Pectus Excavatum (Nuss) v2.0

Explanation of Evidence RatingsSummary of Version Changes

Last Updated: July 2019

Next expected review: July 2024© 2019 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

For questions concerning this pathway,

contact: Pectus@seattlechildrens.org

Discharge Criteria· No increased incision redness or pain

· Afebrile

· Pain adequately controlled without IV meds

· Tolerates diet without emesis

· Urine output >=0.5 mL/kg/hr

· Ambulating

Discharge

Instructions· PE540 Pectus

Excavatum

· PE1453 Pain Medicine

Log

· PE432 Constipation

After Surgery

Inclusion Criteria· Patient age 13 years to

adult with Pectus

Excavatum requiring

repair

Exclusion Criteria· None

Intraoperative ManagementAnesthesia and pain management

· Standard anesthesia procedures

· Ketorolac IV at end of case

· Standard PACU orders

Infection prevention

· Double glove

· Ioban drape

· Irrigate wounds with Betadine® solution

· Perioperative antibiotics

· Cefazolin

· Clindamycin if allergic

· Vancomycin if MRSA

Thrombosis prevention

· Sequential compression device (SCD) if age 16 years or

older, prior to induction

Safety Precautions

· Sternal saw available and open on the field to assure proper

function

Intraoperative Pain Management

· Cryoablation to 2 nerves above and below bar entry level on

each side

· Bupivacaine 0.5% (2mL per nerve) 2 nerves above and below

bar entry level on each side

Other

· Dictation must clearly state number of bars and which side

stabilizer is placed

· Write General Surgery Pectus Repair Plan admit orders

prior to patient transfer out of the O.R.

PE540

PE432

PE1453

Postoperative Management

Admit to surgical floor from PACU

· Chest X-ray in PACU to assess for pneumothorax

Activity

· Showering ok on POD1

· POD1 out of bed to chair and ambulate goal is 3-4 times per day in

halls, minimum of 2 times per day (bathroom does not count)

Nursing

· Temperature, heart rate, pulse oximetry, respiratory rate, pain

assessment q 4 hours

· Pulse oximetry and cardiorespiratory monitoring if on continuous

IV opioid infusion

· Strict I/O

· Diet: ad lib

· Incentive spirometry q 1 hour while awake

· Continue SCD (age ≥16 years) until ambulating

· Place Sternal Precaution sign above bed: Do not lift, no arm lift, 2

person assist, no log roll

Medications

· Continue perioperative antibiotics x 2 doses

Pain

· POD1 or 2: start oral pain medicines.

· Oxycodone short acting (no long-acting), as needed

· Acetaminophen/ibuprofen alternating, scheduled for 3

days

· Ketorolac IV can substitute for ibuprofen, as needed,

for up to 3 days

Home pain meds

· Oxycodone short acting (no long-acting), as needed

· Acetaminophen/ibuprofen alternating, as needed

Approval and Citation

Pectus@seattlechildrens.org

Pectus Excavatum (Nuss) v2.0

OR Card Intraoperative Management

Intraoperative Management

Anesthesia and pain management

· Standard anesthesia procedures

· Standard PACU orders

Infection prevention

· Double glove

· Ioban drape

· Irrigate wounds with Betadine® solution

· Perioperative antibiotics

· Cefazolin

· Clindamycin if allergic

· Vancomycin if MRSA

Thrombosis prevention

· Sequential compression device (SCD) if

age 16 years or older, prior to induction

Safety Precautions

· Sternal saw available and open on the field to

assure proper function

Intraoperative Pain Management

· Cryoablation to 2 nerves above and below bar

entry level on each side

· Bupivacaine 0.5% (2mL per nerve) 2 nerves

above and below bar entry level on each side

Other

· Dictation must clearly state number of bars

and which side stabilizer is placed

· Write General Surgery Pectus Repair Plan

admit orders prior to patient transfer out of the

O.R.

Postoperative Checklist

1. Perioperative antibiotic given?

2. Double gloving performed?

3. Ioban drape used?

4. Povidone iodine (Betadine) washout performed?

Postoperative Checklist

Return to Home

Last Updated: July 2019

Next expected review: July 2024

© 2019 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

For questions concerning this pathway,

contact: Pectus@seattlechildrens.org Pectus@seattlechildrens.org

Pectus Excavatum (Nuss) v2.0: Preoperative Assessment

1. The optimal timing for surgery for Pectus Excavatum repair is 13-17 years of age while the chest

wall is still malleable (adults (over 21) will need formal approval). However, repair at a younger

age is appropriate in the setting of severe cardiac or pulmonary compression with associated

signs of physiologic impairment.

