Introduction

Welcome to the APSA Quality and Safety Committee Pectus Toolkit. This toolkit is intended to help anyone who is interested in quality improvement on the management of pectus excavatum, pectus carinatum and other chest wall deformities.
Available toolkit projects are listed below. Many of the approaches described are evidence based - some are not. These approaches have not been approved by APSA.

Pectus ERAS Pathway

In 2013 the Johns Hopkins All Children’s Hospital began the use of a standardized perioperative practice plan for patients undergoing minimally invasive repair of pectus excavatum (MIRPE) which has resulted in a decrease in resource utilization, narcotic use and length of stay. The use of epidural anesthesia has been abandoned and replaced with a multimodal analgesic approach.

Protocol

ERAS pathway after MIRPE

Pain medication protocol

Resources

• Postoperative order set - Hopkins (pectus)
• Patient controlled analgesia order set (pectus)
• Urinary retention algorithm (pectus)

Stakeholders: surgeons, anesthesiologists, perioperative staff, patients/parents, administration, community

Challenges and solutions: The standardized perioperative practice plan required a collaborative effort amongst services (surgery, anesthesia) as well buy in from perioperative services.

Published data: Enhancing recovery after minimally invasive repair of pectus excavatum [1]

Submitted by Raquel Gonzalez

Additional implementers: Nicole Chandler

Postoperative and Discharge Protocol

The Medical University of South Carolina uses the following standard discharge and postoperative care protocol for patients following pectus repair. There were reduced complications and length of stay following implementation of a standard postoperative physical therapy, discharge criteria and follow-up care protocols.

Resources

• Physical therapy protocol (pectus)
• Discharge instructions (pectus)
• Postoperative schedule (pectus)

Stakeholders: surgery, nursing, anesthesia, radiology, rehab/physical therapists

Submitted by Rob Cina

Additional implementers: Jenny Waterhouse

Postoperative Pain Management

In 2018, the Chest Wall Program at Riley Hospital for Children implemented a multimodal postoperative pain control regimen coupled with a standardized postoperative management bundle for all patients who underwent surgical correction pectus excavatum by either Nuss or Ravitch procedure. The purpose of this program was to decrease narcotic use while providing equivalent or improved postoperative pain control.

Resources

• Postoperative order set - Riley (pectus)
• Pain management protocol (pectus)

Stakeholders: pediatric surgery, pediatric anesthesia, pediatric acute pain service, physical therapy

Challenges and solutions: surgeon by in. Solutions were two-fold. First was education. Second was seeing early successes with the use of the protocol (improved length of stay, equal or better daily pain control and decreased opioid use overall)

Abstract Early results after the implementation of the multimodal analgesic protocol for pectus repair

Submitted by Matt Landman

References

1. Litz CN, Farach SM, Fernandez AM, et al. Enhancing recovery after minimally invasive repair of pectus excavatum. Pediatr Surg Int. 2017;33(10):1123-1129.  [PMID:28852843]