# Shortness of Breath On Exertion — GCMD Library living collection Everything in the library about shortness of breath on exertion — built automatically from dossiers that name it. Updated: n/a · 5 episodes · 127 cited statements ## Episodes ### Surgical Management - [Update Course Rewind: Pectus Excavatum 2021](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806) — podcast · 11:56 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806.md) - [Update Course Rewind: Pectus Excavatum 2021](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807) — video · 11:56 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807.md) - [Update Course Rewind: Pectus Excavatum 2021](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668) — podcast · 11:55 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668.md) - [Update Course Rewind: Pectus Excavatum 2021](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669) — podcast · 11:55 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669.md) - [Update Course Rewind: Pectus Excavatum 2021](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670) — podcast · 11:55 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670.md) ## Chapters - [0:00](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=0) Introduction and Case Presentation (Ep 1) - [1:02](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=62) Cryoanalgesia: Technique and Results (Ep 1) - [3:14](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=194) Alternative Pain Management: Erector Spinal Catheters (Ep 1) - [5:34](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=334) Multimodal Pain Control Regimens (Ep 1) - [7:22](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=442) Nuss Procedure Technical Variations (Ep 1) - [10:28](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=628) Summary and Closing (Ep 1) - [0:00](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=0) Introduction and Case Presentation (Ep 2) - [1:57](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=117) Cryoanalgesia for Pain Management (Ep 2) - [3:55](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=235) Alternative Pain Management Strategies (Ep 2) - [7:04](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=424) Surgical Technique Variations for Nuss Procedure (Ep 2) - [10:28](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=628) Summary and Closing (Ep 2) - [0:00](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=0) Cryoanalgesia for Pain Control (Ep 3) - [3:50](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=230) Alternative Pain Management Strategies (Ep 3) - [6:15](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=375) Bar Stability and Measurement (Ep 3) - [8:01](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=481) Surgical Technique Updates (Ep 3) - [0:00](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=0) Introduction and Case Presentation (Ep 4) - [1:53](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=113) Cryoanalgesia for Pain Control (Ep 4) - [5:34](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=334) Alternative Pain Management Strategies (Ep 4) - [7:24](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=444) Surgical Technique Updates (Ep 4) - [10:55](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=655) Summary and Closing (Ep 4) - [0:00](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=0) Introduction and Cryoanalgesia for Pain Control (Ep 5) - [3:50](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=230) Alternative Pain Management Approaches (Ep 5) - [7:00](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=420) Surgical Technique Updates (Ep 5) - [10:25](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=625) Summary and Closing (Ep 5) ## Statements Every statement is attributed, typed, and timestamped; the link is the citation. - "A 16-year-old male with shortness of breath on exertion, no comorbidities, and pectus index of 5.5 was planned for chest wall reconstruction" — Todd Ponsky (clinical) [Ep 3 · 0:31](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=31) - "A randomized trial of 110 patients comparing epidural and PCA showed epidurals did not provide adequate pain control" — Todd Ponsky (clinical) [Ep 3 · 1:02](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=62) - "After implementing cryoanalgesia, a patient went home on post-operative day one, ending equipoise in the trial" — Cecilia Gigena (clinical) [Ep 3 · 1:21](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=81) - "Cryoanalgesia uses cold temperatures to cause a conduction block that interrupts pain impulses to the brain" — Todd Ponsky (clinical) [Ep 3 · 1:56](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=116) - "Cryoanalgesia technique involves freezing ribs four through seven for two minutes per rib; ribs eight and below should not be treated due to risk of abdominal wall paralysis" — Todd Ponsky (clinical) [Ep 3 · 2:09](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=129) - "Cryoanalgesia reduced hospital length of stay from four days to one day" — Cecilia Gigena (clinical) [Ep 3 · 