DECEMBER 2001, VOL 74, NO 6
Home Study Program THENUSSPROCEDUREFOR
PECTUS EXCAVATUM CORRECTION
he article “The Nuss procedure for pectus excavatum correction” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, education program professional, Center for Perioperative Education. A minimum score of 70% on the multiple-choice examination is necessary to earn 3 contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Dec 3 1,2004. Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711 or fax the information with a credit card number to (303) 750-3212.
BEHAVIORAL O B J E C I M S
After reading and studying the article on correction of pectus excavatum, the nurse will be able to (1) discuss the preoperative assessment and testing of patients undergoing pectus excavatum correction, (2) discuss pain management options, ( 3 ) describe perioperative nursing care of patients undergoing the Nuss procedure for the correction of pectus excavatum, (4) discuss the surgical procedure, and (5) describe the postoperative course and potential complications of pectus excavatum correction. This program meets criteria for CNOR and CRNFA recertification, as weIl as other continuing education requirements.
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The Nuss Procedure for Pectus Excavatum Correction ectus excavatum or “sunken chest” is an anterior chest wall deformity that occurs in one out of 1,000 children. Boys are born with this deformity more often than girls (ie, four to one).’ The deformity becomes noticeably worse with each growth spurt but usually reaches its maximum depression by the mid-teenage years. Ideally, it is easier to correct pectus excavatum before the child reaches puberty because the rib and cartilage structures are more malleable. Surgical intervention is best performed before the age of 14, but it has been performed successfully on older children and adults (ie, people 17 to 30 years of age).’ The Nuss procedure is a minimally invasive technique for the correction of pectus excavatum that was developed by Donald Nuss, MB, ChB, at Children’s Hospital of The King’s Daughters in Norfolk, Va. The procedure does not require resection of bone, rib, or cartilage. The correction is accomplished by placing a curved surgical steel bar under the patient’s sternum to “pop out” the depression. Surgical time is less, large volumes of blood loss no longer occur, and the patient is able to return to full activity much more rapidly.:
MTIENT EVALUATION AND EDUCATION
Pectus excavatum is categorized according to three degrees of severity (ie, mild, moderate, severe). Each child is evaluated to determine whether his or her pectus deformity is severe enough to warrant corrective surgery. The evaluation process begins with a history and physical examination, including preoperative chest photographs and chest measurements (Figures 1 and 2). The surgeon performs a complete history to identify the presence of severe pectus excavatum symptoms (eg, exercise intolerance, shortness of breath, chest pain). The history contains information about other family members who also have this deformity. Genetic predisposition for pectus excavatum has not been proven; however, there is a strong familial prevalence among patients diagnosed with this condition.‘ Diagnostic examination. A computed tomography (CT) scan of the chest, pulmonary function tests (PFTs), and a cardiology evaluation also are performed. The CT scan is used to determine the depth of the deformity based on the Haller index (Figure 3).’ This index is obtained by measuring from side to side inside the rib cage and dividing that measurement by the distance from sternum to vertebral body. This measurement is taken at the A B S T R A C T Pectus excavatum is an anterior chest wall deformity that now deepest point of the pectus deforcan be corrected with a minimally invasive technique known as the mity. A normal chest without Nuss procedure. Patient criteria and assessment for this new surgical pectus excavatum deformity has procedure are defined clearly in advance to ensure the need for sur- a ratio of less than two. A Haller gical intervention. A multidisciplinaryteam approach has been estab- index greater than 3.2 is considlished at Children’s Hospital of The King‘s Daughters, Norfolk, Va. ered severe.(’The CT scan also Team members work cooperatively throughout the perioperative indicates the presence of cardiac cycle, addressing not only the surgical procedure but also pain man- compression or displacement and agement and postoperative recovery. This dedicated team approach secondary lung compression. helps ensure a successful outcome for the patient. AORN J 74 (Dec Pulmonary function tests are used to help determine whether lung 2001) 828-841. B S W O Y E L A N D , RNC; C M E D V I C K ,
RN; M K I R S H , 828 AORN JOURNAL
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capacity has been affected by the squeeze action created by the chest wall depression. The squeeze action also affects the cardiac system and may create benign murmurs, mitral valve prolapse, and mitral valve regurgitation. It also is very important to identify the presence of Marfan’s Syndrome because patients with this condition frequently have numerous other cardiac and vascular anomalies, which increase their surgical risks.’ Surgical intervention is based on demonstrated medical need and is not performed solely for cosmetic or aesthetic reasons.8After all tests and examinations are complete, the surgeon ranks the patient’s deformity according to categories. Patients who have pectus deformities classified as moderate to severe Figure 1 Preoperative Photograph of a Patient Presenting with severe pectus excavaturn deformity as are considered surgical candidates. Preoperative nursing and patient education. Seen from the lateral view. Surgery is scheduled after parents have been informed of the need for surgical correction and have consented to the procedure. The nurse assesses the patient and identifies appropriate patient-specific nursing diagnoses and a plan of care. Table 1 outlines the nursing care plan for patients undergoing the Nuss procedure for correction of pectus excavatum. Nursing diagnoses appropriate for this patient population include ineffective breathing pattern related to pectus excavatum and surgical intervention, risk for decreased cardiac output related to severity of pectus excavatum, anxiety related to planned surgical intervention, pain related to surgical intervention, and deficient knowledge regarding home care Figure 2 Preoperative photograph of the same related to unfamiliarity with information resources. as Seen fro,,, the anterior Educational and instructional materials written in layperson language are provided to teach parents and the patient about pectus excavatum. These materials also offer explanations about preoperative preparation, the surgical procedure, and discharge instructions. Parents and the patient often meet with the anesthesia care provider several days before surgery to discuss the anesthesia process, the use and placement of an epidural catheter, and medications used to manage pain. Parents are encouraged to contact either the surgeon or clinical nurse specialist if they have questions or concerns regarding their child’s surgery. Preoperative anxiety. Surgery causes major disruptions in a child’s routine so the nurse explains to Figure 3 Computed tomography scan illustrating the parents that anxiety and behavioral regression (eg, cardiac compression and displacement as a result of bed wetting) are normal. To lessen the patient’s severe pectus excavatum deformity. 829 AORN JOURNAL
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Table 1 NUSS PROCEDURE FOR CORRECTION OF PECTUS EXCAVATUM NURSING CARE PLAN
Nursing diagnosis Ineffective breathing pattern related to pectus excavatum and surgical intervention
Risk for decreased cardiac output related to severity of pectus excovatum
Anxiety related to planned surgical intervention
intervention Monitors respiratory status changes.
Outcome criteria The patient's pulmonary function is consistent with or improved from baseline levels.
Reviews pulmonary function studies and evaluates postoperative pulmonary status.
Uses monitoring equipment to assess pulmonary function.
Recognizes and reports deviation in arterial blood gas studies.
Uses monitoring equipment to assess cardiac status.
Identifies baseline cardiac function.
Reviews results of diagnostic evaluations.
Evaluates postoperative cardiac function.
Identifies psychosocial status.
Assesses coping mechanisms based on physiological and psychosocial status.
Elicits perceptions of surgery.
Develops individualized care plan (eg, need for distraction, toys).
Consults with child life therapists.
Evaluates psychosocial impact on plan of care.
Outcome statement The patient will exhibit signs of effective breathing patterns including maintaining or improving respira tory status as evidenced by arterial blood gas values within expected range and breath sounds free of adventitious sounds and maintaining or improving base line respiratory and cognitive function.
The potient's cardiac function is consistent with or improved from baseline levels.
The patient will exhibit the following measures of stable cardiac output: blood pressure within expected range; warm, dry skin; baseline respiratory status improved; and urine output > 30 mL per hour.
Patient and family members demonstrate knowledge of psychological and physiological responses to surgical or other invasive procedures.
uneasiness about undergoing surgery and being hospitalized, hospital tours are provided after a surgery date has been chosen. These tours include the same day surgery (SDS) unit, pediatric intensive care unit (PICU), postanesthesia care unit (PACU), medical/ surgical unit, playrooms, cafeteria, and family waiting areas. Parents and patients are encouraged to touch and play with some of the surgical and anesthesia equipment. This helps minimize fear of the unknown. Parents and the patient are directed to the SDS unit on the day of surgery where age-appropriate
Patient and family members will verbalize understanding of the procedure, sequence of events, and expected outcomes. Patient will have blood pressure and pulse within expected range. Patient will verbalize abilifV to cope throughout perioperotive period.
diversional toys and games are available. Therapists from the child life department at Children's Hospital of The King's Daughters are available to help family members deal with any apprehension. These therapists have training that ranges from certification to master's level education. They are prepared to deal with children of various ages and developmental stages. Their specialty training enables them to identify problems that may develop or already have developed as a result of a needed hospitalization. Therapists' interaction with patients and family
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Table 1 NUSS PROCEDURE FOR CORRECTION OF PECTUS EXCAVATUM NURSING CARE PLAN (CONTINUED)
Nursing diagnosis Intervention Pain related to Assesses pain control. surgical intervention
Implements pain guidelines. ImplementS alternative methods of pain control (eg, perioperative Evaluates response to pain management interventions.
Outcome criteria The patient demonstrates
Outcome statement Patient and family members wit1 communicate
and/or rePo‘ s adequate pain throughout the perioperative period.
previous experiences of pain, 0
outcome expectations, an understanding of the plan for pain assessment and management, knowledge of pharmacological and nonpharmacological methods of pain management (eg, play therapy), and the need ta report pain in a timely manner.
