Enhanced pain management for pectus excavatum surgery

Mayo Clinic Children's Center uses a novel system to manage pain after pectus excavatum surgery, typically leading to decreased use of pain medications, improved pain scores and shorter hospital stays. The system, developed by Mayo Clinic pediatric surgeons and anesthesiologists, involves the insertion of paravertebral catheters that pump a local anesthetic to the intercostal nerves for about a week after surgery.

"Since we started a multimodal pain management strategy in 2010, the use of opioids has gone down by more than half while the pain scores dropped significantly, which means children are having less pain. With this strategy, children are getting out of bed sooner and drinking and eating much earlier than before," says Dawit T. Haile, M.D., chair of Pediatric Anesthesiology at Mayo Clinic in Rochester, Minnesota. "The major change to the pain management strategy was the introduction of paravertebral catheters. We use ultrasound to insert nerve catheters to block nerves innervating the chest wall while the patient is asleep, avoiding the pain and anxiety of placing the catheters while the patient is awake, such as when an epidural is placed."

"The enhanced pain management has helped reduce the average length of hospital stay for the procedure from five days to about three," says D. Dean Potter Jr., M.D., chair of Pediatric Surgery at Mayo Clinic's campus in Minnesota. "Pain medication can be infused in the hospital and for two to three days after patients leave. The catheters are removed at home. It's as easy as removing a dressing," Dr. Potter says.

Optimizing outcomes

Ideally, children with pectus excavatum should have an initial evaluation around the age of 8 to 10. Signs and symptoms may include the appearance of the pectus, shortness of breath and exercise intolerance. If the pectus is severe, signs and symptoms might include rapid heartbeat or palpitations, wheezing, and chest pain. Mayo Clinic Children's Center can monitor the child for heart and lung complications before performing surgery if needed.

"The best time to do the surgery is ages 12 to 14," Dr. Potter says. "Younger children generally don't yet have the maturity to go through this procedure. By the time children turn 16 or 17, their chest walls are a little more rigid. While that's not necessarily a problem for successful surgery, it may make the procedure more painful."

To minimize radiation exposure, Mayo Clinic Children's Center uses X-rays rather than CT scans to obtain the chest-cage measurements needed to plan surgery. Pulmonary function tests are done to exclude asthma or other pulmonary conditions as a cause of symptoms. Echocardiography may be performed to assess heart function. Additional monitoring and care are provided for children whose pectus excavatum is associated with a connective tissue disorder, such as Marfan syndrome or Ehlers-Danlos syndrome.

The minimally invasive surgery for pectus excavatum, which involves inserting a customized bar in the chest, takes about one to two hours. Patients generally can resume vigorous exercise three months after surgery and contact sports six months after surgery.

Hundreds of minimally invasive pectus surgeries have been done at Mayo Clinic Children's Center since it became one of the first centers in the United States to offer the procedure. Dr. Potter notes that patients and their parents consistently report high satisfaction with the outcomes.

"We see kids who couldn't run a mile and all of a sudden become runners after recovering from surgery," Dr. Potter says. "Other children who were a bit embarrassed by their appearance come out of their shells and get involved in activities. These kids are much happier."