2:33](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=153) - "Cryoanalgesia dramatically reduced median morphine equivalents compared to previous pain management approaches" — Todd Ponsky (clinical) [Ep 3 · 2:43](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=163) - "There are no long-term studies on cryoanalgesia outcomes, raising concerns about potential chronic neuropathic pain" — Cecilia Gigena (opinion) [Ep 3 · 2:52](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=172) - "Medical devices and techniques are not required to undergo clinical trials before market introduction, unlike medications" — Todd Ponsky (guideline) [Ep 3 · 3:14](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=194) - "Erector spinae catheters are placed by the pain team with ultrasound guidance, stay in for five days, and allow hospital discharge at two days with family removal of catheters on day three" — Cecilia Gigena (clinical) [Ep 3 · 3:50](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=230) - "Erector spinae catheters reduced opioid requirements both in-hospital and post-discharge, achieving two-day hospital stays" — Todd Ponsky (clinical) [Ep 3 · 4:30](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=270) - "Cryoanalgesia changed not just discharge timing but how patients feel at discharge" — Cecilia Gigena (opinion) [Ep 3 · 4:52](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=292) - "Multimodal pain control includes Tylenol, NSAIDs, precedex for gentle wake-up, dexamethasone for nausea, ketamine to avoid opioids, child life specialists, mindfulness resources, and physical therapy" — Todd Ponsky (clinical) [Ep 3 · 5:34](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=334) - "Best multimodal treatments are preoperative counseling, gabapentin pre and postoperatively, methadone, clonidine, bowel regimen medications, and antiemetics" — Cecilia Gigena (clinical) [Ep 3 · 6:15](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=375) - "A multimodal pain regimen achieved hospital length of stay under two days with patients off opioids by one week" — Cecilia Gigena (clinical) [Ep 3 · 6:15](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=375) - "Bar flippage typically occurs early due to bars sitting in incorrect intercostal space, poor positioning, inadequate wrapping, or insufficient securing" — Todd Ponsky (clinical) [Ep 3 · 6:26](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=386) - "Bar flippage is completely a surgical technique issue, not related to the securing method" — Todd Ponsky (opinion) [Ep 3 · 6:26](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=386) - "Computational modeling shows shorter flat bars create more pressure on the sternum compared to traditional U-shaped bars, making them more stable" — Cecilia Gigena (clinical) [Ep 3 · 7:35](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=455) - "Sternal elevator is used in approximately 10% of cases, primarily in younger patients where thoracoscopy provides adequate visualization" — Todd Ponsky (clinical) [Ep 3 · 8:01](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=481) - "Sternal elevation in deep, stiff pectus cases allows less tissue damage and better repair" — Todd Ponsky (clinical) [Ep 3 · 8:01](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=481) - "Sternal elevator enables consistent entry and exit at the same intercostal space" — Todd Ponsky (clinical) [Ep 3 · 8:01](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=481) - "Thoracoscopy, sternal elevator, vacuum bell, and sub-xiphoid incision are all techniques aimed at preventing cardiac injury" — Cecilia Gigena (clinical) [Ep 3 · 8:58](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=538) - "Passing the bar from left to right avoids pointing the introducer directly at the ventricle" — Todd Ponsky (clinical) [Ep 3 · 9:20](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=560) - "Bar passage direction is surgeon preference and does not make significant difference if sub-sternal space is well dissected and clear" — Todd Ponsky (opinion) [Ep 3 · 9:20](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=560) - "A randomized trial of 110 patients comparing epidural and PCA for pectus excavatum pain control showed epidurals did not provide superior pain relief" (clinical) [Ep 4 · 1:02](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=62) - "After implementing cryoanalgesia, a patient went home on postoperative day one, leading to loss of equipoise in the trial comparing cryotherapy to epidural/PCA" — Cecilia Gigena (clinical) [Ep 4 · 1:21](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=81) - "Cryoanalgesia uses cold temperatures to cause a conduction block that interrupts pain impulses to the brain" (clinical) [Ep 4 · 1:56](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=116) - "Cryoanalgesia technique involves freezing underneath ribs 4 through 7 for two minutes per rib" — Cecilia Gigena (clinical) [Ep 4 · 2:07](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=127) - "Cryoanalgesia should not be applied to rib 8 or below because it can cause abdominal wall