Deficient knowledge regarding home care routines related to unfamiliarity with information resources
Provides written discharge instruction based on age and identified need. 0
The patient will
Includes patient and his or her
knowledge of medication management, pain management, nutritional requirements, and wound healing.
family members in discharge planning. Identifies expectations Of home care. Evaluates environment for home care. Provides instruction about wound healing, wound care, prescribed medications, pain management, dietary needs, and activities.
communicate purpose, dosage, route, and possible side effects of medications;
return demonstrate proper medication administration; and communicate proper storage of medications.
Patient and family members Participate in the rehabilitation process.
Evaluates response to instruction.
members helps them develop appropriate coping mechanisms for the disease process or surgical procedure. Interaction may be as simple as talking and listening sessions to very detailed aggression-release sessions with art therapy. Therapists provide safe, constructive measures for preoperative and postoperative education, such as question and answer sessions, translation of procedures and disease processes into understandable language, and reinforcement of education provided by other
team members throughout the perioperative experience. PERIOPERATIVE PHASE
Team members from a variety of disciplines participate in the care of patient’s undergoing this procedure. A clinical pathway, therefore, was developed at Children’s Hospital of The King’s Daughters and is used by all team members to guide the care they provide so that the patient achieves expected outcomes (Table 2). The perioperative
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Table 2 PECTUS EXCAVATUM CLINICAL PATHWAY
Discharge planningAeaching Expected outcomes
Day of Up as tolerated surgery/ preoperative area
Complete Patient and family members prepared learning needs for surgely Vital signs (VS) stable and preop teaching .(eg, exercises and posturing)
Cardiology Pulmonaly Radiology
Intraoper- n/a ative period/ OR
Day of surgery/ post-
Reinforce recovery and limitations
Elevate head of bed 3 hours (hrs) postoperatively Out of bed to chair with assistance 8 hrs postoperatively; physical therapy (Po staff to assist, if available
OR time (level 2) 60 to 75 minutes Pectus excavatum corrected with bar placement without complications
VS stable and minimal to no bleeding
Medical immobilization PRN
First Out of bed to chair twice a day (BID) postoper- with PT assistance
ative Ambulate BID with PT assistance Day/ pediatric No twisting or Waist bending intensive Egg crate mattress PRN care unit No log rolling or side lying (pIcu)
Second Out of bed to chair and ambulate in postoper- room BID wilh PT assistance No twisting or waist bending day/PICU Egg crate mattress PRN
No log rolling of side tying
Out of bed to chair and ambulate in Third postoper- hall BID with PT assistance day/ No twisting or waist bending PlCU No log rolling or side lying
Initiate teaching standards Of care TsOC
Ambulate with assistance
postoper- No twisting or waist bending ative day/ No log rolling or side lying plcu
VS and fluid status stable Minimal to no bleeding Minimal to no nausea or vomiting
Intens'vist Pain controlled with analgesics Physical Oxygen saturation > 93% on room air therapy
VS and fluid status stable No bleeding
Review signs and symptoms of infection, Pain management, and immobilization
Minimal to no nausea or vomiting
Physical therapy Child life with ..... . blowing bubbles
Pain controlled with analgesics Able to tolerate room air Assisted movement
VS and fluid status stable and urine output >1 mlfkglhr No bleeding, nausea, or vomiting Pain controlled with analgesics Able to tolerate room air
VS stable No bleeding and minimal to no pain
May shower if epidural removed Fourth
VS and fluid status stable Minimal to no bleeding Minimal to no nausea or vomiting Pain controlled with analgesics Weaned off oxygen and oxygen saturation z 93% on room air
Breath sounds equal and clear Discharge instructions completed 832 AORN JOURNAL
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Table 2 PECTUS EXCAVATUM CLINICAL PATHWAY
Baseline VS and weight
Complete blood count ECG
NPO after midnight (ie, solid only) Insert peripheral IV line
General anesthesia Antibiotic Epidural for pain management
IV line NPO
surgery/ Day surgery RN assessment preoperative area History and physical Anesthesia assessment Photography and measurement Intraoper- VS every 5 minutes ative Urinary catheter to gravity drainage period/
CT scan PFT tests Chest x-ray n/a
Patient-controlledanalaesia (PCA) ~
PACU RN admission assessment
"p'd'd"u"y/ vs per PACU protocol Strict intake and output (I&O)
x-rays for bar placement, Urinary catheter to gravity drainage Pneumothorax, pleural Observe pressure dressing for bleeding effusion or drainaae
Epidural and PCA
Morphine IV for break through pain
Ice chips to clear liquids as tolerated
Blowby oxygen by facemask Nasal trumpet as needed (PRN) Room air as tolerated
First VS and assessment per PlCU protocol Portable chest Epidural and PCA for pain x-ray for bar management Posto~er- Incentive spirometry (1s) every (Q) placement day/ hr while awake Morphine IV for break through pain Strict I&O Q 8 hrs Antibiotic D/C urinary catheter 6 hrs postop Bisacodyl suppository PRN Oxygen PRN for saturation > 93% Assess pain using pain scale Q 2 hrs
Assess surgical site; call clinician in charge about abnormalities Second Continue monitorina, VS, and assesspostoper- ments per PICU proibcol'
Saline lock IV line when tolerating diet Advance
