Patients Undergoing Pectus Excavatum Repair Research Articles

The implementation of a pectus bar insertion enhanced recovery after surgery pathway: A quality improvement initiative.

Pectus excavatum repair is associated with significant discomfort, and pain is a primary contributor to postoperative hospital length of stay. Recent advances in postoperative pain control include the use of intercostal cryoablation techniques that may now make it possible to discharge patients on the day of surgery. Unnecessary variation in patient care and noncompliance with care bundles may be a factor in extended length of stay. The global aim of this quality improvement initiative was to successfully implement an enhanced recovery after surgery (ERAS) pathway on patients undergoing pectus excavatum repair. The SMART aim was to have a greater than 70% compliance for the perioperative bundle elements within 1 year of the pathway implementation. Multiple Plan-Do-Study-Act (PDSA) cycles were designed to create and implement an ERAS pathway for patients undergoing a pectus bar insertion procedure. This multidisciplinary pathway was designed, managed, and implemented with key stakeholders from the Departments of Evidence Based Practice, Surgery, Anesthesiology, and Perioperative Nursing. Patient characteristics, outcomes, and compliance with elements of the pathway were measured for analysis for both the baseline and post-intervention groups with monthly automated reports. After implementation of the ERAS pathway, data on the first 50 patients showed a 90% compliance with the perioperative bundle elements. Mean length of stay was significantly decreased from 33 h (95% CI [28.76, 37.31]) to 18 h (95% CI [14.54, 21.70]). There were zero readmissions within 24 hours for patients who were discharged on the day of surgery. Employing a multidisciplinary approach in both planning and execution that standardized clinician practices and minimized unnecessary variation in patient care, an ERAS pathway for pectus bar insertion has been successfully established at our institution.

Analysis of Factors Affecting Postoperative Opioid Requirement in Pediatric Patients Undergoing Pectus Excavatum Repair with Multimodal Analgesic Management.

Children with pectus excavatum are treated with surgical repair in a procedure known as minimally invasive repair of pectus excavatum (MIRPE). MIRPE causes considerable postoperative pain, resulting in the administration of a substantial dose of opioids. This study aimed to identify perioperative factors that influence the requirement for opioids in children undergoing MIRPE. Retrospective data from children who underwent MIRPE were analyzed. A multimodal analgesic protocol was implemented with a continuous wound infiltration system and administration of non-opioid analgesics. Intravenous opioid analgesics were administered if the pain score was greater than 4. The cumulative opioid use was assessed by calculating the morphine equivalent dose at 6, 24, and 48 h after surgery. Perioperative factors affecting the postoperative opioid use were identified with multiple linear regression analyses. This study included 527 children aged 3-6 years, with a mean age of 3.9 years. Symmetrically depressed chest walls, a lower Haller index, and a lower revised depression index were found to be associated with decreased postoperative opioids. Boys required higher opioid doses than girls. Longer pectus bars (10 inches versus 9 inches) were associated with increased opioid use. Severity indices, gender, and the length of pectus bars influence postoperative opioid requirement in children undergoing MIRPE surgery with multimodal analgesia.

R15. Initiation of Clinical Care Guidelines for Pectus Excavatum Patients: A Retrospective Review

Adolescents undergoing pectus deformity repairs typically have significant postoperative pain. Management following repair consists of opioids, non-opioid adjuvants with either a thoracic epidural or paravertebral catheter.1,2 Enhanced Recovery After Surgery (ERAS) protocols have been established in the adult population and are now becoming more common in pediatrics and adolescents.2,3 A standardized Pectus Pain Management Clinical Pathway (PPMCP) was established in 2017 at our institution by the anesthesiology team. Later a multidisciplinary clinical care guideline (CCG) was established in May 2019 through collaboration with the surgery, anesthesia, physical therapy and nursing teams. The acute pain team at Lurie Children's Hospital of Chicago have observed improvement in the postoperative course of these patients since the establishment of both the PPMCP and then the CCG. Therefore, a retrospective study was done to evaluate the effects of standardization of care for patients undergoing pectus excavatum repair.

A New Device for Thoracoscopic Cryoanalgesia in Pectus Excavatum Repair: Preliminary Single Center Experience.