paralysis" — Cecilia Gigena (clinical) [Ep 4 · 2:07](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=127) - "After implementing cryoanalgesia, length of stay decreased from four days (previous baseline) to one day" (clinical) [Ep 4 · 2:33](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=153) - "Cryoanalgesia dramatically reduced median morphine equivalents compared to previous pain control methods" — Cecilia Gigena (clinical) [Ep 4 · 2:43](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=163) - "There are no long-term studies on cryoanalgesia outcomes for pectus excavatum repair" (clinical) [Ep 4 · 2:52](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=172) - "Medical devices and implants are not required to undergo clinical trials before introduction to market, unlike drugs" — Cecilia Gigena (guideline) [Ep 4 · 3:14](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=194) - "FDA requires clinical trials with long-term results before approving medications for use" — Cecilia Gigena (guideline) [Ep 4 · 3:35](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=215) - "A comparison study of approximately 100 patients examined epidurals versus erector spinae catheters for pectus excavatum pain control" — Cecilia Gigena (clinical) [Ep 4 · 3:50](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=230) - "Erector spinae catheters are placed by the pain team with ultrasound guidance and are juxtaposed to but not in the vertebral space" — Cecilia Gigena (clinical) [Ep 4 · 4:08](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=248) - "Erector spinae catheters stay in place for five days on an automated pump, with families removing them on day three while patients are at home" — Cecilia Gigena (clinical) [Ep 4 · 4:08](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=248) - "With erector spinae catheters, hospital length of stay is two days" (clinical) [Ep 4 · 4:30](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=270) - "Erector spinae catheters reduced opioid requirements both in the hospital and outside the hospital" (clinical) [Ep 4 · 4:30](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=270) - "Cryoanalgesia changes not just when patients go home but how they feel when they go home" (opinion) [Ep 4 · 4:30](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=270) - "Multimodal pain control for pectus excavatum includes Tylenol, NSAIDs, precedex for gentle wake up, dexamethasone for post-anesthetic nausea, ketamine to avoid opioids, child life specialists, mindfulness resources, and physical therapists" — Cecilia Gigena (clinical) [Ep 4 · 5:34](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=334) - "Optimal multimodal therapy includes preoperative counseling, gabapentin both pre and postoperatively, methadone, clonidine, bowel regimen medications, and antiemetics" (clinical) [Ep 4 · 6:02](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=362) - "At one center using multimodal pain control, length of stay is under two days and patients are off opioids by one week" (clinical) [Ep 4 · 6:02](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=362) - "When bars flip, they typically flip early due to sitting in a funky intercostal space, sitting in a bad spot, insufficient bar wrapping, or inadequate securing" — Cecilia Gigena (clinical) [Ep 4 · 6:26](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=386) - "Bar flipping is completely a surgical technique issue, not related to the securing method" — Cecilia Gigena (opinion) [Ep 4 · 6:26](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=386) - "Computational modeling shows that shorter flat bars create more pressure on the sternum compared to traditionally U-shaped bars, making them more stable" (clinical) [Ep 4 · 7:35](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=455) - "One center uses sternal elevator in about 10% of cases, primarily in younger patients where thoracoscopy provides adequate visualization" — Cecilia Gigena (clinical) [Ep 4 · 8:01](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=481) - "Sternal elevation in really deep stiff pectus cases allows less tissue damage and better repair" — Cecilia Gigena (clinical) [Ep 4 · 8:01](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=481) - "One center uses sternal elevator in every case to eliminate guesswork and enable consistent access to the same intercostal space" — Cecilia Gigena (clinical) [Ep 4 · 8:01](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=481) - "Thoracoscopy, sternal elevator, vacuum bell in the operating room, and sub-xiphoid incision are all techniques aimed at preventing cardiac injury during pectus repair" (clinical) [Ep 4 · 8:58](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=538) - "Passing the bar from right chest to left chest means the introducer is pointing directly at the ventricle" — Cecilia Gigena (clinical) [Ep 4 · 9:20](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=560) - "Bar passage direction (left-to-right versus right-to-left) probably does not make a significant difference as long as the sub-sternal space is well dissected and everything is