x-ray for Discontinue (D/C) epidural catheter Child life activities (if < 8 years old) or bar placement PCA for pain management IS (if > 8 years old) Q hr while awake PRN Morphine IV for break Strict I&O Q 8 hrs throuah Dain Assess pain using pain scale and Bisacodyl suppository PRN surgicul site Q 2 hrs Oxygen PRN for saturation > 93%
to regular diet as tolerated then saline lock IV line
RN assessment Q shift
Saline lock IV line Regular diet
Clear liquids to
Analoesics by mouth (PO) or IV PRN -
postoper- VS and I&O per orders ative day/ Continue IS Q hr while awake PRN plcu Assess pain using pain scale and suraical site Q 4 hrs while awake
Fourth Continue IS Q 1 hr and assess pain Portable chest postoper- using pain scule Q 4 hrs while awake x-rays with day/ RN assessment including surgical site, from and D/C VS; call clinician in charge out of area about abnormalities
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gesia postoperatively between T4 and T l Z 9 Additional medication with an epidural patient-controlled analgesia (PCA) pump is available if needed. Side effects (ie, nausea, itching, motor block, respiratory depression) are minimized using this technique. The epidural catheter usually is placed during light sedation in older, cooperative patients or after induction of general anesthesia in younger patients. The epidural inhsion is started during surgery so that it has time to become maximally effective before the patient emerges from anesthesia and is transferred to the PACU. The anesthesia care provider and circulating nurse transfer the sedated patient to the PACU sedated on oxygen by nasal cannula with a pulse oximeter unit attached for continuous monitoring. Often, supplemental IV analgesics and sedatives are necessary to provide comfort during the postoperative period, especially in younger patients. All patients are observed initially in the PACU where they can be better monitored and where respiratory depression can be treated, if necessary. Usually after two postoperative hours, the patient may be cared for safely on the nursing unit where nurses have been specifically trained to care for this patient population. Pain assessment and associated scoring tools are introduced to the patient preoperatively and again during the postoperative period. The tools are individually chosen to accommodate for both the patient’s chronological and developmental age. The three most common tools used are the Numbers scale, in which the patient chooses from W N MANAGEMENT zero to 10 with zero being no pain and 10 being Surgical repair of pectus excavatum, even using the worst possible pain; the minimally invasive Nuss procedure, can result in Wong Faces scale, in which the patient’s facial significant postoperative pain. Epidural analgesia expressions from serene to agitated correspond initiated during the procedure provides excellent with numbers zero to five; and postoperative pain management for most patients. FLACC scale, which measures expression and The anesthesia care provider discusses in detail activity with five categories-face, legs, activity, the organized approach to postoperative pain management with parents and the patient before surgery. cry, consolability. Each category can earn zero to Parents and the patient then know realistically what two points resulting in a maximum possible score to expect in terms of comfort, side effects, possible between zero and 10.” Pain is considered the fifth vital sign and is risks, complications, and how to manage related issues if they arise. Most commonly, the epidural assessed and documented on an hourly basis. It also catheter is placed at a spinal level that closely relates is assessed and reassessed after each administration to the dermatome of the surgical site (ie, usually T7 of pain medication and nonpharmacological intervento T9). Placing the tip of the epidural catheter at this tion. Adjustments are made to the pain medication level allows for the use of a mixture of dilute local and management regimen based on pain scores to anesthetic (eg, bupivicaine 0.1%) and narcotic (eg, ensure that the patient remains both comfortable and fentanyl 1 mcg per mL). This mixture then infuses at fbnctional. Anesthesia care providers are the primary the slowest possible rate adequate to provide effective managers of the patient’s pain while the epidural is in analgesia. The objective is to obtain a band of anal- place. Most epidural catheters remain in place for
nurse assesses the parents and the patient, addressing learning barriers as they are encountered, and uses appropriate methods to communicate instructions. The surgeon obtains the informed consent for the surgical procedure, which includes consent for photographs. The nurse ensures that a parent or legal guardian signs all required forms and answers any further questions. The nurse obtains and documents the patient’s vital signs, weight, medical history, and allergies and verifies any preoperative laboratory results. The nurse helps parents dress the patient in hospital pajamas and gives parents the patient’s personal belongings for safekeeping. The patient is allowed to take a favorite toy or stuffed animal to the OR for reassurance. The nurse or anesthesia care provider may administer preoperative sedation at this time, if needed, to decrease anxiety. A topical anesthetic cream may be applied to the top of both of the patient’s hands if he or she is older than 10 years of age or weighs more than 66 lbs (ie, 30 kg.) This cream decreases discomfort during IV line placement. Intravenous lines for younger patients (ie, less than 10 years old) are started after induction of an inhalation anesthetic to avoid the fear younger patients have of needles. The anesthesia care provider reviews with parents and the patient the anesthesia induction process and methods for controlling postoperative pain, including epidural placement.
