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 Pathway
Guideline · Aug 2019 · 1 min read
In brief
In brief
Clinical management pathway for pectus excavatum, outlining evaluation, treatment decision-making, and surgical approaches for this common chest wall deformity in pediatric patients.
Written by the GCMD Library team from the guideline.
Pre-Operative Preparation
Standard surgical preparation including sequential compression devices, type and screen, prophylactic antibiotics (Ancef or Vancomycin for MRSA), and pre-operative antiseptic wash with chlorhexidine or Hibiclens in same-day surgery. This establishes infection prevention and DVT prophylaxis protocols before pectus excavatum repair.
Post-Operative Day 0 (Immediate Post-Op)
Immediate post-operative management focuses on pain control via epidural with multimodal adjuncts (valium, robaxin, toradol, IV acetaminophen, methadone, scheduled ondansetron), early mobilization to chair if first case, and bowel regimen initiation. Continuous pulse oximetry, maintenance IV fluids, foley catheter placement, and incentive spirometry 10 times per hour are standard. Early chewing gum protocol (5 times for 20 minutes) promotes bowel function recovery.
Post-Operative Day 1
Advancement to regular diet with increased mobilization (ambulation three times daily) and foley catheter removal. Pain management continues with epidural plus multimodal medications, transitioning to include oral oxycodone. Bowel regimen with senna, miralax, and Movantik continues alongside chewing gum protocol.
Post-Operative Day 2
Epidural discontinued at 0600 and removed during pain team rounds with full transition to oral pain medications (oxycodone, valium, robaxin, ibuprofen, acetaminophen). Two-view chest X-ray obtained to assess bar position and screen for pleural effusion or pneumothorax. Dressings removed and daily chest washing initiated while IV fluids discontinued.
Post-Operative Day 3 and Discharge
Physical and occupational therapy clearance for stair climbing obtained and discharge prescriptions filled with medication schedule provided. Patient discharged home when pain is adequately controlled on oral medications and tolerating regular diet. All previous mobilization, respiratory therapy, and bowel regimen protocols continue through discharge.
Statements in this guideline
Sequential compression devices should be applied pre-operatively.
Ancef or vancomycin (if MRSA positive) should be administered prior to incision.
Pre-operative wash with Dynahex or Hibiclens should be performed in same-day surgery.
Continuous pulse oximetry should be maintained on postoperative day 0.
Patients should be out of bed to chair and then ambulate if first case of the day on postoperative day 0.
Incentive spirometry should be performed 10 times per hour.
Maintenance intravenous fluids should be D5 half normal saline with 20 mEq potassium chloride.
Ancef should be given for 3 doses (or clindamycin if MRSA positive).
Pain management should include epidural, valium, robaxin, toradol, IV Tylenol, methadone once, and scheduled Zofran.
Chewing gum should be used 5 separate times for 20 minutes each if fully awake post-operatively.
Senna/miralax twice daily and Movantik should be started on postoperative day 0.
Patients should be out of bed to chair and ambulate three times daily starting on postoperative day 1.
Foley catheter should be removed on postoperative day 1.
Oxycodone should be started on postoperative day 1 while continuing epidural, valium, robaxin, toradol, and IV Tylenol.
Intravenous fluids should be continued until the patient is drinking well and urinates after foley removal.
Zofran should be changed from every 8 hours scheduled to as needed on postoperative day 1.
Intravenous fluids should be stopped on postoperative day 2 if still running.
Epidural should be stopped at 0600 on postoperative day 2.
Epidural catheter should be removed when pain team rounds on postoperative day 2.
Pain management should transition to all oral medications on postoperative day 2: oxycodone, valium, robaxin, motrin, and Tylenol.
Two-view chest X-ray should be obtained on postoperative day 2 to evaluate bar location and assess for pleural effusion or pneumothorax.
Dressings should be removed and chest washed daily starting on postoperative day 2.
Physical therapy and occupational therapy should sign off on stair walking on postoperative day 3.
Prescriptions should be filled and medication schedule provided on postoperative day 3.
Discharge home is appropriate if pain is well controlled and patient is tolerating oral intake.