clear" — Cecilia Gigena (opinion) [Ep 4 · 9:20](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13669?t=560) - "A randomized trial of 110 patients comparing epidural and PCA for pectus excavatum pain control showed that epidurals did not provide superior pain relief" — Cecilia Gigena (clinical) [Ep 5 · 1:02](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=62) - "After implementing cryoanalgesia, a patient went home on post-operative day one, which was a dramatic improvement over previous pain control methods" (clinical) [Ep 5 · 1:21](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=81) - "Cryoanalgesia uses cold temperatures to cause a conduction block that interrupts pain impulses to the brain" — Cecilia Gigena (clinical) [Ep 5 · 1:56](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=116) - "The cryoanalgesia technique involves freezing underneath ribs four through seven for two minutes per rib" — Cecilia Gigena (clinical) [Ep 5 · 2:09](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=129) - "Cryoanalgesia should not be performed on rib eight or below because it can cause abdominal wall paralysis" — Cecilia Gigena (clinical) [Ep 5 · 2:09](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=129) - "With cryoanalgesia, hospital length of stay decreased from four days to one day" (clinical) [Ep 5 · 2:33](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=153) - "Cryoanalgesia dramatically reduced median morphine equivalents compared to previous pain control methods" — Cecilia Gigena (clinical) [Ep 5 · 2:43](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=163) - "There are no long-term studies on cryoanalgesia outcomes" (clinical) [Ep 5 · 2:52](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=172) - "Medical devices and techniques are not required to undergo clinical trials before introduction to market, unlike medications" — Cecilia Gigena (guideline) [Ep 5 · 3:14](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=194) - "Erector spinae catheters are placed by the pain team with ultrasound guidance and are juxtaposed to but not in the vertebral space" (clinical) [Ep 5 · 4:08](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=248) - "Erector spinae catheters stay in for five days, with hospital stay of two days, and catheters are pulled out by the family on the third day while at home" (clinical) [Ep 5 · 4:08](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=248) - "Erector spinae catheters reduced opioid requirements both in the hospital and outside of the hospital" — Cecilia Gigena (clinical) [Ep 5 · 4:30](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=270) - "With erector spinae catheters, hospital stay is two days, which is much less than the four or five days seen with epidurals" — Cecilia Gigena (clinical) [Ep 5 · 4:30](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=270) - "Cryoanalgesia changed not just when patients go home but how they feel when they go home" (opinion) [Ep 5 · 4:50](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=290) - "For multimodal pain therapy, the best treatments are preoperative counseling, gabapentin both pre and postoperatively, methadone, clonidine, bowel regimen medications and antiemetics" — Cecilia Gigena (clinical) [Ep 5 · 5:40](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=340) - "With multimodal pain control at one institution, length of stay is under two days and patients are off opioids by one week" — Cecilia Gigena (clinical) [Ep 5 · 6:20](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=380) - "If bars are going to flip, they flip early because they were sitting in a bad spot, the bar was not wrapped tight enough, or it was not secured well" (clinical) [Ep 5 · 6:40](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=400) - "Bar flippage is completely a surgical issue related to bar positioning and securing technique" (opinion) [Ep 5 · 6:40](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=400) - "Computational modeling showed that shorter flat bars have more pressure on the sternum compared to traditionally U-shaped bars, making them more stable" — Cecilia Gigena (clinical) [Ep 5 · 7:00](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=420) - "Sternal elevator is used in about 10% of cases at one institution" — Cecilia Gigena (clinical) [Ep 5 · 7:40](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=460) - "In younger patients with average anatomy, thoracoscopy provides adequate visualization without needing a sternal elevator" — Cecilia Gigena (clinical) [Ep 5 · 8:00](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=480) - "In really deep stiff pectus cases, sternal elevation allows less tissue damage and a better repair" — Cecilia Gigena (clinical) [Ep 5 · 8:20](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=500) - "One surgeon uses the sternal elevator in every case to eliminate guesswork and enable passage in and out at the same intercostal space" — Cecilia Gigena (clinical) [Ep 5 · 8:40](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=520) - "Thoracoscopy, sternal elevator, vacuum bell in the operating room, or