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three days. After removal of the catheter, surgical team members, in conjunction with personnel from other disciplines, assume responsibility for postoperative pain management using ketorolac, morphine, oral analgesics, and nonpharmacological pain management strategies. The assigned unit nurse continuously monitors the patient with pulse oximetry, frequent pain score evaluation, sedation level, and routine vital signs as long as the patient is receiving epidural analgesia. Historically, a score of four on the Numbers and FLACC scales with this patient population has been an acceptable level of pain control and functionality. It is best, however, for parents, the patient, and nursing staff members not to fixate on numbers but rather to determine at what level the patient feels both comfortable and functional. Nursing staff members then should develop a pain management regimen in cooperation with the parents and patient. PREPARATION FOR SURGERY The surgical team’s goal is for each patient to have a successful surgical outcome and for the patient and his or her family members to feel cared for and special. Before the patient’s arrival in the OR, surgical team members ensure that the OR is prepared appropriately so that they are free to focus on the patient. Parents and the patient are greeted and assessed by the circulating nurse and RN first assistant (RNFA). The RNFA is a perioperative nurse who functions in a more expanded role by helping prepare the patient and assisting with the surgical procedure. To function as an RNFA at Children’s Hospital of The King’s Daughters, a perioperative nurse must complete an accredited certification program and be approved to practice by the hospital’s professional services committee and board of directors. At Children’s Hospital of The King’s Daughter, a certified RNFA (CRNFA) holds specialty certification as a perioperative nurse and also is certified in pediatric advanced life support. These certifications ensure that the RNFA has advanced proficiency in perioperative nursing practice. A CRNFA’s training provides the nurse with a broader knowledge and skill base in applying advanced principles of asepsis, infection control, surgical anatomy, physiology, and surgical techniques. Preparation for the Nuss procedure begins approximately 15 niinutes before the start of the procedure. The room temperature is increased to help
maintain the patient’s internal temperature. A heating lamp and temperature-regulating blanket are available as adjunct measures. The circulating nurse obtains padding for positioning to help prevent dependent pressure intraoperatively. The scrub person and circulating nurse, are responsible for setting up the sterile field and ensuring that the correct supplies and instruments are available. The setup includes a pectus tray, minor surgery tray, minor basin, thoracoscope with camera, and full complement of pectus bars and stabilizers. Additional equipment (ie, sternal saw, appropriately sized sternal retractor, vascular tray) is immediately available but remains sterilely packaged ready to be opened if a median stemotomy becomes necessary. The anesthesia care provider, circulating nurse, and possibly a parent accompany the patient to the warm, quiet OR. The mode of transportation depends on the patient’s age, cooperation, and sedation status. The patient either can ambulate to the OR or be transported via stretcher, toy car, tricycle, or wheelchair. When the patient arrives in the OR, surgical team members greet him or her. The circulating nurse or CRNFA helps transfer the patient to the OR bed and helps the anesthesia care provider prepare the patient for epidural catheter placement and induction of general anesthesia. The electrocardiogram leads, pulse oximetery monitor, and blood pressure cuff are placed, and IV line access is obtained. If it is less traumatic for the patient, these activities are performed after the patient is sedated. Different positioning techniques are employed for placing the epidural catheter depending on the patient’s age, sedation status, and ability to cooperate. Older patients (ie, 13 years of age or older) have their catheters placed after light sedation while they are in the side-lying or sitting position. The sitting position is the preferred position for older patients. The circulating nurse and anesthesia care provider help the patient sit on the edge of the OR bed. The circulating nurse ensures that warm sheets are wrapped around the patient where possible to keep him or her comfortable and warm. Stepby-step instructions are given to the patient as the
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procedure progresses so that the patient is not startled and anxiety is reduced. A Mayo stand with a pillow is placed directly in front of the patient so that he or she can rest his or her head and arms. A footstool is placed to help stabilize the patient in the sitting position. This position allows the patient’s back to be arched, which accentuates the vertebrae and allows for easy identification of landmarks (ie, scapular ridge, iliac crest, vertebral bodies). Proper positioning for epidural catheter placement creates a wider space between the vertebras. After the catheter is placed and secured with a clear tape dressing, the circulating nurse and anesthesia care provider return the patient passively to the supine position, and the anesthesia care provider begins induction of general anesthesia. Younger patients (ie, less than 13 years of age) are sedated heavily and placed in a lateral decubitus position before placing the epidural catheter. The circulating nurse brings the patient’s head and knees forward to create an arch in the spine. The anesthesia care provider identifies the landmarks and inserts the epidural catheter. After securing the catheter with a clear tape dressing, the anesthesia care provider and circulating nurse passively return the patient to a supine position.
field for the surgeon to use to custom fit the bars as needed. The surgeon traces the intercostal spaces bilaterally with a sterile marking pen, correlating the intercostal spaces with the deepest point of the pectus. This is the spot where the bar will enter the chest cavity and rest under the sternum providing support to the reconfigured chest wall. The circulating nurse preps the patient’s chest from chin to umbilicus in a circumferential fashion using antimicrobial scrub and solution. Preoperative photographs are taken after additional antimicrobial solution is poured into the area to help emphasize the degree of the deformity (Figures 4 and 5). The remainder of the chest is prepped after the photographs are taken.
