria for this study. The mean age at the time of operation was 15.7 ± 2.1 years, 84% of patients were male (n = 302), and the mean body mass index (BMI) was 19.0 ± 2.3. The mean reported Haller Index score was 4.5 ± 1.5. The mean intravenous morphine equivalent dose administered was 1.5 ± 1.2 mg/kg/day per patient with a mean duration of stay of 4.5 ± 1.1 days. Hospital 1 contributed 189 patients (53%) and hospital 2 contributed 171 patients (47%) to the total study population. Intraoperative Foley catheter use varied at the 2 institutions, with hospital 1 placing intraoperative Foley catheters in 39% of patients (74/189) and hospital 2 placing Foley catheters in 84% of patients (144/171) undergoing MIRPE (P < .01) (Fig). Median duration of Foley catheter use for the 218 patients with an intraoperatively placed Foley catheter was 55 hours (IQR 42–73 hours). Median duration of Foley catheter was less at hospital 1 compared with hospital 2 (28 hours [IQR 23–47 hours] vs 71 hours [IQR 52–75 hours]; P < .001). A comparative analysis of patients with and without intraoperative Foley catheter placement found no significant difference in sex, BMI, or Haller Index score. The postoperative regimen of pain control did, however, influence placement of an intraoperative Foley catheter. Of the 360 patients, 221 (61%) received a PCA exclusively, 114 (32%) received an epidural exclusively, and 25 (7%) received both for postoperative pain management. The average duration of epidural use in our cohort was 2.9 ± 1.1 days and the average duration of PCA use was 2.7 ± 0.8 days. Patients who had an epidural placed for immediate postoperative pain control were 2.2 times more likely to have had an intraoperative Foley catheter placed than those who received PCA pain control postoperatively (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.4–3.6, P < .01) (Table 1). The Foley catheter was removed before epidural discontinuation in 62% (63/ 102) of patients with an epidural and intraoperative Foley. Overall, the average time of Foley removal was 23 hours before epidural discontinuation in these patients; however, hospital 1 removed the Foley on average 51 hours before epidural discontinuation while hospi-
100% 27
90%
84%
80% 70%
115
60% 50%
39%
40%
144
30% 20%
74
10% 0%
Hospital 1 (n=189)
Hospital 2 (n=171) Foley
No Foley
Fig. Variation in practice of intraoperative Foley catheter placement: comparison of 2 tertiary-care academic pediatric hospitals.
tal 2 removed the Foley on average 19 hours after epidural discontinuation. The urinary retention rate of patients who had an intraoperative Foley catheter placed was 1.4% (3/218) compared with 34% (48/142) in patients without an intraoperatively placed Foley catheter (P < .01). There were no urinary tract infections in the entire study population. A multivariable analysis was then performed to identify risk factors that may increase the likelihood of urinary retention in patients without intraoperative placement of a Foley catheter. After adjusting for sex, age at time of operation, BMI, Haller index, and pain control regimen, only epidural pain control was a risk factor for urinary retention. Patients with epidural pain control were 3.7 times more likely to have urinary retention than those with a PCA (OR 3.7, 95% CI 1.6–8.5, P < .01) (Table 2). In patients without an intraoperative Foley catheter, the rate of urinary retention with an epidural (55%, 18/33) was greater (P = .002) compared with PCA (26%, 27/105). Discussion The Nuss procedure or a modified Nuss procedure is a common approach for the repair of pectus excavatum by pediatric sur-
Table 1 Comparison of children with intraoperative Foley catheter placed and those children without an intraoperative Foley catheter placed. Overall (n = 360)
Intraoperative Foley catheter (n = 218)
Demographic characteristics Sex, % male 84% 85% BMI, 19.0 ± 2.3 18.9 ± 2.2 mean ± SD Haller Index, 4.5 ± 1.5 4.5 ± 1.5 mean ± SD Immediate postoperative pain control regimen PCA 221 (61%) 116 (52%) Epidural 114 (32%) 81 (71%) Both 25 (7%) 21 (84%)
No Intraoperative Foley catheter (n = 142)
P value
82% 19.2 ± 2.5
.53 .43
4.4 ± 1.5
.64
105 (48%) 33 (29%) 4 (16%)
<.01
PCA, patient controlled analgesia; SD, standard deviation.