subxiphoid incision all serve the purpose of avoiding cardiac injury" — Cecilia Gigena (clinical) [Ep 5 · 9:00](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=540) - "Passing the bar from left chest to right chest is preferred by some surgeons because going right to left means the introducer points directly at the ventricle" (opinion) [Ep 5 · 9:30](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=570) - "Bar passage direction probably does not make a significant difference as long as the substernal space is well dissected and everything is clear" (opinion) [Ep 5 · 10:00](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13670?t=600) - "Cryoanalgesia uses cold temperatures to cause a conduction block, interrupting pain impulses to the brain." — Cecilia Gigena (host_summary) [Ep 2 · 1:57](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=117) - "Cryoanalgesia technique involves counting down to the 4th rib and freezing underneath it for 2 minutes per rib, treating ribs 4 through 7." (clinical) [Ep 2 · 2:19](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=139) - "Cryoanalgesia should not be performed on rib 8 or below because it can cause abdominal wall paralysis." (clinical) [Ep 2 · 2:29](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=149) - "With cryoanalgesia, length of stay decreased from 4 days to 1 day." (clinical) [Ep 2 · 2:37](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=157) - "Cryoanalgesia dramatically reduced median morphine equivalents compared to previous pain management methods." (clinical) [Ep 2 · 2:46](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=166) - "There are no long-term studies on cryoanalgesia outcomes." — Victor Garcia (clinical) [Ep 2 · 3:04](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=184) - "Medical devices and implants are not required to undergo clinical trials before being introduced to market, unlike drugs." — Victor Garcia (guideline) [Ep 2 · 3:24](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=204) - "The FDA requires clinical trials with long-term results for medications before approval, but not for medical devices and techniques." — Cecilia Gigena (host_summary) [Ep 2 · 3:36](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=216) - "Erector spinal catheters are placed by the pain team with ultrasound guidance, positioned juxtaposed to but not in the vertebral space." — Victor Garcia (clinical) [Ep 2 · 4:09](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=249) - "With erector spinal catheters, hospital stay is 2 days, catheters stay in for 5 days, and are pulled out by the family on day 3 while the patient is at home." — Victor Garcia (clinical) [Ep 2 · 4:19](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=259) - "Erector spinal catheters reduced opioid requirements both in the hospital and outside the hospital." — Victor Garcia (clinical) [Ep 2 · 4:33](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=273) - "With erector spinal catheters, hospital stays are 2 days, which is much less than the 4-5 days seen with epidurals." — Victor Garcia (clinical) [Ep 2 · 4:45](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=285) - "With cryoanalgesia, it is not just when patients go home but how they feel when they go home that has changed dramatically." — Steven Rothenberg (opinion) [Ep 2 · 5:08](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=308) - "For multimodal pain therapy, the best treatments are preoperative counseling, gabapentin both pre and postoperatively, and then methadone, clonidine, bowel regimen medications, and anti-emetics." — Justin Wagner (clinical) [Ep 2 · 6:02](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=362) - "In Nebraska, where Steve Rayner practices, length of stay is under 2 days and patients are off opioids by 1 week." — Justin Wagner (host_summary) [Ep 2 · 6:19](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=379) - "If bars are going to flip, they flip early because they were sitting in a funky inner space, in a bad spot, the bar wasn't wrapped tight enough, or it wasn't secured well." (clinical) [Ep 2 · 6:39](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=399) - "The bar must sit in a comfortable position before securing it or it probably will not stay there." (clinical) [Ep 2 · 6:54](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=414) - "Bar flippage is completely a surgical issue." — Steven Rothenberg (opinion) [Ep 2 · 6:59](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=419) - "Computational modeling showed that shorter flat bars have different stress points compared to traditionally U-shaped bars, with shorter bars having more pressure on the sternum and therefore being more stable." — Justin Wagner (host_summary) [Ep 2 · 7:40](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=460) - "A sternal elevator is used in about 10% of cases, primarily in really deep stiff pectuses where it allows less tissue damage and a better repair." — Steven Rothenberg (clinical) [Ep 2 · 8:19](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=499) - "In the average younger patient, thoracoscopy