The circulating nurse and anesthesia care provider position the patient supine with his or her arms extended and secured with straps on padded armboards at less than 90 degrees. Care is taken to pad and protect all pressure points and maintain proper body alignment. The circulating nurse places an indwelling Foley catheter with an attached urometer. Thoracic placement of the epidural catheter does not affect bladder h c t i o n , so the Foley catheter is removed six hours postoperatively. The circulating nurse places an electrosurgical unit dispersive pad on the patient. The surgeon then measures the width of the chest and determines which size pectus bar is anticipated. The surgeon also determines whether the chest will require one or two bars and whether stabilizers may be needed. The circulating nurse opens two bars (ie, one the actual size, the other a size smaller). The surgeon scrubs and gowns, and then, using a tape measure, he or she measures the patient’s chest. Using a large bench-type steel bar bender on the sterile backtable, the surgeon bends both bars to the approximate anticipated shape. A smaller bar bender also is available on the sterile
Figure 4 lntraoperative preparation and scrub for surgery allows antimicrobial solution to pool to emphasize deformity.
Figure 5 Bar placement over antimicrobial solution pool also emphasizes deformity.
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The patient is draped with four adhesive towels and a thoracoscopy drape. The scrub person pulls the Mayo table up to the surgical field and stands at the surgeon’s right. The scrub person passes the light, camera, suction, and electrosurgery cords to the circulating nurse, who then connects them to the thoracoscopic equipment. The camera is white balanced, and the surgical lights are positioned appropriately. The surgeon stands on the patient’s right side, and the pediatric surgery resident or CRNFA stands on the left side of the patient. The surgeon verifies the patient’s readiness with the anesthesia care provider before making the initial incision in the right lateral chest wall, with another incision made in the left lateral chest wall. Approximate intraoperative time is two hours, the majority of which is spent during patient preparation (eg, placement of the epidural catheter, induction of general anesthesia, patient positioning, skin prep). This surgery is considered minimally invasive because no resection of rib or costal cartilage or stemotomy is needed. There is minimal blood loss and the procedure is done under thorascopic control. The steel support strut allows the patient’s body to reconfigure in much the same way that braces remold tooth positioning.”Visualization of the entire chest cavity is possible with the thoracoscope. The surgeon inserts a curved introducer through the right or left thoracostomy incision to tunnel a tract through which the bar will be placed. The surgeon passes the bar under the sternum from right to left, with the curvature of the bar facing posteriorly and in contact with the sternum. When the bar has reached across the chest and out the opposing incision, it then is flipped so the sternum that previously was concave now is convex. Stabilization of the bar is absolutely essential for success of this procedure. Small (ie, less than 4 cm x 2 cm), rectangular steel stabilizer plates may need to be placed to ensure more surface area footing. These plates have a grooved slot in which the ends of the support strut can slide. If stabilizer plates are used, they are secured to the bar with #3 cardiac wire in a figure eight pattern encompassing the bar and stabilizer. This ensures that the stabilizer plates will not slide off the end of the bar. The surgeon makes a final evaluation with the thoracoscope to ensure that the bar is stable, no bleeding has occurred, and the pericardium has not been disrupted. The ends of the bar are inserted in the subcutaneous pockets previously created. The bar and stabilizer plates, if applicable, then are secured with numerous heavy absorbable
mattress sutures. The skin is closed with self-adhesive wound approximating strips. No other dressings are necessary.’’ Postoperative photographs and a chest x-ray are taken to visualize bar placement and rule out pneumothorax. The patient is extubated and carefully transferred by surgical team members to his or her bed. The anesthesia care provider and circulating nurse then transfer the patient to the PACU. POSTOPERATWEPHASE
Slow emergence and stationary body positioning are essential in the early postoperative recovery phase. The PACU nurse ensures that the patient remains on his or her back without twisting or turning during emergence from anesthesia. Several nurses may be needed to keep an agitated patient from trying to turn onto his or her side. The patient is transferred to the medical/surgical unit after he or she is awake and alert and has a pain score of less than four on the numbers scale. The nurse on the medicalisurgical unit interfaces with hospital personnel in other disciplines to ensure that everyone caring for the patient understands the key actions needed for favorable recovery and surgical outcome. Working with the patient and parents in an interdisciplinary approach provides continuity and makes hospitalization more tolerable. Parents often feel guilty and anxious about subjecting their child to surgery. This anxiety