Transcript Evidence-Based Perioperative Care for Pectus Excavatum

Jennifer Kasten, MD, MSc(Oxon), MSc(London)
PGY-1, University of Washington
26 August 2010
Pectus Excavatum: Overview
 Most common congenital chest wall deformity
 Incidence: 1/400– 7.9/1000 live births
 Male predominance, roughly 4:1
 Created by posterior angulation of sternum, as well as
posterior angulation of costal cartilages
 May be symmetric or asymmetric
 90% of cases: noticed in first year of life
Presentation
 Most common symptoms: shortness of breath during




exercise, limited physical activity
Improvement after repair is often noted
Multiple studies have demonstrated a restrictive defect on
PFTs
Relief of symptoms is likely related to decompression of the
right ventricle as much as intrathoracic volume expansion
Adolescents often troubled by cosmetic implications
Shamberger, R. Congenital Chest Wall Deformities. Current Problems in Surgery
1996: 33: 471-542.
Cosmesis is an important operative indication
Operative Techniques
 Ravitch versus Nuss
 Ravitch: open technique involves resection of costal
cartilage and perichondrium, sternal osteotomies,
anterior fixation of the sternum with wires
 Nuss: thoracoscopic repair: place introducer in deepest
apex of chest, flip to correct deformity, place
permanent bar
Meta-Analysis Comparing the Two
Techniques Shows Equivalency
 Sick Kids group reviewed 9 retrospective & prospective studies; no
RTCs exist
 No difference:
1) overall complication rates
2) hospital stay
3) time to ambulation post-op
4) patient satisfaction with outcome
 Ravitch superior to Nuss in:
1) rates of bar migration
2) persistent deformity
3) post-op PTX, hemothorax
 Nuss superior to Ravich in:
1) operative time
1. Nasr A, Fecteau A, Wales PW. Comparison of the Nuss and the Ravitch procedure
for pectus excavatum repair: a meta-analysis.J Pediatr Surg. 2010 May;45(5):880-6.
“Learning Curve”
 “One hundred and sixty seven patients… were included in this study.
Major complications occurred in seven patients (4.2%) and consisted of
one intraoperative heart perforation, one piercing of the liver with the
trocar, bar infections (n = 2) and significant bar displacement (n = 3).
Minor complications were seen in 122 patients (73.1%) and consisted of
breakage of wires used to secure the lateral stabilizer plate (n = 48),
pleural effusions (n = 28), intraoperative rupture of the intercostal
muscle (n = 15), pericardial tears without clinical significance (n = 7)
and lung atelectasia (n = 4). Major complications related to the Nuss
procedure were rare but preventable and could mainly be attributed to
the learning curve.”
Castellani C, Schalamon J, Saxena AK, Höellwarth ME.
Early complications of the Nuss procedure for pectus excavatum:
a prospective study. Pediatr Surg Int. 2008 Jun;24(6):659-66.
Criteria for Operation
Need two or more of the following per Dr Nuss:
 1) Haller Index >3.25
 2) PFTs demonstrating restrictive/obstructive pulmonary
airway disease
 3) EKG or ECHO showing cardiac compression, murmurs,
MVP, or conduction anomalies
 4) physical symptomatology
Nuss D. “Surgical Treatment of Chest Wall Deformities.” Operative Pediatric Surgery, 6th
Edition (2006).
Cardiopulmonary Benefits of the
Nuss are Questionable
 One study reviewed all data published on CP outcomes
of pectus correction since 1965
 5 studies had homogenous definition criteria and
could be meta-analyzed
 No improvements were found in left ventricular size,
stroke volume, and cardiac output
1. Guntheroth WG, Spiers PS. Cardiac function before and after surgery for pectus
excavatum. Am J Cardiol. 2007 Jun 15;99(12):1762-4. Epub 2007 Apr 25.
The Ravitch Procedure Might Temporarily
Impede Pulmonary Function
 Postoperative total lung capacity for patients who had
Ravitch repair was significantly lower (SMD, 0.71) than
preoperative
 after removal of the Nuss bar, FEV(1) was significantly
increased from preoperative values (SMD, 0.39)
 In this study, stroke volume increased after surgery
(SMD, 0.40)
1. Johnson JN, Hartman TK, Pianosi PT, Driscoll DJ.
Cardiorespiratory function after operation for pectus excavatum. J Pediatr. 2008
Sep;153(3):359-64.
“Satisfactory” Results are Primarily
Cosmetic
 Long-term studies measuring outcomes nearly always
define a satisfactory result in aesthetic terms