provides adequate visualization without needing a sternal elevator." — Steven Rothenberg (clinical) [Ep 2 · 8:22](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=502) - "Using a sternal elevator in every case eliminates guesswork and allows entry and exit at the same interspace." — Victor Garcia (clinical) [Ep 2 · 8:35](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=515) - "Techniques to avoid cardiac injury include thoracoscopy, sternal elevator, vacuum bell in the operating room, or subxiphoid incision." (clinical) [Ep 2 · 8:59](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=539) - "Passing the bar from left chest to right chest is preferred by some because going right to left means the instrument points directly at the ventricle." (clinical) [Ep 2 · 9:31](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=571) - "Bar passage direction (left-to-right versus right-to-left) is surgeon preference and probably does not make much difference as long as the substernal space is well dissected and everything is clear." (opinion) [Ep 2 · 10:12](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=612) - "Dr. Saint Peter's institution completed a randomized trial of 110 patients comparing epidural to PCA for pectus excavatum pain control, and epidurals did not show superior performance." — Shawn St. Peter (clinical) [Ep 1 · 1:07](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=67) - "In Dr. Saint Peter's cryoanalgesia trial with approximately 30 patients per group, equipoise was lost when patients went home on post-op day one." — Shawn St. Peter (clinical) [Ep 1 · 1:32](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=92) - "Cryoanalgesia uses cold temperatures to cause a conduction block that interrupts pain impulses to the brain." — Cecilia Gigena (host_summary) [Ep 1 · 1:57](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=117) - "The cryoanalgesia technique involves counting down to the 4th rib and freezing underneath it for 2 minutes per rib, treating ribs 4 through 7." — Shawn St. Peter (clinical) [Ep 1 · 2:10](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=130) - "Cryoanalgesia should not be performed on rib 8 or below because it can cause abdominal wall paralysis." — Shawn St. Peter (clinical) [Ep 1 · 2:29](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=149) - "With cryoanalgesia, hospital length of stay decreased from 4 days to 1 day at Dr. Saint Peter's institution." — Shawn St. Peter (clinical) [Ep 1 · 2:37](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=157) - "Cryoanalgesia dramatically reduced median morphine equivalents compared to previous pain management approaches." — Shawn St. Peter (clinical) [Ep 1 · 2:46](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=166) - "Dr. Garcia's concern about cryoanalgesia is the absence of long-term studies and unknown potential for future adverse effects such as chronic neuropathic pain." — Victor Garcia (opinion) [Ep 1 · 3:01](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=181) - "Unlike drugs, medical devices and implants are not required to undergo clinical trials before being introduced to the market by the FDA." — Victor Garcia (guideline) [Ep 1 · 3:24](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=204) - "For medications, the FDA requires clinical trials with long-term clinical results before approval, but this is not required for medical devices and techniques like cryoanalgesia." — Cecilia Gigena (host_summary) [Ep 1 · 3:36](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=216) - "Dr. Garcia's institution studied approximately 100 patients comparing epidurals to erector spinal catheters for pectus excavatum pain management." — Victor Garcia (clinical) [Ep 1 · 3:55](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=235) - "Erector spinal catheters are placed by the pain team with ultrasound guidance and are positioned juxtaposed to but not in the vertebral space." — Victor Garcia (clinical) [Ep 1 · 4:08](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=248) - "With erector spinal catheters, the catheters stay in for 5 days, hospital stay is 2 days, and on the 3rd day while patients are at home, the catheters are pulled out by the family." — Victor Garcia (clinical) [Ep 1 · 4:19](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=259) - "Dr. Garcia's institution achieved 2-day hospital stays with erector spinal catheters and reduced opioid requirements both in-hospital and at home." — Victor Garcia (clinical) [Ep 1 · 4:31](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=271) - "Erector spinal catheters achieve shorter stays than the 4-5 days seen with epidurals, though not the one-day stays achieved with cryoanalgesia." — Victor Garcia (clinical) [Ep 1 · 4:45](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=285) - "Dr. Rothenberg's initial concerns about cryoanalgesia were the added operative time and concerns about neuralgia and complications." — Steven Rothenberg (opinion) [Ep 1 · 4:53](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=293) - "After approximately 4 cases, Dr. Rothenberg observed that cryoanalgesia