Lisa E. McMahon

Sternal elevation before passing bars: A technique for improving visualization and facilitating minimally invasive pectus excavatum repair in adult patients

Minimally invasive repair of pectus excavatum (MIRPE) is performed by placement of substernal metal bars. Visualization across the mediastinum is compromised in severe defects, and cardiac puncture and aortic injury have been described. In adults with less chest wall flexibility, the bars require more force to rotate and intercostal muscle stripping may result, leading to bar malpositioning. We present a technique to elevate the sternum and facilitate adult MIRPE.

Life-Threatening Hemorrhage During Removal of a Nuss Bar Associated With Sternal Erosion

We present a case of life-threatening hemorrhage occurring during Nuss bar removal without obvious cardiac or major vascular injury. A 19-year-old woman with marfanoid features had undergone a Nuss procedure 3 years earlier for a pectus index of 7.2. A lateral chest radiograph revealed erosion of the upper bar into the sternum. During surgery, a 3.5-L blood loss occurred after removal of the eroded bar. This case provided many opportunities to improve preparedness for bar removal.

Pediatric trauma patient alcohol screening: A 3 year review of screening at a Level I Pediatric Trauma Center using the CRAFFT tool

INTRODUCTION Alcohol use is a risk factor for adult trauma. Alcohol may significantly influence pediatric trauma risk, but literature is sparse. The aim of this study was to examine the impact of alcohol use screening in pediatric trauma patients. METHODS A retrospective review was performed of all trauma patients to identify those undergoing CRAFFT alcohol screening assessment between July 1, 2009, and January 31, 2011. Inclusion criteria involved screening of level 1 or 2 trauma activations for patients greater than 12 years. RESULTS During the study period, 232 patients were eligible for screening, of which 51% (n=118) were screened. Among the patients screened, 21 (18%) had a positive screen (mean age 14.6 years, range 13-16). Twenty patients were referred for further counseling. Sixteen males and 5 females screened positive during the study. The most common mechanism of injury in the positive screen patients was motor vehicle or ATV accident (n=9), followed by assault (n=6), and motor versus pedestrian collision (n=2). Of the 21 patients who screened positive, 10 had positive blood alcohol content (BAC) or urine drug screen (UDS) at the time of injury. No patients with a positive screen returned during the study as a trauma patient. CONCLUSION Alcohol and drug screening for injured pediatric trauma patients is frequently omitted despite policy-required screening. Of those patients screened, 18% admitted to risky alcohol or drug-related behaviors or had positive BAL or UDS at presentation. Pediatric trauma screening for risky alcohol use identifies a significant number of children. Alcohol and drug screening in pediatric trauma appears over age 13 years to have a yield which justifies continued screening. Alcohol related trauma recidivism, however, does not seem common.

Pectus excavatum repair after sternotomy: the Chest Wall International Group experience with substernal Nuss bars

OBJECTIVES Patients with pectus excavatum (PE) after prior sternotomy for cardiac surgery present unique challenges for repair of PE. Open repairs have been recommended because of concerns about sternal adhesions and cardiac injury. We report a multi‐institutional experience with repair utilizing substernal Nuss bars in this patient population. METHODS Surgeons from the Chest Wall International Group were queried for experience and retrospective data on PE repair using sub‐sternal Nuss bars in patients with a history of median sternotomy for cardiac surgery (November 2000 to August 2015). A descriptive analysis was performed. RESULTS Data for 75 patients were available from 14 centres. The median age at PE repair was 9.5 years (interquartile range 10.9), and the median Haller index was 3.9 (interquartile range 1.43); 56% of the patients were men. The median time to PE repair was 6.4 years (interquartile range 7.886) after prior cardiac surgery. Twelve patients (16%) required resternotomy before support bar placement: 7 pre‐emptively and 5 emergently. Sternal elevation before bar placement was used in 34 patients (45%) and thoracoscopy in 67 patients (89%). Standby with cardiopulmonary bypass was available at 9 centres (64%). Inadvertent cardiac injury occurred in 5 cases (7%) without mortality. CONCLUSIONS Over a broad range of institutions, substernal Nuss bars were used in PE repair for patients with a history of sternotomy for cardiac surgery. Several technique modifications were reported and may have facilitated repair. Cardiac injury occurred in 7% of cases, and appropriate resources should be available in the event of complications. Prophylactic resternotomy was reported at a minority of centres.

Successful Singleton and Twin Pregnancies With the Nuss Bars in Place

Pectus excavatum (PE) occurs less commonly in women, and the implications on a pregnancy after repair during the period when support bars are in place are unknown. We present 2 cases: 1 with a successful twin gestation and another with a successful singleton gestation. These women carried the pregnancies to term and delivered their infants with the Nuss bars in place.