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Pectus Excavatum Pathway

Video Published 2019-12-06 Updated 2026-08-01

Timestops (3)

Immediate Postoperative Care and Mobilization

Pain Management and Epidural Protocol

Discharge Preparation and Pathway Outcomes

Topic Overview

Dr. Rebecca L. Brown, co-director of the Chestwall Center at Cincinnati Children's, presents a standardized clinical care pathway for pectus excavatum repair that reduced length of stay from 4.5 to 3 days while improving patient satisfaction. The pathway addresses five components: pain management (epidural with multimodal adjuncts), mobility (early ambulation with PT/OT stair training), lung recruitment (incentive spirometry 10 times/hour), daily intake (early diet advancement, gum chewing), and daily output (aggressive bowel regimen, Foley management). The protocol includes specific antibiotic prophylaxis, postoperative day-by-day milestones for epidural removal and transition to oral pain medications, and discharge criteria centered on pain control and oral intake tolerance.

Key Takeaways

Standardized pectus pathway cut LOS from 4.5 to 3 days while improving satisfaction via 5 components: pain, mobility, lungs, intake, output (0:19)
Multimodal pain protocol: epidural + Valium/Robaxin/Toradol/IV Tylenol/methadone, transition to PO oxycodone POD1, epidural removed POD2 AM (1:17)
Early mobilization key: Foley removed POD1, ambulation 3x daily POD2+, PT/OT stair training POD3 before discharge (1:56)
Aggressive bowel regimen (Senna/MiraLax BID + Movantik) plus gum chewing 5x daily for 20min prevents postop ileus (1:31)
Discharge criteria POD3: pain controlled on oral meds, tolerating PO intake, passed PT/OT stair assessment, CXR reviewed for bar position (3:10)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Rebecca L. Brown — guest

Chapters

0:05Introduction and Preoperative Preparation — Speaker introduces herself and outlines the five pathway components, then describes preoperative measures including compression boots, type and screen, antibiotic prophylaxis, and skin preparation.
0:46Postoperative Day 0 Management — Immediate postoperative care including continuous pulse oximetry, early diet advancement, early mobilization, incentive spirometry protocol, IV fluids, compression boots, antibiotic continuation, and multimodal pain management with epidural.
1:43Postoperative Days 1-2 Progression — Day 1 includes Foley removal to encourage ambulation, continued epidural with addition of oral oxycodone. Day 2 involves epidural discontinuation in morning, transition to all oral pain medications, chest X-ray, and dressing removal.
2:49Postoperative Day 3 and Discharge — PT/OT stair training and clearance, prescription filling, medication schedule education, and discharge criteria of adequate pain control on oral medications and tolerating oral intake.
4:41Pathway Outcomes — Implementation results showing reduction in length of stay from 4.5 to 3 days and increased patient satisfaction over 2-3 years of use.

Key claims

0:19The clinical care pathway has five major components: pain management, mobility, lung recruitment, daily intake, and daily output — Rebecca L. Brown
0:33Preoperative antibiotic prophylaxis is ANF or vancomycin if the patient is MRSA positive — Rebecca L. Brown
0:33Preoperative washes of Dynahex or Hibiclens scrub are applied to prevent infection after surgery — Rebecca L. Brown
0:49Patients are given clear liquids and advanced as tolerated to a full regular diet on postoperative day 0 — Rebecca L. Brown
1:01Incentive spirometry is performed 10 times per hour throughout the postoperative course — Rebecca L. Brown
1:11Postoperative antibiotics are ANF times 3 doses, or clindamycin if MRSA positive — Rebecca L. Brown
1:17Epidural analgesia is routinely used and supplemented with Valium, Robaxin, Toradol, IV Tylenol, methadone times 1, and scheduled Zofran — Rebecca L. Brown
1:31Patients are encouraged to chew gum 5 separate times a day for 20 minutes if fully awake postoperatively — Rebecca L. Brown
1:33Bowel management includes Senna and MiraLax twice a day as well as Movantik — Rebecca L. Brown
1:56The Foley catheter is removed on postoperative day 1 to encourage ambulation — Rebecca L. Brown
2:03Oral oxycodone is started on postoperative day 1 once patients are tolerating a diet — Rebecca L. Brown
2:21Maintenance IV fluids are continued until the patient is drinking well and urinates after Foley removal — Rebecca L. Brown
2:34Zofran is changed from scheduled every 8 hours to as needed on postoperative day 1 — Rebecca L. Brown
2:53The epidural catheter is stopped at 6 AM on postoperative day 2 — Rebecca L. Brown
2:57The epidural is removed when the pain team rounds later in the morning of postoperative day 2 — Rebecca L. Brown
3:01Patients are transitioned to all oral pain medications on postoperative day 2, including oxycodone, Valium, Robaxin, Motrin, and Tylenol — Rebecca L. Brown
3:10A two view chest X-ray is obtained on postoperative day 2 to evaluate bar location and to rule out pleural effusion or pneumothorax — Rebecca L. Brown
3:19Dressings are removed and the chest is washed daily starting on postoperative day 2 — Rebecca L. Brown
3:26Patients are encouraged to ambulate at least 3 times in the halls starting postoperative day 2 — Rebecca L. Brown
3:51PT and OT work with the patient on postoperative day 3 to help them walk up and down stairs, and sign off once able — Rebecca L. Brown
4:27Patients are discharged home on postoperative day 3 if pain is well controlled and they are tolerating oral intake — Rebecca L. Brown
4:46Since institution of the clinical care pathway 2 to 3 years ago, length of stay has been reduced from 4.5 days to 3 days — Rebecca L. Brown
4:46Patient satisfaction has increased since institution of the clinical care pathway — Rebecca L. Brown

