Update Course Rewind: Pectus Excavatum 2021

A 16-year-old male with shortness of breath on exertion, no comorbidities, and pectus index of 5.5 was planned for chest wall reconstruction

A randomized trial of 110 patients comparing epidural and PCA showed epidurals did not provide adequate pain control

After implementing cryoanalgesia, a patient went home on post-operative day one, ending equipoise in the trial

Cryoanalgesia uses cold temperatures to cause a conduction block that interrupts pain impulses to the brain

Cryoanalgesia technique involves freezing ribs four through seven for two minutes per rib; ribs eight and below should not be treated due to risk of abdominal wall paralysis

Cryoanalgesia reduced hospital length of stay from four days to one day

Cryoanalgesia dramatically reduced median morphine equivalents compared to previous pain management approaches

There are no long-term studies on cryoanalgesia outcomes, raising concerns about potential chronic neuropathic pain

Medical devices and techniques are not required to undergo clinical trials before market introduction, unlike medications

Erector spinae catheters are placed by the pain team with ultrasound guidance, stay in for five days, and allow hospital discharge at two days with family removal of catheters on day three

Erector spinae catheters reduced opioid requirements both in-hospital and post-discharge, achieving two-day hospital stays

Cryoanalgesia changed not just discharge timing but how patients feel at discharge

Multimodal pain control includes Tylenol, NSAIDs, precedex for gentle wake-up, dexamethasone for nausea, ketamine to avoid opioids, child life specialists, mindfulness resources, and physical therapy

Best multimodal treatments are preoperative counseling, gabapentin pre and postoperatively, methadone, clonidine, bowel regimen medications, and antiemetics

A multimodal pain regimen achieved hospital length of stay under two days with patients off opioids by one week

Bar flippage typically occurs early due to bars sitting in incorrect intercostal space, poor positioning, inadequate wrapping, or insufficient securing

Bar flippage is completely a surgical technique issue, not related to the securing method

Computational modeling shows shorter flat bars create more pressure on the sternum compared to traditional U-shaped bars, making them more stable

Sternal elevator is used in approximately 10% of cases, primarily in younger patients where thoracoscopy provides adequate visualization

Sternal elevation in deep, stiff pectus cases allows less tissue damage and better repair

Sternal elevator enables consistent entry and exit at the same intercostal space

Thoracoscopy, sternal elevator, vacuum bell, and sub-xiphoid incision are all techniques aimed at preventing cardiac injury

Passing the bar from left to right avoids pointing the introducer directly at the ventricle

Bar passage direction is surgeon preference and does not make significant difference if sub-sternal space is well dissected and clear