Pectus Excavatum Flashcards
What is pectus excavatum?
Posterior decompression of the chest caused by a defect in the proper growth of the sternum and adjacent costal cartilages.
What are the most common symptoms of untreated pectus excavatum?
DOE
Loss of endurance
How is pectus excavatum repaired?
Most commonly via the Nuss thoracoscopic technique in which rigid bars are placed under the sternum and costal cartilages until the chest wall is permanently remodeled.
What comorbidities and conditions are associated with pectus excavatum?
Inherited connective tissue disorders:
Marfan’s, homocysteinuria, Ehler’s-Danlos
Scoliosis
Mitral valve prolapse
Leftward heart shift with some compression
What is the Haller Index?
The ratio of the transverse diameter of the thorax to the anterior-posterior diameter of the thorax as measured in a CT scan.
It is a measure of the severity of pectus excavatum and in the original paper (Haller 1987) patient’s with an index >= 3.25 had surgical repairs.
What information of unique interest to the anesthesiologist may be gleaned from the CT scan of a patient presenting for pectus excavatum repair?
The approximate depth of epidural space and the angle of approach should the patient have scoliosis.
What complications may occur with endoscopic pectus excavatum repair?
Most commonly bar displacement, pneumothoraces, and infection.
But also:
Direct injury to heart and mediastinal structures
sternal erosion
arterial pseudoaneurysm
persistent cardiac arrhythmias
What is important to avoid during emergence from anesthesia after a Nuss repair of pectus excavatum?
Coughing
The increased intrathoracic pressure may force air in the pleural cavity from a residual pneumothorax and cause subcutaneous emphysema - which could be extensive.
A well-functioning epidural can avoid what issues associated with opioid usage?
Poor dynamic pain relief
Sedation
Nausea and vomiting
pruritis
hallucinations
ileus
urinary retention
respiratory depression
What sources of pain are often present after pectus excavatum repair?
Spasmodic
Incisional
Bony
What analgesic modalities are usually appropriate after pectus excavatum repair?
Epidural analgesia
Opioids
Muscle relaxants (methocarbamol, diazepam)
NSAID
Tylenol
What mode of analgesia will get rid of the “tight” chest sensation often complained of by patients after pectus repair.
No mode of analgesia will completely relieve that feeling, thus preoperative education will help patients have realistic postoperative expectations, reduce anxiety, and prevent unneeded adjustments to the epidural analgesia.
When checking the epidural insertion site in a patient s/p pectus repair, how should the patient sit?
Straight up instead of rolling to one side as to avoid dislodging the pectus bar
What is generally considered the correct level to insert an epidural for pectus repair?
T5-T6
(as pain postoperatively can reach as high as T1.