2. Carefully and accurately dictate history and symptoms with regard to exercise, especially aerobic

exercise intolerance:

a. How far can youth run

b. Can they keep up with their peers

c. Key on aerobic events such as long distance running (more than 1 mile), soccer and

basketball. Be aware that anaerobic activity (sprints, weight lifting) will usually NOT

demonstrate the symptoms.

3. Referral if Marfan Syndrome suspected:

a. Cardiology for potential ECHO

b. Ophthalmology

c. Genetics if Marfan Syndrome proven from either a or b above

4. If allergy suspected by history, outpatient trial with nickel

5. Pre-op testing:

Required

a. Chest CT scan to measure Haller index

b. Assess for associated cardiac or pulmonary compression

If there is cardiac and/or pulmonary compression – the patient should be referred to PASS

clinic

c. Cardiopulmonary exercise test (questionable correlation as current SCH test is an anaerobic

test on treadmill with increase tilt until failure)

Optional

c. EKG, if symptoms consistent with ectopy. May be indicated to rule out other problems. (RAD

is uniformly present: irrelevant finding.)

d. Echocardiogram

i. Should obtain if Marfan Syndrome (aortic root, AV)

ii. May be indicated to rule out other anomalies

iii. Poor correlation when performed at rest

e. Pulmonary Function Tests have been eliminated

6. Nuss procedure is indicated for patients with a severe pectus excavatum deformity and

associated physiologic impairment. Specific inclusion criteria include two or more of the

following:

a. Computed tomography (Haller) index greater than 3.25 (normal approx 2.80) with associated

cardiac or pulmonary compression. An index greater than 3.25 is considered severe.

b. Cardiology evaluation demonstrating cardiac compression, displacement, mitral valve

prolapse, or murmurs.

c. Documentation of progression of the deformity with advancing age in association with

development of or worsening of physiologic symptoms (i.e. shortness of breath, lack of

endurance, exercise intolerance, palpitations, and chest pain).

7. Refer to PASS clinic for any of the following:

a. Evidence of cardiac or pulmonary compression

b. Exercise intolerance

c. Need for further consultation with any other subspecialties (pulm, cardiac, etc)

National and local expert opinion (Frantz 2011) Return to Home

Return to Home

Pneumothorax

· Small pneumothorax

· Almost universal

· Follow-up chest x-ray unneessary

· Large pneumothorax

· Consider chest tube placement

· Supplemental oxygen for O2 sats <92%

· Repeat chest x-ray on day of discharge

Evidence [expert opinion]

Return to Home

Pain Management: Postoperative Day 1

· Start oral pain meds EARLY if not already on them

· Discontinue other IV pain meds

· Bowel movement not required for discharge

Evidence [expert opinion]

What is best practice for minimizing postop pain?

Return to Home

Epidural

Using epidural postop did not lower pain scores to a clinically significant degree compared to PCA.

[LOE: Very low certainty due to lack of blinded outcome assessment, inclusion of young

children, heterogeneity, small study size, and inconsistency of statistical significance. (Stroud 2014)]

Cryoablation

In 1 RCT and 5 non-randomized cohort studies reporting outcomes which included 196 patients who

received cryoablation with a range of 1 week to 3 years follow-up, compared to controls, using

cryoablation shortened LOS by around 1.1 to 3.5 days, added 20-30 minutes of surgery time, and

reduced need for narcotics. Few complications or long-term pain have been reported.

[LOE: Very low certainty due to few patients (Graves 2019, Harbach 2018, Keller 2016,

Graves 2017, Sujka 2018, Morikawa 2018)] In the RCT of 40 patients (Graves 2019), LOS was

reduced by 2 days with cryoablation and all patients returned to normal sensation by 1 year. In the

largest cohort study of 26 patients, none reported pain at 3 months.(Keller, 2016)

Surgical Outcomes

Return to Home

Does surgery improve heart or lung function?

In a meta-analysis of 23 RCTs and cohort studies including 4272 patients, patients undergoing Nuss

or Ratvich procedures did not experience an improvement in FEV1 from baseline at 1 or 3 years

postop. [LOE Very low quality due to lack of historical controls and heterogeneity in

outcomes at 3 years (Chen 2012)].