 A worthwhile reason to operate
 Pt subjectively report an increase in exercise tolerance,
activity level which is not borne out by
cardiopulmonary testing
Perioperative Care: Pain Control
 Studies have repeatedly demonstrated the superiority of epidural anesthesia
postoperatively.
-- versus PCA alone, pts use less opioid and are weaned from opioids earlier (1); they had
lower pain scores and a greater sense of well-being (4)
-- in a randomized study, epidural anesthesia was superior to PCA in terms of length of
therapy (2.3 versus 3.3 days) and inpatient pain scores (2)
-- Just don’t get your epidural in Kansas City; 65/188 (34.6%) lost their catheter within
24h; PCA was superior re: hospital stay, transition to PO medications (3)
1. Reinoso-Barbero F, Fernández A, Durán P, Castro LE, Campo G, Melo MM. Thoracic epidural analgesia vs
patient-controlled analgesia with intravenous fentanyl in children treated for pectus excavatum with the
Nuss procedureRev Esp Anestesiol Reanim. 2010 Apr;57(4):214-9.
2. Soliman IE, Apuya JS, Fertal KM, Simpson PM, Tobias JD. Intravenous versus epidural analgesia after surgical
repair of pectus excavatum. Am J Ther. 2009 Sep-Oct;16(5):398-403
3. St Peter SD, Weesner KA, Sharp RJ, Sharp SW, Ostlie DJ, Holcomb GW3rd Is epidural anesthesia truly the best
pain management strategy after minimally invasive pectus excavatum repair?.J Pediatr Surg. 2008 Jan;43(1):7982; discussion 82.
4. Weber T, Mätzl J, Rokitansky A, Klimscha W, Neumann K, Deusch E; Superior postoperative pain relief with
thoracic epidural analgesia versus intravenous patient-controlled analgesia after minimally invasive pectus
excavatum repair. J Thorac Cardiovasc Surg. 2007 Oct;134(4):865-70.
Severity of Pectus Predicts Opioid Use
 Survey of 236 patients undergoing Nuss Procedure:
preoperative CT measuring Haller Index linearly regressed
to opoid use
 Found each 1cm increase accounted for a 6% increase in
opiate consumption
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 Apr;37(4):833-9.
Physical Therapy: Useful in the
Acute Inpatient Setting
 Postural/skeletal defects common in pectus kids
 Need for teaching re: sternal precauations, monitoring
mobility
 Use in acute, inpatient setting validated (1)
1. Schoenmakers MA, Gulmans VA, Bax NM, Helders PJ.
Physiotherapy as an adjuvant to the surgical treatment of anterior chest
wall deformities: a necessity? A prospective descriptive study in 21
patients. J Pediatr Surg. 2000 Oct;35(10):1440-3.
Pectus Kids Value Pain Control over
Emesis Control
 Intriguing study questioned 45 Nuss patients re: their
preferences : if they could have zero pain, how much
vomiting were they willing to accept?
 The maximum risk of vomiting that the overall study
population was willing to accept to decrease the pain level
to zero was 32% +/- 24%.
 Girls were willing to take a significantly higher risk (41% +/24%) compared to boys (25% +/- 22%).
1. Cucchiaro G, Farrar JT, Guite JW, Li Y.What
postoperative outcomes matter to pediatric patients?
Anesth Analg. 2006 May;102(5):1376-82.
Chart Review: Inclusion Criteria
 Underwent pectus repair at SCH in 2009 or 2010:
39 patients
 Primary repairs only (exclude bar removal procedures):
37 patients
 Chart available for review 8/25/2010:
32 patients, of whom 2 are current inpatients
 Therefore 32 charts thoroughly reviewed
Demographics
 Males: 26; Females: 6
 2 Hispanic, 2 East/South Asian, 28 Caucasian
 Average age at surgery: 16 years, 3 months (range:
11.67 y – 22.5y)
 No age difference between males & females: 16.13y (F)
versus 16.31y (M)
 Procedure undergone: 1 bar Nuss (20); 2 bar Nuss (2);
Ravitch (0)
Body Habitus
 Slim and asthenic
 Scoliosis documented in
2/32 (6.25%)
 Average BMI: 19.63
(range: 13.6 – 24.2)
 Females slimmer: (18.57
versus 19.88)
Pre-Op Workup
 31/32 (96.9%) of patients received preoperative
Pulmonary Function Tests and cardiovascular stress
tests
 13/31 (41.9%) had demonstrable restrictive lung
deficits, cardiac compression, or both
 28/32 (87.5%) had a documented preoperative CT scan
to assess the Haller Index
Average Haller Index
 4.36
(normal ~2.5; upper limit
of normal 3.25)
 Males more severe: 4.10
(F) versus 4.43 (M)
Length of Stay
 Average Length of Stay: 3.96 days
 Females had slightly shorter stays: 3.8 days versus 4.0 days







