# Shortness of Breath On Exertion — GCMD Library living collection

Everything in the library about shortness of breath on exertion — built automatically from dossiers that name it.

Updated: n/a · 3 episodes · 49 cited statements

## Episodes
### Surgical Management
- [Update Course Rewind: Pectus Excavatum 2021](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806) — podcast · 11:56 · [machine version](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806.md)
- [Update Course Rewind: Pectus Excavatum 2021](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807) — video · 11:56 · [machine version](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807.md)
- [Update Course Rewind: Pectus Excavatum 2021](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668) — podcast · 11:55 · [machine version](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668.md)

## Chapters
- [0:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=0) Introduction and Case Presentation (Ep 1)
- [1:02](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=62) Cryoanalgesia: Technique and Results (Ep 1)
- [3:14](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=194) Alternative Pain Management: Erector Spinal Catheters (Ep 1)
- [5:34](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=334) Multimodal Pain Control Regimens (Ep 1)
- [7:22](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=442) Nuss Procedure Technical Variations (Ep 1)
- [10:28](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=628) Summary and Closing (Ep 1)
- [0:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=0) Introduction and Case Presentation (Ep 2)
- [1:57](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=117) Cryoanalgesia for Pain Management (Ep 2)
- [3:55](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=235) Alternative Pain Management Strategies (Ep 2)
- [7:04](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=424) Surgical Technique Variations for Nuss Procedure (Ep 2)
- [10:28](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=628) Summary and Closing (Ep 2)
- [0:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=0) Introduction and Case Presentation: Pain Control Options (Ep 3)
- [1:53](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=113) Cryoanalgesia: Technique, Results, and Concerns (Ep 3)
- [3:50](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=230) Alternative Pain Control: Erector Spinae Catheters and Multimodal Regimens (Ep 3)
- [6:15](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=375) Bar Stability and Measurement Considerations (Ep 3)
- [8:01](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=481) Surgical Technique: Safe Introducer Passage and Bar Direction (Ep 3)
- [10:25](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=625) Summary and Closing (Ep 3)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "Cryoanalgesia uses cold temperatures to cause a conduction block, interrupting pain impulses to the brain." — Cecilia Gigena (host_summary) [Ep 2 · 1:57](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=117)
- "Cryoanalgesia technique involves counting down to the 4th rib and freezing underneath it for 2 minutes per rib, treating ribs 4 through 7." (clinical) [Ep 2 · 2:19](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=139)
- "Cryoanalgesia should not be performed on rib 8 or below because it can cause abdominal wall paralysis." (clinical) [Ep 2 · 2:29](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=149)
- "With cryoanalgesia, length of stay decreased from 4 days to 1 day." (clinical) [Ep 2 · 2:37](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=157)
- "Cryoanalgesia dramatically reduced median morphine equivalents compared to previous pain management methods." (clinical) [Ep 2 · 2:46](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=166)
- "There are no long-term studies on cryoanalgesia outcomes." — Victor Garcia (clinical) [Ep 2 · 3:04](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=184)
- "Medical devices and implants are not required to undergo clinical trials before being introduced to market, unlike drugs." — Victor Garcia (guideline) [Ep 2 · 3:24](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=204)
- "The FDA requires clinical trials with long-term results for medications before approval, but not for medical devices and techniques." — Cecilia Gigena (host_summary) [Ep 2 · 3:36](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=216)
- "Erector spinal catheters are placed by the pain team with ultrasound guidance, positioned juxtaposed to but not in the vertebral space." — Victor Garcia (clinical) [Ep 2 · 4:09](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=249)
- "With erector spinal catheters, hospital stay is 2 days, catheters stay in for 5 days, and are pulled out by the family on day 3 while the patient is at home." — Victor Garcia (clinical) [Ep 2 · 4:19](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=259)
- "Erector spinal catheters reduced opioid requirements both in the hospital and outside the hospital." — Victor Garcia (clinical) [Ep 2 · 4:33](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=273)
- "With erector spinal catheters, hospital stays are 2 days, which is much less than the 4-5 days seen with epidurals." — Victor Garcia (clinical) [Ep 2 · 4:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=285)
- "With cryoanalgesia, it is not just when patients go home but how they feel when they go home that has changed dramatically." — Steven Rothenberg (opinion) [Ep 2 · 5:08](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=308)