Jayaramakrishnan et al (2013) conducted a qualitative systematic review of 22 cohort and case-

control studies that was not eligible to be GRADEd. After Nuss procedure, pulmonary function

decreased in the early postop period (6-8 months) then showed a small improvement during the late

postoperative period after bar removal.

In a meta-analysis of 13 studies (n=465 participants) assessing difference in pulmonary function

testing results over 3 months to 3 years postop compared to baseline, changes in FEV1 (0.17, 95%

CI 0.1 to 0.33) and FVC (-0.18, 95% CI -0.41 to 0.06) did not reach clinical significance. [LOE

Very low quality due to lack of control group, small studies, and heterogeneity (Wang

2018)].

What is the optimal procedure?

A meta-analysis found no randomized-controlled trials comparing Nuss to Ratvich procedures that

met incusion criteria. Eight trials were potentially eligible: 3 were prospective but not randomized, 4

compared the interventions but were retrospective and not randomized. One was a meta-analysis of

retrospective studies. (De Oliveria, 2014) Johnson and Singhal (2014) conducted a systematic

review of studies for adult and pediatric patients with pectus excavatum. They identified 39 cohort

studies of the procedures and reported results qualitatively (a meta-analysis was not attempted). It

is not possible to draw conclusions of comparative effectiveness from this paper because of its

design.

In a meta-analysis of 13 quasi-experimental studies (n=1432 patients), comparing Nuss and Ratvich

procedures,

· Operation time shorter for Nuss by 67 minutes (95% CI: 9 to 125 minutes), all ages

· Hospital LOS comparable (weighted mean difference -1.6, 95% CI -4.4 to 1.3)

· Analgesia and duration mean blood loss not well reported and not pooled

· In pediatric data, complications were not different between Nuss and Ratvich procedures.

[Level of Evidence (LOE): Very low quality (Kanagaratnam 2016), downgraded for small

sample size and lack of historical control.]

In a meta-analysis of 19 quasi-experimental studies (n=1731 patients), Nuss procedure was

associated with 51mL less blood loss (95% CI 33 to 70 mL) and no difference in length of stay (-

0.85 days, 95% CI -0.54 to 2.22). [Level of Evidence (LOE): Very low quality (Mao 2017),

downgraded for small sample size and significant heterogeneity]

Return to Home

Pectus Excavatum (Nuss) v2.0: Approval & Citation

Approved by the CSW Pectus Pathway team for 7/31/19 go-live

CSW Pectus Pathway Team:

General Surgery, Owner John Meehan, MD

Surgical Clinical Quality Leader: Kirsten Oldroyd

General Surgery, Stakeholder: Patrick Javid, MD

Anesthesia, Pain Medicine Stakeholder: Lizabeth Martin, MD

Anesthesia, Pain Medicine Stakeholder: Shilpa Verma, MD

Recovery Room Stakeholder: Pamela Christensen, CNS

Surgical Coordination Stakeholder: Shannon Gaffney

Clinical Effectiveness Team:

Consultant: Jennifer Hrachovec, PharmD, MPH

Project Manager: Dawn Hoffer

CE Data Analyst: Nathan Deam

Librarian: Jackie Morton

Program Coordinator: Kristyn Simmons

Clinical Effectiveness Leadership:

Medical Director: Darren Migita, MD

Operations Director: Karen Rancich Demmert, BS, MA

Retrieval Website: https://www.seattlechildrens.org/pdf/pectus-excavatum-nuss-pathway.pdf

Please cite as:

Seattle Children’s Hospital, Meehan J, Deam N, Hoffer D, Hrachovec J, Oldroyd K, Migita D, 2019

July. CSW Pectus Excavatum (Nuss) Pathway. Available from: https://www.seattlechildrens.org/

pdf/pectus-excavatum-nuss-pathway.pdf

Return to Home To Bibliography

Evidence Ratings

Quality of Evidence:

High: The authors have a lot of confidence that the true effect is similar to the estimated effect

Moderate: The authors believe that the true effect is probably close to the estimated effect

Low: The true effect might be markedly different from the estimated effect

Very low: The true effect is probably markedly different from the estimated effect

Guideline: Recommendation is from a published guideline that used methodology deemed acceptable by the team

Expert Opinion: Based on available evidence that does not meet GRADE criteria (for example, case-control studies).

