Pathway for Pectus Excavatum Repair (see pectus excavatum orderset) •SCDs•Type and Screen•Ancef or Vanc(+ORSA) prior to incision•Pre-op wash (Dynahexof HIbiclens) in SDS •Continuous pulse oximetry•Clears, advance as tolerated•OOB to chair and then ambulate (if first case of the day)•Incentive spirometry 10x/hour•mIVFD5 ½ NS + 20 meqKCL @ maintenance•SCDs•Ancef x 3 doses (Clindaif +ORSA) •Pain management per pain team: Epidural, valium, robaxin, toradol, IV Tylenol, methadone x1, scheduled Zofran •Chewing gum 5 separate times for 20 min (if fully awake post-op)•Senna/miralaxBID and Movantik•Foley catheter Initiate POD1•OOB (up to chair and ambulate) TID•Remove foleycatheter •Pain management per pain team: Continue Epidural, valium, robaxin, toradol, IV Tylenol, start oxycodoneContinue from POD0•Regular diet•Incentive spirometry 10x/hour•mIVFuntil drinking well and urinates after foleyremoval•SCDs •Chewing gum 5 separate times for 20 min •Zofran Q8H (changes to prn) •Senna/miralaxBID and Movantik Initiate POD2•Stop IVF (if still running) •Stop epidural at 0600•Epidural removed when pain team rounds•Transition to all PO pain medication: oxycodone, valium, robaxin, motrin, Tylenol•2V CXR to evaluate bar location(s) and for pleural effusion/pneumothorax•Remove dressings and wash chest daily Continue from POD0/1•Regular diet•Ambulate TID•Incentive spirometry 10x/hour•SCDs •Chewing gum 5 separate times for 20 min •Zofran Q8H prn•Senna/miralaxBID and Movantik Pre-OperativelyPOD 0 POD 1 POD 2 Initiate POD3•PT/OT will sign off on walking stairs•Prescriptions filled and medication schedule givenContinue from POD0/1/2•Regular diet•Ambulate TID•Incentive spirometry 10x/hour•SCDs•Chewing gum 5 separate times for 20 min •Wash chest daily•PO pain medication •Senna/miralaxBIDDischarge home if pain well controlled, tolerating PO intake POD 3 v2 Updated 11/2019
Pectus Excavatum Management Pathway
Guideline · Dec 2019 · 1 min read
In brief
In brief
Cincinnati Children's Chest Wall Center's standardized clinical care pathway for pectus excavatum patients. Dr. Brown outlines the systematic approach to evaluation, treatment decision-making, and surgical management of this common chest wall deformity in pediatric patients.
- Multimodal pain control includes epidural through POD2, then transition to PO regimen with oxycodone, valium, robaxin, motrin, and Tylenol
- Early mobilization protocol: ambulate TID starting POD1, with PT/OT stair clearance required before discharge on POD3
- Bowel regimen (senna/miralax BID, Movantik) and gum chewing (5×20min daily) prevent postoperative ileus and constipation
- POD2 chest X-ray evaluates bar position and screens for pneumothorax or pleural effusion after Nuss procedure
- Discharge criteria: adequate pain control on oral medications, tolerating regular diet, and independent stair ambulation
Written by the GCMD Library team from the guideline.
Pre-Operative Preparation
Standard surgical preparation includes type and screen, prophylactic antibiotics (Ancef or Vancomycin for MRSA-positive patients), and pre-operative antiseptic wash with chlorhexidine or Hibiclens in the Same Day Surgery unit. Sequential compression devices are applied for DVT prophylaxis.
Post-Operative Day 0 (Day of Surgery)
Immediate post-operative care focuses on pain control via epidural with multimodal adjuncts (valium, robaxin, toradol, IV acetaminophen, methadone), early mobilization if first case, and bowel regimen initiation. Foley catheter remains in place with maintenance IV fluids, and early gum chewing is encouraged to promote bowel function if patient is alert.
Post-Operative Day 1
Foley catheter is removed and patient advances to regular diet with continued multimodal pain management including epidural and initiation of oral oxycodone. Mobilization increases to three times daily with ongoing incentive spirometry, gum chewing protocol, and bowel regimen.
Post-Operative Day 2
Epidural is discontinued at 0600 hours with complete transition to oral pain medications (oxycodone, valium, robaxin, ibuprofen, acetaminophen). Two-view chest radiograph evaluates bar position and screens for pleural effusion or pneumothorax, and surgical dressings are removed with daily chest washing initiated.
Post-Operative Day 3 and Discharge
Physical and occupational therapy clear patient for stair climbing, and discharge prescriptions with medication schedule are provided. Patient is discharged home when pain is adequately controlled on oral regimen and oral intake is tolerated, typically on POD 3.
Statements in this guideline
Sequential compression devices are applied pre-operatively.
Type and screen is performed pre-operatively.
Ancef or vancomycin (if MRSA positive) is given prior to incision.
Pre-operative wash with Dynahex or Hibiclens is performed in same-day surgery.
Continuous pulse oximetry is maintained on postoperative day 0.
Clear liquids are started and advanced as tolerated on postoperative day 0.
Patients are mobilized out of bed to chair and then ambulated if first case of the day on postoperative day 0.
Incentive spirometry is performed 10 times per hour starting postoperative day 0.
Maintenance intravenous fluids are D5 half normal saline with 20 mEq potassium chloride at maintenance rate on postoperative day 0.
Ancef is given for 3 doses postoperatively, or clindamycin if MRSA positive.
Pain management includes epidural, valium, robaxin, toradol, intravenous acetaminophen, methadone once, and scheduled ondansetron.
Chewing gum is used 5 separate times for 20 minutes each if fully awake post-operatively.
Senna/miralax twice daily and naloxegol are started on postoperative day 0.
Foley catheter is placed on postoperative day 0.
Patients are mobilized out of bed to chair and ambulated three times daily starting postoperative day 1.
Foley catheter is removed on postoperative day 1.
Oxycodone is started on postoperative day 1 while continuing epidural, valium, robaxin, toradol, and intravenous acetaminophen.
Regular diet is started on postoperative day 1.
Intravenous fluids are continued until patient is drinking well and urinates after foley removal.
Ondansetron is changed from scheduled every 8 hours to as needed on postoperative day 1.
Intravenous fluids are stopped on postoperative day 2 if still running.
Epidural is stopped at 0600 on postoperative day 2 and removed when pain team rounds.
Pain management is transitioned to all oral medications on postoperative day 2: oxycodone, valium, robaxin, ibuprofen, and acetaminophen.
Two-view chest X-ray is obtained on postoperative day 2 to evaluate bar location and assess for pleural effusion or pneumothorax.
Dressings are removed and chest is washed daily starting postoperative day 2.
Physical therapy and occupational therapy sign off on stair walking on postoperative day 3.
Prescriptions are filled and medication schedule is provided on postoperative day 3.
Patient is discharged home if pain is well controlled and oral intake is tolerated.