Update Course Rewind: Who to Send Home from the OR #4 Part 1: Pectus Excavatum Repair 2023

Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello, pediatric surgery family. I'm Cecilia Gijena, a research fellow from Cincinnati Children's Hospital Medical Center. In August 2023, we held our annual update course in pediatric surgery. In this session, the surgeons discussed in round table fashion who can go home from the OR on the same day of their procedure. The first case is a 15-year-old male with severe pectus excavatum, who underwent a minimally invasive repair with intercostal neuro cryoablation. So, what do we do after surgery? Approximately ⅓ of surgeons would put the patient on bed rest for the first 24 hours, ambulate with PT/OT the next day, and discharge home on postoperative day three. Approximately 10% would discharge on postop day number two, and only 20% discharge patients on the same day. But what about the other ⅓ of surgeons? What is the something else? So, there's some that talk about this concept that cryoablation takes a period of time to set up before you actually have full effect of the cryoablation. The cryoreps say it takes six to eight hours to kick in. And so that's why they recommend you do rib blocks at the same time. So, Matt, question. Katie, if you add a rib blocker, are you doing it intrathoracic at the time of the cryoablation, or are you doing it extrathoracic at the end of the case? You know, it's so simple. You have all this wasted time while you're doing the cryoablation, so just get somebody to hold the cryoprobe, and then you can under direct visualization put your rib blocks in. It's really pretty fun, actually. We don't rib block. It doesn't change the data for us in doing that. Let's look at the data. This prospective study out of Kaiser Permanente sought to evaluate if patients who underwent NUSS procedures with intercostal neurocryoablation and intercostal nerve blocks could safely be discharged on the same day of their procedure. But this group also compared to their previous data set where they were doing only cryo, then they introduced intercostal nerve block, and they did ERAS protocol, and the length of stay changed, and the conclusion was the combination of cryo with intercostal nerve block and ERAS protocol is what changed the length of stay. I'm not sure if it's a rib block that really changed the result versus the other extras that he did. Because of this question as to whether or not to nerve block is a game changer, Dr. Oyetunji's group is now collecting data for patients undergoing NUSS procedures with cryoablation, but without intercostal nerve block. They also have a well-structured ERAS protocol and counsel the patient and family prior to the OR. We tell the parents, we set expectations. It's going to hurt. It's a pectus repair, so you're not going to be pain-free. But, once you're comfortable, you can get up, you can walk around, there's no huge pneumothorax, you can go home. And we started that in July last year. And as you can see, the length of stay dropped significantly, and the rate of same day discharge is still around 65-68%. What's your oral pain medication that you send them home with? So, we do a scheduled Tylenol Motrin, they get that straight 48 hours, then they use the oxycodone as needed, and they get some oxycodone for a few days. By the time we see most of these kids include, they stopped all that by day six. Yeah, there's a reduction in the opioid use for sure when they're in the hospital compared to before we started doing this and then after. So far, they found a reduction in opioid use and a decreased length of stay using cryoablation and ERAS protocols for these patients. So, what's the ideal time to do this procedure if you are hopeful for a same day discharge? So, the fastest you can get out of the OR is like 9:30. 11 hours from now, it's like the middle of the night, almost. It's like sometimes, every now and then, they can just go home, and then a lot of kids probably just need to spend the night, but overall you're decreasing your length of stay. Exactly. So, we give them the option. If it's 10:00, 11:00, you want to stay? It's fine. But if you want to go home, that's okay too. In summary, patients who undergo a minimally invasive pectus excavatum repair with intercostal neurocryoablation can go home on the same day, but often they go home on postop day two or three, depending on pain control. Setting expectations with the patient and family beforehand is important. And a well-structured ERAS protocols with or without rib block may also decrease length of stay. Don't forget to subscribe to the stay current MD YouTube channel. Follow our social media channels and download the stay current MD app for tons of content in pediatric surgery. Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.