This pathway was developed through local consensus based on published evidence and expert

opinion as part of Clinical Standard Work at Seattle Children’s. Pathway teams include

representatives from Medical, Subspecialty, and/or Surgical Services, Nursing, Pharmacy, Clinical

Effectiveness, and other services as appropriate.

When possible, we used the GRADE method of rating evidence quality. Evidence is first assessed

as to whether it is from randomized trial or cohort studies. The rating is then adjusted in the

following manner (from: Guyatt G et al. J Clin Epidemiol. 2011;4:383-94, Hultcrantz M et al. J Clin

Epidemiol. 2017;87:4-13.):

Quality ratings are downgraded if studies:

· Have serious limitations

· Have inconsistent results

· If evidence does not directly address clinical questions

· If estimates are imprecise OR

· If it is felt that there is substantial publication bias

Quality ratings are upgraded if it is felt that:

· The effect size is large

· If studies are designed in a way that confounding would likely underreport the magnitude

of the effect OR

· If a dose-response gradient is evident

Summary of Version Changes

· Version 1.0 (5/22/2013): Go live

· Version 2.0 (7/31/2019): Changed pain management to use cryoablation and remove soaker

catheter

Return to Home

Return to Home

Medical Disclaimer

Medicine is an ever-changing science. As new research and clinical experience

broaden our knowledge, changes in treatment and drug therapy are required.

The authors have checked with sources believed to be reliable in their efforts to

provide information that is complete and generally in accord with the standards

accepted at the time of publication.

However, in view of the possibility of human error or changes in medical sciences,

neither the authors nor Seattle Children’s Healthcare System nor any other party

who has been involved in the preparation or publication of this work warrants that

the information contained herein is in every respect accurate or complete, and

they are not responsible for any errors or omissions or for the results obtained

from the use of such information.

Readers should confirm the information contained herein with other sources and

are encouraged to consult with their health care provider before making any

health care decision.

Bibliography

Literature Search Methods

For this update, we revised all our search strategies in line with current SCH Library practices. The

initial literature search was conducted on June 8, 2019. The search targeted synthesized literature

on all of the following concepts: funnel chest, pectus excavatum, or Nuss Ravitch and Robicsek

procedures. The search was executed in Ovid Medline, Embase.com, Cochrane Database of

Systematic Review, and Turning Research into Practice database (TRIP) for 2012 to current and

limited to English. An expanded search was conducted on April 26, 2019 to capture any literature on

the use of cryosurgery with funnel chest or pectus excavatum. The search was executed in Ovid

Medline, Embase.com with no limits for language or dates.

Two reviewers screened abstracts and included guidelines and systematic reviews that addressed

treatment of patients who meet pathway inclusion/exclusion criteria as well as randomized-

controlled trials and cohort studies on the use of cryoablation to prevent pain. One reviewer

screened full text and extracted data and a second reviewer quality checked the results. Differences

were resolved by consensus.

Literature Search Results

The searches of the 4 databases (see Electronic searches) retrieved 66 records. Once duplicates

had been removed, we had a total of 48 records. We excluded 18 records based on titles and

abstracts. We obtained the full text of the remaining 30 records and excluded 16.

We included 14 studies. The flow diagram summarizes the study selection process.

To Bibliography, Pg 2Return to Home

Identification

Screening

Eligibility

Included

Records identified through database searching (n=66)

Additional records identified through other sources (n=0)

Records after duplicates removed (n=48)

Records screened (n=48) Records excluded (n=18)

Records assessed for eligibility (n=30)Articles excluded (n=16)

Did not answer clinical question (n=1)Did not meet quality threshold (n=15)

Studies included in pathway (n=14)

Bibliography

Chen Z, Amos EB, Luo H, et al. Comparative pulmonary functional recovery after nuss and ravitch

procedures for pectus excavatum repair: A meta-analysis. J Cardiothorac Surg. 2012;7:101.

Accessed 6/8/2018 2:42:11 PM. https://dx.doi.org/10.1186/1749-8090-7-101.

Das B, Sadhasivam S. Response to intercostal nerve cryoablation versus thoracic epidural

catheters for postoperative analgesia following pectus excavatum repair. J Pediatr Surg.

