Dr. Rebeccah L. Brown discusses the clinical care pathway for patients with pectus excavatum in place at Cincinnati Children's Chest Wall Center.
Type: video · 5 min · posted 2019-12-06 Canonical: https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973 ## Chapters - [0:05](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=5) Introduction and Preoperative Preparation - [0:46](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=46) Postoperative Day 0 Management - [1:43](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=103) Postoperative Days 1-2 Progression - [2:49](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=169) Postoperative Day 3 and Discharge - [4:41](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=281) Pathway Outcomes ## Statements - "The clinical care pathway has five major components: pain management, mobility, lung recruitment, daily intake, and daily output" — Rebecca Brown (clinical) [0:19](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=19) - "Preoperative antibiotic prophylaxis is ANF or vancomycin if the patient is MRSA positive" — Rebecca Brown (guideline) [0:33](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=33) - "Preoperative washes of Dynahex or Hibiclens scrub are applied to prevent infection after surgery" — Rebecca Brown (guideline) [0:33](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=33) - "Patients are given clear liquids and advanced as tolerated to a full regular diet on postoperative day 0" — Rebecca Brown (clinical) [0:49](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=49) - "Incentive spirometry is performed 10 times per hour throughout the postoperative course" — Rebecca Brown (clinical) [1:01](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=61) - "Postoperative antibiotics are ANF times 3 doses, or clindamycin if MRSA positive" — Rebecca Brown (guideline) [1:11](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=71) - "Epidural analgesia is routinely used and supplemented with Valium, Robaxin, Toradol, IV Tylenol, methadone times 1, and scheduled Zofran" — Rebecca Brown (clinical) [1:17](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=77) - "Patients are encouraged to chew gum 5 separate times a day for 20 minutes if fully awake postoperatively" — Rebecca Brown (clinical) [1:31](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=91) - "Bowel management includes Senna and MiraLax twice a day as well as Movantik" — Rebecca Brown (clinical) [1:33](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=93) - "The Foley catheter is removed on postoperative day 1 to encourage ambulation" — Rebecca Brown (clinical) [1:56](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=116) - "Oral oxycodone is started on postoperative day 1 once patients are tolerating a diet" — Rebecca Brown (clinical) [2:03](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=123) - "Maintenance IV fluids are continued until the patient is drinking well and urinates after Foley removal" — Rebecca Brown (clinical) [2:21](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=141) - "Zofran is changed from scheduled every 8 hours to as needed on postoperative day 1" — Rebecca Brown (clinical) [2:34](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=154) - "The epidural catheter is stopped at 6 AM on postoperative day 2" — Rebecca Brown (clinical) [2:53](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=173) - "The epidural is removed when the pain team rounds later in the morning of postoperative day 2" — Rebecca Brown (clinical) [2:57](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=177) - "Patients are transitioned to all oral pain medications on postoperative day 2, including oxycodone, Valium, Robaxin, Motrin, and Tylenol" — Rebecca Brown (clinical) [3:01](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=181) - "A two view chest X-ray is obtained on postoperative day 2 to evaluate bar location and to rule out pleural effusion or pneumothorax" — Rebecca Brown (clinical) [3:10](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=190) - "Dressings are removed and the chest is washed daily starting on postoperative day 2" — Rebecca Brown (clinical) [3:19](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=199) - "Patients are encouraged to ambulate at least 3 times in the halls starting postoperative day 2" — Rebecca Brown (clinical) [3:26](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=206) - "PT and OT work with the patient on postoperative day 3 to help them walk up and down stairs, and sign off once able" — Rebecca Brown (clinical) [3:51](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=231) - "Patients are discharged home on postoperative day 3 if pain is well controlled and they are tolerating oral intake" — Rebecca Brown (clinical) [4:27](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=267) - "Since 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 Brown (epidemiological) [4:46](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=286) - "Patient satisfaction has increased since institution of the clinical care pathway" — Rebecca Brown (epidemiological) [4:46](https://library.globalcastmd.com/watch/pectus-excavatum-pathway-1973?t=286) ## 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. --- Not medical advice · citation policy: https://library.globalcastmd.com/ai