Introduction: Cryoanalgesia has been recently described as alternative technique for immediate and persistent pain treatment after pectus excavatum repair. Cryoanalgesia has the potentiality to reduce analgesic consumption and length of hospitalization. However, cryoanalgesia has not been standardized yet: the previous reports describe different techniques and systems and include only small series. In Europe, no reports on cryoanalgesia for pectus repair have been published so far.Materials and Methods: This is a prospective single center pilot study performed in adolescents undergoing minimally invasive pectus excavatum repair with a new cryoanalgesia system, using a probe designed specifically for thoracoscopy. This new double lumen probe has the theoretical advantage of freezing only in its tip, so reducing the risk of complications.Results: Seven patients undergoing pectus excavatum repair were treated with cryoanalgesia performed with the new probe. No complications of cryoanalgesia were reported. Total consumption of morphine during hospital stay was between 0.1 and 0.35 mg/kg, with no side effects reported. Mean time to discharge was 2.4 days. All patients reported a good pain control with a fair need of rescue medications for pain relief during the first week after discharge, and a very good pain control without need of rescue medications during following weeks.Conclusions: Our pilot study showed that the new cryoanalgesia device is efficacious in terms of pain control, hospital stay and resumption of post-operative activities. The cryoprobe designed allowed an easy and safe maneuver. A prospective trial is needed to better define the risks and benefits of this technique.

Analyzing Outcomes of Nuss and Ravitch Repair for Primary and Recurrent Pectus Excavatum in Adults

Limited data exist for pectus excavatum repair in adults. We reviewed outcomes in adult patients undergoing Ravitch or Nuss pectus excavatum repairs to determine whether there was a statistical difference in postoperative complications and recurrence between primary and redo operations. Patients undergoing pectus excavatum repair between 2001 and 2018 were excluded if they were receiving a concurrent unrelated operation, aged younger than 18 years, or had less than 1 year of follow-up (for recurrence analysis). Postoperative complications were recorded based on procedure type (Ravitch/Nuss) and iteration of repair (primary/redo). Continuous patient data were compared using Student t tests for variables such as age, length of stay, estimated blood loss, body mass index, and number of bars inserted. Fisher exact or χ2 tests were performed for postoperative complications and recurrence rates between groups. Of 290 patients, there were no significant differences in postoperative complications or recurrence rates between all Nuss repairs (n= 237; P= .59) and all Ravitch repairs (n= 53; P= .48), redo Nuss repairs (n=53; P= .26) and Ravitch repairs (n=26; P= .99), and primary (P= .26) and redo Nuss (P= .10) repairs or primary (P= .99) and redo Ravitch (P= .99) repairs. There were significant differences in age, length of stay, follow-up, bars inserted, and estimated blood loss betweenall Nuss and Ravitch repairs (P < .05). Postoperative complication and recurrence rates were not statistically different between Nuss and Ravitch procedures of all types, suggesting either procedure may have utility in recurrent pectus excavatum. Further research may look to expand sample size and a prospective study investigating long-term outcomes.

Abstract 16138: Chest and Cardiac Compression on CT/MRI and on TEE Predicts Improvement in Right Heart Chamber Size and Right Ventricular Deformation Post Pectus Excavatum Repair Surgery

Background: Pectus excavatum (PE) deformity involves posterior depression of the sternum and adjacent costal cartilages. The relationship of CT/MRI chest cardiac compression indices used as indications for surgical repair of PE with echocardiographic findings and with improvement in cardiac chamber compression and function post PE repair is unknown. Methods: We evaluated right atrial (RA) size, tricuspid annulus (TA size, right ventricular (RV) outflow tract size as well as RV 2D strain on intra-operative trans-esophageal echocardiography (TEE) immediately pre and post surgical PE repair. Inspiratory and expiratory Haller Index (HI) and cardiac compression indices (CCI) were measured on pre op CT/MR scans (Figure). Offline measurement of chamber dimensions on TEE images was performed and Speckle tracking strain measurements were made using Syngo US Workplace software (Siemens). P&lt;0.05 was considered significant. Results: 60 patients, 73% male, 27% female, age 33.6±10.3 yrs underwent PE repair following CT/MRI from 2010-2014 (Figure). There was a strong correlation between expiratory CT/MRI chest AP diameter and pre-op RA size (panel A). Pre op RA and TA compression on TEE inversely correlated with pre op RV global longitudinal strain rate(RVGLSR) (panels B &amp; C). CCI predicted improvement in RA size post PE repair (panels D &amp; E). In addition pre op RA size on TEE correlated with improvement in RVGLSR post PE repair surgery (panel F). Conclusion: In patients with PE deformity, pre surgical CCI correlated with right-sided cardiac chamber compression on pre op TEE. Severity of chest and cardiac compression also predicted magnitude of improvement in right-sided chamber size and RV longitudinal deformation post PE repair. Our findings provide insight regarding the beneficial effects of PE surgery on right heart chamber compression and improvement in RV function and the important role of intraoperative TEE for patients undergoing PE repair surgery.

