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Pectus Excavatum Pathway

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

Timestops (3)

0:05
Immediate Postoperative Care and Mobilization
2:23
Pain Management and Epidural Protocol
4:13
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.

Structured Pathway Design for Pectus Excavatum Repair Recovery

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

The clinical care pathway for pectus excavatum repair at Cincinnati Children's demonstrates how systematic protocol design can compress recovery time without compromising outcomes. The framework rests on five interdependent components — pain management, mobility, lung recruitment, intake, and output — each with specific interventions timed to the postoperative course 0:19.

Multimodal analgesia drives early mobilization. Epidural analgesia alone is insufficient for the chest wall pain following Nuss bar placement. The pathway supplements the epidural with Valium, Robaxin, Toradol, IV Tylenol, a single dose of methadone, and scheduled Zofran 1:17. This combination addresses muscle spasm, inflammation, and nausea simultaneously, creating a pain control foundation that permits ambulation on postoperative day 0 0:49. The transition off epidural is structured: the catheter stops at 6 AM on day 2, removal occurs later that morning when the pain team rounds, and oral medications — oxycodone, Valium, Robaxin, Motrin, and Tylenol — are already in place before the epidural comes out 2:53 2:57 3:01. This sequencing prevents the gap in coverage that can derail early discharge.

Bowel motility requires active intervention, not passive waiting. Postoperative ileus is predictable after thoracic surgery, and the pathway attacks it from multiple angles. Patients chew gum five times daily for 20 minutes if fully awake 1:31 — the act of chewing stimulates vagal tone and accelerates return of bowel function. Scheduled Senna and MiraLax twice daily plus Movantik provide pharmacologic support 1:33. This is not conservative management; it is aggressive prevention of the constipation that extends hospital stay.

Mobilization milestones are tied to specific interventions. The Foley catheter is removed on postoperative day 1 specifically to encourage ambulation 1:56 — patients will not walk the halls with a catheter in place. By day 2, the expectation is at least three trips into the hallway 3:26. Physical and occupational therapy assess stair climbing on day 3 and must sign off before discharge 3:51. These are not suggestions; they are discharge criteria. The pathway makes mobility non-negotiable by building it into the structure rather than leaving it to nursing discretion.

Infection prevention is bundled, not piecemeal. Preoperative skin preparation with Dynahex or Hibiclens scrub, appropriate antibiotic prophylaxis (ANF or vancomycin for MRSA-positive patients), and three postoperative doses of antibiotics (or clindamycin if MRSA-positive) establish the baseline 0:33 0:33 1:11. Dressings are removed and the chest is washed daily starting on postoperative day 2 3:19. This daily washing is not wound care in the traditional sense — it is active surveillance, forcing daily inspection of the incision sites and preventing the occult infection that declares itself after discharge.

Lung recruitment is continuous, not episodic. Incentive spirometry 10 times per hour throughout the postoperative course 1:01 is the minimum acceptable effort. A two-view chest X-ray on postoperative day 2 evaluates bar position and rules out pleural effusion or pneumothorax 3:10 — complications that would abort the discharge plan. The pathway does not assume the lungs will recover on their own; it structures the work required to make them recover.

The pathway's value is in its outcomes, not its elegance. Since implementation two to three years ago, length of stay dropped from 4.5 days to 3 days, and patient satisfaction increased 4:46 4:46. The reduction is not from discharging patients sicker; it is from eliminating the variability that kept some patients in the hospital an extra day because a step was missed or delayed. Patients are discharged on postoperative day 3 if pain is controlled on oral medications and they are tolerating oral intake 4:27 — criteria that the pathway is designed to meet, not hope to meet. The structure does not constrain clinical judgment; it ensures that judgment is applied to every patient, every day, in the same sequence.

Takeaways from this story

  • Multimodal analgesia with epidural plus adjuncts enables day-0 ambulation and structured day-2 transition to oral medications.
  • Gum chewing five times daily plus scheduled laxatives actively prevents ileus rather than waiting to treat constipation.
  • Foley removal on day 1 and mandatory hall ambulation by day 2 make mobility a discharge criterion, not a suggestion.
  • Daily chest washing after dressing removal on day 2 provides active infection surveillance, not just wound care.
  • Pathway implementation reduced length of stay from 4.5 to 3 days while increasing patient satisfaction.

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

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