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Keywords

pectus excavatum pleural effusion pneumothorax nausea pectus excavatum repair epidural placement Foley catheter insertion chest X-ray incentive spirometry ANF vancomycin Dynahex Hibiclens clindamycin Valium

Hashtags

#PediatricSurgery #PectusExcavatum #PainManagement #PostoperativeCare #SurgicalPathway #PatientSafety #Mobility #IncentiveSpirometry #BowelManagement #EpiduralAnalgesia #CompressionBoots #PatientSatisfaction #PhysicalTherapy #OccupationalTherapy #DietProgression #SurgicalInfection #Ambulation #IVFluids #MedicationRegimen #DischargePlanning #EnhancedRecovery #ChestWallSurgery #ClinicalPathway #ChestWallDeformity

Transcript

I am Rebecca L. Brown, and I'm a pediatric surgeon at Cincinnati Children's and the co-director of the Chestwall Center. I'm here today to discuss our standardized clinical care pathway for pectus excavatum. There are 5 major components to the clinical care pathway pain management, mobility, lung recruitment, daily intake, and daily output. Preoperatively, compression boots are applied. a type and screen is performed. ANF or vancomycin, if the. Patient is ORSA positive, are given prior to incision, and preoperative washes of Dynahex or Hibiclens scrub are applied in order to prevent infection after surgery. Patients are placed on continuous pulse oximetry. They're given clear liquids and advanced as tolerated to a full regular diet. They are encouraged to be out of bed to the chair, and then to ambulate, especially if they're the first case of the day. Incended spirometry is performed 10 times per hour. Maintenance IV fluids are infused. Compression boots are applied. Patients are given Af times 3 doses, or clindamycin if they're Osa positive. Pain management is per the pain team. An epidural is routinely used, and this is supplemented with Valium, Robaxin, Toradol, IV Tylenol, methadone times 1, and scheduled Zofran for nausea. Patients are encouraged to chew gum. 5 separate times a day for 20 minutes if fully awake postoperatively for bowel management, patients are given Senna and MiraLax twice a day as well as Movantik. The Foley catheter, which was inserted during surgery, is continued on postoperative day number 1. The patients are again encouraged to be out of bed, up to a chair, and ambulating about the room 3 times a day. The Foley catheter is removed to encourage ambulation as well. Pain management is continued for the pain team. The epidural remains in place, and the medications are supplemented with Valium, Robaxin, Toradol, IV Tylenol, and oxycodone is started orally as well once the patients are tolerating a diet. Incentive spirometry is encouraged 10 times per hour. The maintenance IV fluids are continued until the patient is drinking well and urinates after Foley removal. The compression boots are continued. The patient is again encouraged to chew gum 5 separate times a day for 20 minutes. Zofran, which was initially given routinely every. 8 hours is changed to as needed. The patient is continued on Senna and MiraLax BID as well as Movantik to enhance bowel motility on postoperative day number 2. The IV fluids are discontinued if they are still running. The epidural catheter is stopped at 6 in the morning. The epidural is removed when the pain team rounds later that morning. The patient is transitioned to all PO pain medications, including oxycodone, Valium, Robaxin, Motrin, and Tylenol. Later in the day, a two view chest X-ray is obtained to evaluate bar location and to rule out any pleural effusion or pneumothorax. Also, the dressings are removed and the chest is washed daily. The patient is continued on a regular diet. They are encouraged to ambulate at least 3 times in the halls. Incentive spirometry is continued 10 times per hour. The patients are continued on compression boots. Patients are again encouraged to chew gum 5 separate times a day for 20 minutes. Zofran is given as needed for nausea, and Senna and MiraLax are given BID as well as Movantik to encourage bowel motility. On post-operative day 3, PT and OT works with the patient to help them walk up and down the stairs, and PTOT will sign off once they are able to do this. The prescriptions are filled, and the medication schedule is given to the parent and the patients. The patient is. Continued on a regular diet, they are encouraged again to ambulate 3 times a day in the halls. Incentive spirometry is encouraged 10 times per hour. They're continued on compression boots. They're encouraged to chew gum 5 separate times a day for 20 minutes. Their chest is washed daily to prevent infection. The patient should be on PO pain medication only. Senna and MiraLax are given twice a day for bowel movements, and the patient is discharged home if the patient is well controlled and tolerating PO intake. What I have now described as our clinical care pathway for pectus excavatum. Since institution of our clinical care pathway about 2 to 3 years ago, we have reduced our length of stay from 4.5 days to 3 days and have also increased our patient satisfaction. If you have any questions, please feel free to contact us using the information on the screen. We look forward to hearing from you. Thank you.

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