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