level often is transferred to the child and may intensify his or her perception of pain. Providing an outlet for discussion and play helps keep anxiety at a manageable level and allows the child to progress more quickly toward discharge. Careful attention is required during postoperative recovery to ensure that the bar remains stable. Staff members are instructed not to log roll the patient during the initial postoperative phase. The patient also is instructed not to lie on his or her side for the first four weeks. Physical therapy staff members, in conjunction with nursing staff members and the perioperative clinical nurse specialist, teach the patient and parents proper body mechanics and movements needed to maintain the bar in a stable position. After removal of the epidural catheter on approximately the second postoperative day, surgical team members assume responsibility for postoperative pain management using ketorolac, morphine, codeine, oral analgesics, and nonpharmacological pain management strategies. Child life ther-
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Table 3 apy department staff members reinforce education about proper body mechanics and provide alternative methods for pain management and diversional activity (eg, play therapy, relaxation therapy, music or art therapy). Respiratory therapy staff members also are members of the multidisciplinary team. They are involved actively with teaching the patient proper breathing mechanics so that complications from surgery do not develop. Breathing and posture exercises are taught preoperatively, and the patient is encouraged to start the exercises before surgery. Incentive spirometry and other age-appropriate devices (eg, pinwheels, bubbles) are used after establishing individual, obtainable goals for the patient. Breathing exercises are taught to ensure that full lung volume is attained in the reconfigured chest cavity. Reconfiguring the chest produces more room in the internal chest cavity. The lungs and heart, which previously were compressed by the deformity, now are expected to accommodate this increased space. The patient must breathe deeper to force expansion of the lungs to the chest wall. Compliance with these exercises not only increases oxygen reserves but also helps keep the chest cavity expanded outward. This ensures greater success after the bar is removed. These breathing exercises must be performed once an hour while awake after discharge and continued during the entire time the bar is in place.
Do not overexert for the first 4 weeks. Maintain good posture to keep the bar in place. Bend at the hip and do not slouch or slump when sitting. Walk for 5 to 10 minutes 2 to 3 times per day to help build strength. Avoid heavy lifting for 8 weeks, especially heavy school backpacks. Do not engage in karate, judo, gymnastics, or contact sports for 12 weeks.
Bathe or shower on the 5th day after surgery.
Self-adhesivewound approximating strips on the incisions will come off slowly while bathing or showering. Completely remove the strips after 7 to 10 days. Future medical care
A medical alert bracelet or necklace is recommended identifying that the patient has a pectus excavatum bar in place.
Cardiopulmonary resuscitation can be performed but more external force may be necessary due to the surgical bar. Defibrillation for cardiac arrhythmia may be performed; however, anterior/posterior paddle placement is necessary. Magnetic resonance imaging (MRI) examinations may be performed; however, the bar may cause artifact if the MRI is of the upper chest or abdomen. The recommended examination is a computerized tomography (CT) scan. A temperature higher than 101' F (38.5' C).
Call if you hove
A continual cough or any problems breathing. Chest pain, especially with deep breaths. Any chest injury that may cause the bar ta move. Redness, drainage, or swelling at the incision site. under the arms.
The patient is ready for discharge after discharge teaching is complete and acceptable pain management is achieved. The patient is limited in activity for the first six weeks after surgery and then allowed to slowly resume normal activities. The patient should be able to return to normal activity
within six weeks depending on his or her specific circumstances. Written educational materials are given to reinforce verbal instructions (Table 3). These instructions clearly define allowed activities, weight lifting restrictions, signs and symptoms to be aware of, and when to notify the physician." Success of the procedure depends not only on the surgeon and surgical team members, but also on
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Figure 6 9 Postoperative photograph of the patient after correction of severe pectus excavatum deformity as seen from the lateral view.
Figure 7 Postoperative photograph of the same patient as seen from the anterior view.
the entire postoperative team. The patient, with a newly configured chest, is allowed to play and grow (Figures 6 and 7). The patient returns for an initial postoperative visit in three to four weeks. Thereafter, follow-up visits are made annually to verify that proper bar alignment has been maintained. The bar is left in for a minimum of three years to allow for growth and molding of the chest. The surgeon then meets with the parents and patient to discuss removing the bar. This final procedure is performed as an outpatient procedure.