1d:
2d:
3d:
4d:
5d:
6d:
7d:
0
0
13
10
5
0
2
Epidural Anesthesia
 Epidural catheters were used for postoperative pain




control in 100% (32/32) patients
A variety of local anesthetics were used, most often
ropivucaine
PCEAs were used in 8/32 (25%)
Additional morphine or dilaudid PCAs were used in
13/32 (40.6%)
 in 2 of these cases, the epidural failed
10 patients had an epidural alone
Epidural Out?
 On average, the epidural was successfully discontinued
after 2.54 days
 POD #2: 15 pts (46.9%); POD#3: 12 pts (37.5%); POD
#5: 1 patient (3.1%); failed: 2 patients (6.25%)
 14/32 patients experienced moderate-severe nausea
while an inpatient (43.4%); this was not associated
with time till dc of epidural
Discharge Pain Regimens
 Known regimens: 25/30 (83.3%) documented in






discharge summaries, paper chart.
Tylenol: 25/25 (100%)
ibuprofen: 23/25 (92%)
oxycodone: 25/25 (100%)
oxyContin: 17/25 (68%)
flexeril: 1/25 (4%)
lorezapam: 1/25 (4%)
Physical Therapy
 PT advised for mobilization, teaching re: sternal
precautions
 10/30 (33%) patients who have completed their
hospital course were formally seen by Physical
Therapy
Postoperative Complications









Pneumothorax: 20/30
Inadequate pain control: 19/30
Nausea & vomiting: 12/30
Presented to Emergency Room/ Surgery Clinic within 3
days of discharge: 7/30 (23.3%)
Significant weight loss, > 5% preop weight: 4/30
Constipation requiring medical attention: 4/30
Readmitted to SCH: 3/30 (10%!)
Hallucinations: 2/30
Fever, urinary retention, hematoma, RUQ pain, diarrhea: 1
each
Suggestions for the Future
 Standardize criteria for discharge with long-lasting opioids
(i.e. OxyContin); potentially use Haller index as predictor
 Incorporate physical therapy for mobilization, sternal
precautions teaching
 Aggressive bowel regimens as outpatient and inpatient
 Closer look at inpatient pain regimens; descriptive
statistics on patient outcomes regressed to specific pain
regimens
Standardizing a Pathway
 Per IT we can amend the existing “Pectus” orderset;
turnaround is 2-3 weeks
 Existing set: Labs (CBC, coags); CXR/CT; EKG/ECHO;
Consults
 Could include standard medications (esp bowel prep,
muscle relaxants[1]), physical therapy consult, antiemetics
1. Inge TH, Owings E, Blewett CJ, Baldwin CE, Cain WS, Hardin W, Georgeson KE.
Reduced hospitalization cost for patients with pectus excavatum treated
using minimally invasive surgery. Surg Endosc. 2003 Oct;17(10):1609-13.