Please cite this article in press as: Tyler C. Friske, et al., Are Foley catheters needed after minimally invasive repair of pectus excavatum?, Surgery (2017), doi: 10.1016/ j.surg.2017.10.049
ARTICLE IN PRESS T.C. Friske et al. / Surgery ■■ (2017) ■■–■■
Table 2 Multivariate analysis of risk factors that may increase the likelihood of urinary retention in children without an intraoperative Foley catheter placed. Variable
Odds Ratio (95% CI)
P value
Female versus male Age at operation BMI Haller Index Immediate postoperative pain control regimen: epidural versus PCA
0.53 (0.18, 1.52) 0.95 (0.79, 1.15) 1.11 (0.95, 1.31) 1.21 (0.92, 1.58) 3.66 (1.58, 8.46)
.23 .58 .18 .18 <.01
geons. These less invasive techniques are often more appealing to patients and families but still necessitate the need for substantial pain control with narcotics in the immediate postoperative period. One of the theoretic adverse effects of the increased narcotic requirements is the potential for urinary retention in this mostly adolescent population. The sacral parasympathetic nervous system controls detrusor emptying, and systemic opioids have been found to inhibit acetylcholine release from these nerves.11 In this study, we evaluated the postoperative rate of urinary retention in this population to determine the need for routine postoperative placement of a Foley catheter. Our data from 2, tertiary-care, academic children’s hospitals indicates that there is substantial variation in practice in the use of routine postoperative Foley catheters after MIRPE. Patient characteristics did not seem to influence the decision for intraoperative placement of a Foley catheter at either institution; however, patients who received an epidural in the operating room were 2.2 times more likely to have an intraoperative Foley catheter placed than patients to be treated with PCA pain control. As we analyzed the cohort of patients who did not have an intraoperative Foley catheter placed, we determined that the urinary retention rate was 34% in this population compared with just 1.4% in patients who did have an intraoperatively placed Foley catheter. Further multivariable analysis indicated that the only risk factor for increasing the likelihood of urinary retention was epidural pain control. Although patients with epidural pain control were 3.7 times more likely to have urinary retention compared with those who had PCA pain control, there was still a high rate of urinary retention in the PCA group. Ultimately, our study demonstrated that 55% of patients with epidural pain control and 26% of patients with PCA pain control have urinary retention after MIRPE if an intraoperative Foley catheter is not placed. Frawley et al12 reported their experience recently with postoperative pain management after a minimally invasive repair of pectus excavatum in children. Mean duration of PCA for their patients was 3.8 days and was associated with a urinary retention rate of 18%.12 Our PCA duration was less at a mean of 2.7 days, and although their total average morphine equivalent daily dose was 2.2 mg/kg/day, ours was less at 1.5 mg/kg/day. In the literature, morphine equivalent daily doses reported after pectus excavatum repair range from 0.6 to 5 mg/kg/day.13-16 With the relatively high urinary retention rate after MIRPE in patients without an intraoperative Foley catheter (34%), regardless of postoperative pain control regimen, and no urinary tract infections in the entire study population, some may suggest that routine placement of a Foley catheter and continuation should be considered during MIRPE. The added fact that the treatment for urinary retention in this population resulted in straight catheterization or Foley catheter placement in an awake population of adolescents may influence some surgical and pain management teams. Although the potential for urinary retention after epidural catheter placement is routinely recognized by most providers, these data also suggest that
3