ing the minimally invasive Nuss procedure, and it poses a risk to the patient. The most common complications associated with the Nuss procedure are the introduction of air into the thoracic cavity, thus creating a pneumothorax; wound infections due to placing a foreign object in the body, as well as breaking the skin integrity through bilateral axillary incisions; and bar shift. A pneumothorax of less than 20% of the lung’s volume is allowed to resolve spontaneously. Vigorous breathing exercises with the use of incentive spirometry can help quickly resolve this complication. Chest tube drainage is necessary if the patient loses more than 20% of lung volume. Wound infections may necessitate bar removal. The bar could become a transport medium for infectious agents and could cause pericarditis, particularly due to the close proximity of the bar to the heart. Adhering strictly to the principles of aseptic technique and administering antibiotics has helped minimize postoperative wound infections. At Children’s Hospital of The King’s Daughters, there have been very few postoperative wound infections, none of which has resulted in early bar removal. Finally, the bar has the potential to shift from side to side or up and down, thus losing optimal contact with the sternum. With the use of stabilizer plates, the incidence of bar shift has decreased. Anterior/posterior and lateral chest x-rays are performed immediately if a bar shift is suspected. After confirmation of bar shift, the patient is scheduled for surgery. This surgery often is performed as an overnight stay with adjustments made through the previous incisions. Repositioning the bar often can be performed without total removal of the bar. Recovery from the second procedure is similar to that of the original procedure; however, the patient has less difficulty managing postoperative pain. Nursing and medical staff members recommend stricter adherence to postoperative instructions. The patient also is instructed to restrict activities for a longer period of time (ie, 12 to 16 weeks) before resuming normal activities. CONCLUSION
The surgeon clearly explains to the patient and parents the possible complications of surgery at the time the procedure is scheduled. They are informed that any surgery is an invasion into the body, includ-
This new procedure allows the chest wall deformity to be corrected without resection, fracturing, or large volume blood loss. Surgical time is greatly diminished in comparison to the standard open procedure, and the overall recovery time is shortened. 840
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This surgery offers an alternative to the standard procedure and hope to children who are in need of correction from both physiological and psychological standpoints. The skills of the surgeon- and surgical team members combined with a multidisciplinary team approach that physiological, psychological, and educational needs of the patient and parents are met throughout the patient’s perioperative experience. A Barbara Swoveland, RNC, MSN, was the program coordinatorfor pediatric surgery at Children’s Hospital of The Kings Daughters, Norfolk, Va, at the time this article was written.
NOTES 1. D Nuss et al, “Repair of pectus excavatum,” Pediatric Endosurgey and Innovative Technique 2 (Winter 1998) 205-221; D Nuss et al, “A 10year review of a minimally invasive technique for the correction of pectus excavatum,” Journal of Pediatric Surgery 33 (April 1998) 545-552. 2. Nuss et al, “Repair of pectus excavatum,” 205-221. 3. Ibin’, Nuss et al, “A 10-year review of a minimally invasive technique for the correction of pectus excavatum,” 545-552. 4. Ibid. 5. J A Haller, Jr, S S Kramer, S A Lietman, “Use of CT scans in selection of patients for pectus excavatum
Clare Medvick, RN,CNOR, is the OR director at Children k Hospital of The Kings Daughters, Norfolk, va. MariIyn Kirsh, RN,CNOR, CRNFA, is an RNfirst assistant and specialty coordinatorfor pediatric urology and laparoscopy at Children5 Hospital of The King’s Daughters, Norfolk, va, G. Kevin Thompson, MD, is a pediawic anesthesiologist at Children’sHospital of The Kings Daughters, Norfolk, Va. Donald Nuss, MB, ChB, is the surgeon-in-chief at Children ’s Hospital of The Kings Daughters, Not$olk,
surgery: A preliminary report,”
of Pediatric Nursing, fifth ed (St
Journal of Pediatric Surgery 22
Louis: Mosby Co, 1997) 1215-1216; S I Merkel et al, “The FLACC: A behavioral scale for scoring postoperative pain in young children,” Pediatric Nursing 23 (May/June 1997) 293-297. 1 1. Nuss et al, “A 10-year review of a minimally invasive technique for the correction of pectus excavatum,” 545-552. 12. Nuss et al, “Repair of pectus excavatum,” 205-221. 13. Way to Grow, Healthy Facts from Children’s Hospital of The King’s Daughters and Its Physician Partners. “Pectus Excavatum Correction Discharge Instructions” January 2000.
(October 1987) 904-906. 6. Ibid. 7. R C Shamberger, “Congenital chest wall deformities,” Current Problems in Surgery 33 (June 1996) 469-542. 8. Nuss et al, “Repair of pectus excavatum,” 205-221. 9. J D Tobias et al, “Thoracic epidural anaesthesia in infants and children,” Canadian Journal of Anaesthesia 40 (September 1993) 879-882. 10. M McCaffery, C Pasero, Pain: Clinical Manual, second ed (St Louis: Mosby Co, 1999) 62; D L Wong, Whaley & Wongk Essentials
“Chapter Resource Center” Available on AORN Online AORN Online has a new section called the “Chapter Resource Center,” where chapter officers can obtain valuable information about chapter governance and management. The Chapter Resource Center is based on the current Chapter Resource Manual and is designed to provide a fast and easy way for officers to locate information about chapter guidelines, polices, and elections. It also allows officers to submit required forms online, such as the chapter officer update form, dues change form, and delegate submission form.
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