Preoperative Patch Testing In Patients Undergoing Pectus Excavatum Repair

The Nuss procedure is a minimally invasive surgery to correct pectus deformities using a stainless-steel rod containing several metals including nickel. Occasionally, devastating complications occur in patients who develop delayed type hypersensitivity to the implanted rod. A retrospective study showed the incidence of metal hypersensitivity was 2.2% in patients having undergone the Nuss procedure. Yet, if metal contact dermatitis is determined a priori, a titanium bar is customized. This case series investigated preoperative incidence of metal allergy in patients scheduled to undergo the Nuss procedure.

Is epidural anesthesia truly the best pain management strategy after minimally invasive pectus excavatum repair?

The repair of pectus excavatum with bar placement is associated with substantial postoperative pain. Optimal pain control strategy has not been addressed with level 1 or substantial level 2 evidence. Many institutions operate under the assumption that a thoracic epidural offers the best pain control for these patients. Therefore, we conducted a retrospective evaluation to examine the validity of this assumption. A retrospective review of patients undergoing pectus excavatum repair with bar placement from January 2000 to February 2006 was conducted. The demographic variables collected included age, sex, weight, and Haller's index scores. Outcome variables included total operating room time, number of calls to the anesthesiologist, hours of urinary catheterization, hours until complete transition to oral pain medication, length of hospitalization, and maximum pain scores for each of the first 5 postoperative days. There were a total of 203 patients, of which 188 had an epidural, compared with 15 with intravenous narcotic therapy. Of the 188 patients committed to an epidural, 65 had a failed attempt in the operating room or a dysfunctional catheter removed within 24 hours. Patients without an epidural had a shorter operating room time, less time of urinary catheterization, decreased time to complete transition to oral medication, and decreased length of hospitalization with lower maximum scores. Our data challenge the assumption that routine epidural catheter placement on all patients undergoing pectus excavatum repair with bar placement offers the best pain management strategy. There is clearly a role for a prospective randomized trial to clarify the best management for these patients.

The effects of intercostal nerve block and IV fentanyl on emergence delirium after sevoflurane anesthesia in pediatric patients undergoing pectus excavatum repair

Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital, Chunan, Republic of Korea

Intravenous Patient-Controlled Analgesia Using Fentanyl after Nuss Procedure in Pediatric Patients Undergoing Pectus Excavatum Repair

Background: Nuss procedure used in pectus excavatum repair is preferred, because of its excellent effect from the cosmetic point of view and improved pulmonary function, but it cause severe pain due to thoracic expansion after the operation. This study was designed to evaluate effective fentanyl dose using an intravenous patient-controlled analgesia (IV-PCA) pump for pain control following pectus excavatum repair in pediatric patients. Methods: Sixty patients undergoing elective thoracic surgery were randomly assigned to received fentanyl 0.5/kg/hr (Group I, n = 20), 0.7/kg/hr (Group II, n = 20), and 1.0/kg/hr (Group III, n = 20) via an IV-PCA pump (basal, 1 ml/h; bolus, 0.5 ml; lock out interval, 30 min) after operation. A blind observer evaluated each patient using the Children’s Hospital of Eastern Ontario pain scale (CHEOPS) and the faces scale (FS). Incidences of side effects and pain control satisfaction were assessed at postoperative 48 hrs. Results: There were no significant differences in CHEOPS or FS score between the groups the postoperative 48 hrs period. CHEOPS and FS scores at 4 and 8 hrs in groups II and III were significantly lower than in group I (P ＜ 0.05), but all groups showed lower CHEOPS and FS scores during the first postoperative 48 hrs. Satisfaction of pain control assessment by mothers was significantly higher in groups II and III than in group I (P ＜ 0.05). CHEOPS and FS scores were highly correlated with each other (P ＜ 0.001). Conclusions: We conclude that infusion of fentanyl at 0.5/kg/hr using an IV-PCA pump is effective for pain control of 5 years of age or older after Nuss procedure.