the potential for urinary retention should be considered with PCA pain control after minimally invasive repair of pectus excavatum. This study had several limitations. As a retrospective review, the rates of urinary retention and urinary tract infections may be underrepresentative because of the limitations of the accuracy of the medical charts and completeness of documentation. Also, the lack of monitoring of pain control does not permit us to comment on the appropriateness of epidural vs PCA for pain control which may in itself help to suggest whether epidural and/or PCA should be used to control pain. Additionally, although we analyzed 2 institutions with different practices regarding placement of Foley catheters in patients undergoing MIRPE, the sample size of this study may not be sufficiently large to detect all differences, especially for urinary retention, a complication that is relatively rare. Conclusions Intraoperative Foley catheter placement obviates the risk of urinary retention without increasing the risk of urinary tract infection in children and young adults after a minimally invasive repair of pectus excavatum. These results will allow surgeons to better counsel patients and families regarding placement of Foley catheter during minimally invasive repair of pectus excavatum. References 1. Fokin AA, Steuerwald NM, Ahrens WA, Allen KE. Anatomical, histologic, and genetic characteristics of congenital chest wall deformities. Semin Thorac Cardiovasc Surg 2009;21:44-57. 2. Nuss D, Kelly RE Jr, Croitoru DP, Katz ME. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998;33:545-52. 3. Kanagaratnam A, Phan S, Tchantchaleishvili V, Phan K. Ravitch versus Nuss procedure for pectus excavatum: systematic review and meta-analysis. Ann Cardiothorac Surg 2016;5:409-21. 4. Weissler EH, Sanati-Mehrizy P, Massenburg B, Jenny H, Taub PJ, Midulla PS. Abstract: complications, length of stay, and economic burden among children undergoing pectus excavatum repair. Plast Reconstruct Surg Glob Open 2016;4:198-9. 5. Molik KA, Engum SA, Rescorla FJ, West KW, Scherer LR, Grosfeld JL. Pectus excavatum repair: experience with standard and minimal invasive techniques. J Pediatr Surg 2001;36:324-8. 6. Fonkalsrud EW. Current management of pectus excavatum. World J Surg 2003;27:502-8. 7. St Peter SD, Weesner KA, Sharp RJ, Sharp SW, Ostlie DJ, Holcomb GW 3rd. Is epidural anesthesia truly the best pain management strategy after minimally invasive pectus excavatum repair? J Pediatr Surg 2008;43:79-82, discussion 82. 8. Sedor J, Mulholland SG. Hospital-acquired urinary tract infections associated with the indwelling catheter. Urol Clin North Am 1999;26:821-8. 9. Tambyah PA, Maki DG. Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients. Arch Intern Med 2000;160:678-82. 10. Shaheen PE, Walsh D, Lasheen W, Davis MP, Lagman RL. Opioid equianalgesic tables: are they all equally dangerous? J Pain Symptom Manage 2009;38:409-17. 11. Baldini G, Bagry H, Aprikian A, Carli F. Postoperative urinary retention: anesthetic and perioperative considerations. Anesthesiology 2009;110:1139-57. 12. Frawley G, Frawley J, Crameri J. A review of anesthetic techniques and outcomes following minimally invasive repair of pectus excavatum (Nuss procedure). Paediatr Anaesth 2016;26:1082-90. 13. Papic JC, Finnell SM, Howenstein AM, Breckler F, Leys CM. Postoperative opioid analgesic use after Nuss versus Ravitch pectus excavatum repair. J Pediatr Surg 2014;49:919-23, discussion 23. 14. Sacco Casamassima MG, Goldstein SD, Salazar JH, McIltrot KH, Abdullah F, Colombani PM. Perioperative strategies and technical modifications to the Nuss repair for pectus excavatum in pediatric patients: a large volume, single institution experience. J Pediatr Surg 2014;49:575-82. 15. Grosen K, Pfeiffer-Jensen M, Pilegaard HK. Postoperative consumption of opioid analgesics following correction of pectus excavatum is influenced by pectus severity: a single-centre study of 236 patients undergoing minimally invasive correction of pectus excavatum. Eur J Cardiothorac Surg 2010;37:833-9. 16. Singhal NR, Jones J, Semenova J, et al. Multimodal anesthesia with the addition of methadone is superior to epidural analgesia: a retrospective comparison of intraoperative anesthetic techniques and pain management for 124 pediatric patients undergoing the Nuss procedure. J Pediatr Surg 2016;51:612-6.
Please cite this article in press as: Tyler C. Friske, et al., Are Foley catheters needed after minimally invasive repair of pectus excavatum?, Surgery (2017), doi: 10.1016/ j.surg.2017.10.049