2017;52(6):1076. Accessed 4/26/2019 11:08:25 AM. https://dx.doi.org/10.1016/

j.jpedsurg.2017.01.069.

de Oliveira CP, da SM, Rodrigues O.R., Cataneo A.J.M. Surgical interventions for treating pectus

excavatum. Cochrane Database Syst Rev. 2014;2014(10). Accessed 6/8/2018 3:44:41 PM.

10.1002/14651858.CD008889.pub2.

Graves C, Idowu O, Lee S, Padilla B, Kim S. Intraoperative cryoanalgesia for managing pain after

the nuss procedure. J Pediatr Surg. 2017;52(6):920-924. Accessed 4/26/2019 11:08:25 AM.

https://dx.doi.org/10.1016/j.jpedsurg.2017.03.006.

Graves CE, Moyer J, Zobel MJ, et al. Intraoperative intercostal nerve cryoablation during the nuss

procedure reduces length of stay and opioid requirement: A randomized clinical trial. J Pediatr

Surg. 2019. Accessed 4/26/2019 11:08:25 AM. https://dx.doi.org/10.1016/

j.jpedsurg.2019.02.057.

Harbaugh CM, Johnson KN, Kein CE, et al. Comparing outcomes with thoracic epidural and

intercostal nerve cryoablation after nuss procedure. J Surg Res. 2018;231:217-223. Accessed

4/26/2019 11:08:25 AM. https://dx.doi.org/10.1016/j.jss.2018.05.048.

Jayaramakrishnan K, Wotton R, Bradley A, Naidu B. Does repair of pectus excavatum improve

cardiopulmonary function? Interact Cardiovasc Thorac Surg. 2013;16(6):865-870. Accessed

6/8/2018 2:42:11 PM. https://dx.doi.org/10.1093/icvts/ivt045.

Kanagaratnam A, Phan S, Tchantchaleishvili V, Phan K. Ravitch versus nuss procedure for pectus

excavatum: Systematic review and meta-analysis. Ann cardiothorac surg. 2016;5(5):409-421.

Accessed 6/8/2018 2:42:11 PM.

Keller BA, Kabagambe SK, Becker JC, et al. Intercostal nerve cryoablation versus thoracic

epidural catheters for postoperative analgesia following pectus excavatum repair: Preliminary

outcomes in twenty-six cryoablation patients. J Pediatr Surg. 2016;51(12):2033-2038.

Accessed 4/26/2019 11:08:25 AM. https://dx.doi.org/10.1016/j.jpedsurg.2016.09.034.

Mao YZ, Tang S, Li S. Comparison of the nuss versus ravitch procedure for pectus excavatum

repair: An updated meta-analysis. J Pediatr Surg. 2017;52(10):1545-1552. Accessed 6/8/

2018 2:42:11 PM. https://dx.doi.org/10.1016/j.jpedsurg.2017.05.028.

Morikawa N, Laferriere N, Koo S, Johnson S, Woo R, Puapong D. Cryoanalgesia in patients

undergoing nuss repair of pectus excavatum: Technique modification and early results. J

Laparoendosc Adv Surg Tech A. 2018;28(9):1148-1151. Accessed 4/26/2019 11:08:25 AM.

https://dx.doi.org/10.1089/lap.2017.0665.

Stroud AM, Tulanont DD, Coates TE, Goodney PP, Croitoru DP. Epidural analgesia versus

intravenous patient-controlled analgesia following minimally invasive pectus excavatum

repair: A systematic review and meta-analysis. J Pediatr Surg. 2014;49(5):798-806. Accessed

6/8/2018 2:42:11 PM. https://dx.doi.org/10.1016/j.jpedsurg.2014.02.072.

Sujka J, Benedict LA, Fraser JD, Aguayo P, Millspaugh DL, St Peter SD. Outcomes using

cryoablation for postoperative pain control in children following minimally invasive pectus

excavatum repair. J Laparoendosc Adv Surg Tech A. 2018;28(11):1383-1386. Accessed 4/

26/2019 11:08:25 AM. https://dx.doi.org/10.1089/lap.2018.0111.

Wang Q, Fan S, Wu C, Jin X, Pan Z, Hong D. Changes in resting pulmonary function testing over

time after the nuss procedure: A systematic review and meta-analysis. J Pediatr Surg. 2018.

Accessed 6/8/2018 2:42:11 PM. https://dx.doi.org/10.1016/j.jpedsurg.2018.02.052.

Return to Home