changed not just when patients go home but how they feel when they go home, describing the results as unbelievable." — Steven Rothenberg (opinion) [Ep 1 · 5:08](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=308) - "Dr. Rothenberg agrees with Dr. Garcia's concerns and supports the need for a registry to track long-term cryoanalgesia outcomes." — Steven Rothenberg (opinion) [Ep 1 · 5:23](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=323) - "Multimodal pain control options include Tylenol, NSAIDs, precedex for gentle wake-up, dexamethasone for post-anesthetic nausea, and ketamine to avoid opioids." — Justin Wagner (clinical) [Ep 1 · 5:40](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=340) - "Non-pharmacologic multimodal approaches include child life specialists, mindfulness resources, and supportive physical therapists." — Justin Wagner (clinical) [Ep 1 · 5:55](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=355) - "Dr. Ponsky's best multimodal treatments are preoperative counseling, gabapentin both pre and postoperatively, methadone, clonidine, bowel regimen medications, and anti-emetics." — Justin Wagner (host_summary) [Ep 1 · 6:02](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=362) - "At the institution where Dr. Wagner trained in Nebraska, Steve Rayner achieves length of stay under 2 days with patients off opioids by 1 week." — Justin Wagner (host_summary) [Ep 1 · 6:19](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=379) - "Bar flippage typically occurs early and is caused by the bar sitting in a funky interspace, sitting in a bad spot, not being wrapped tight enough, or not being secured well." — Shawn St. Peter (clinical) [Ep 1 · 6:39](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=399) - "The bar must sit in a comfortable position before securing or it will not stay in place; securing alone does not prevent bar flippage." — Shawn St. Peter (clinical) [Ep 1 · 6:54](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=414) - "Dr. Rothenberg believes bar flippage is completely a surgical issue, not related to pain management technique." — Steven Rothenberg (opinion) [Ep 1 · 6:59](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=419) - "Physics-minded surgeons created a computational model showing that shorter flat bars have more pressure on the sternum compared to traditionally U-shaped bars, making them more stable." — Justin Wagner (host_summary) [Ep 1 · 7:36](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=456) - "Dr. Wolon uses a sternal elevator for pectus excavatum repair at Akron Children's Hospital." — Victor Garcia (host_summary) [Ep 1 · 8:08](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=488) - "Dr. Rothenberg uses a sternal elevator in about 10% of cases, primarily in really deep stiff pectuses where it allows less tissue damage and a better repair." — Steven Rothenberg (clinical) [Ep 1 · 8:19](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=499) - "In average younger patients, thoracoscopy provides adequate visualization without needing a sternal elevator." — Steven Rothenberg (clinical) [Ep 1 · 8:22](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=502) - "Dr. Garcia uses the sternal elevator in every case because it eliminates guesswork and allows entry and exit at the same interspace." — Victor Garcia (clinical) [Ep 1 · 8:35](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=515) - "Dr. Saint Peter continues to use subxiphoid incision along with thoracoscopy, sternal elevator, or vacuum bell in the operating room as safety techniques to avoid cardiac injury." — Shawn St. Peter (clinical) [Ep 1 · 8:50](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=530) - "Dr. Holcomb's principle is that whatever technique helps avoid injuring the heart is the technique that should be used." — Shawn St. Peter (host_summary) [Ep 1 · 9:05](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=545) - "One surgeon passes the bar from left chest to right chest because passing right to left directs the instrument toward the ventricle." (clinical) [Ep 1 · 9:31](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=571) - "Dr. Slater has always performed the Nuss procedure right to left and had not previously considered left to right." — Cecilia Gigena (host_summary) [Ep 1 · 9:41](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=581) - "One surgeon learned left to right but switched to right to left and found it easier, particularly when using external elevator and thoracoscopy for safety." — Shawn St. Peter (clinical) [Ep 1 · 9:54](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=594) - "Direction of bar passage is likely surgeon preference and does not make much difference as long as the substernal space is well dissected and everything is clear." — Shawn St. Peter (opinion) [Ep 1 · 10:12](https://library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=612) ## Changelog - Sep 7: 5 items added automatically --- Educational content from recorded physician discussions — not medical advice. Cite the canonical URL or the ?t= deep link. Policy: https://library.globalcastmd.com/ai