- "For multimodal pain therapy, the best treatments are preoperative counseling, gabapentin both pre and postoperatively, and then methadone, clonidine, bowel regimen medications, and anti-emetics." — Justin Wagner (clinical) [Ep 2 · 6:02](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=362)
- "In Nebraska, where Steve Rayner practices, length of stay is under 2 days and patients are off opioids by 1 week." — Justin Wagner (host_summary) [Ep 2 · 6:19](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=379)
- "If bars are going to flip, they flip early because they were sitting in a funky inner space, in a bad spot, the bar wasn't wrapped tight enough, or it wasn't secured well." (clinical) [Ep 2 · 6:39](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=399)
- "The bar must sit in a comfortable position before securing it or it probably will not stay there." (clinical) [Ep 2 · 6:54](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=414)
- "Bar flippage is completely a surgical issue." — Steven Rothenberg (opinion) [Ep 2 · 6:59](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=419)
- "Computational modeling showed that shorter flat bars have different stress points compared to traditionally U-shaped bars, with shorter bars having more pressure on the sternum and therefore being more stable." — Justin Wagner (host_summary) [Ep 2 · 7:40](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=460)
- "A sternal elevator is used in about 10% of cases, primarily in really deep stiff pectuses where it allows less tissue damage and a better repair." — Steven Rothenberg (clinical) [Ep 2 · 8:19](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=499)
- "In the average younger patient, thoracoscopy provides adequate visualization without needing a sternal elevator." — Steven Rothenberg (clinical) [Ep 2 · 8:22](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=502)
- "Using a sternal elevator in every case eliminates guesswork and allows entry and exit at the same interspace." — Victor Garcia (clinical) [Ep 2 · 8:35](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=515)
- "Techniques to avoid cardiac injury include thoracoscopy, sternal elevator, vacuum bell in the operating room, or subxiphoid incision." (clinical) [Ep 2 · 8:59](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=539)
- "Passing the bar from left chest to right chest is preferred by some because going right to left means the instrument points directly at the ventricle." (clinical) [Ep 2 · 9:31](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=571)
- "Bar passage direction (left-to-right versus right-to-left) is surgeon preference and probably does not make much difference as long as the substernal space is well dissected and everything is clear." (opinion) [Ep 2 · 10:12](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5807?t=612)
- "Dr. Saint Peter's institution completed a randomized trial of 110 patients comparing epidural to PCA for pectus excavatum pain control, and epidurals did not show superior performance." — Shawn St. Peter (clinical) [Ep 1 · 1:07](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=67)
- "In Dr. Saint Peter's cryoanalgesia trial with approximately 30 patients per group, equipoise was lost when patients went home on post-op day one." — Shawn St. Peter (clinical) [Ep 1 · 1:32](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=92)
- "Cryoanalgesia uses cold temperatures to cause a conduction block that interrupts pain impulses to the brain." — Cecilia Gigena (host_summary) [Ep 1 · 1:57](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=117)
- "The cryoanalgesia technique involves counting down to the 4th rib and freezing underneath it for 2 minutes per rib, treating ribs 4 through 7." — Shawn St. Peter (clinical) [Ep 1 · 2:10](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=130)
- "Cryoanalgesia should not be performed on rib 8 or below because it can cause abdominal wall paralysis." — Shawn St. Peter (clinical) [Ep 1 · 2:29](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=149)
- "With cryoanalgesia, hospital length of stay decreased from 4 days to 1 day at Dr. Saint Peter's institution." — Shawn St. Peter (clinical) [Ep 1 · 2:37](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=157)
- "Cryoanalgesia dramatically reduced median morphine equivalents compared to previous pain management approaches." — Shawn St. Peter (clinical) [Ep 1 · 2:46](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=166)
- "Dr. Garcia's concern about cryoanalgesia is the absence of long-term studies and unknown potential for future adverse effects such as chronic neuropathic pain." — Victor Garcia (opinion) [Ep 1 · 3:01](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=181)
- "Unlike drugs, medical devices and implants are not required to undergo clinical trials before being introduced to the market by the FDA." — Victor Garcia (guideline) [Ep 1 · 3:24](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=204)
- "For medications, the FDA requires clinical trials with long-term clinical results before approval, but this is not required for medical devices and techniques like cryoanalgesia." — Cecilia Gigena (host_summary) [Ep 1 · 3:36](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=216)
- "Dr. Garcia's institution studied approximately 100 patients comparing epidurals to erector spinal catheters for pectus excavatum pain management." — Victor Garcia (clinical) [Ep 1 · 3:55](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=235)
- "Erector spinal catheters are placed by the pain team with ultrasound guidance and are positioned juxtaposed to but not in the vertebral space." — Victor Garcia (clinical) [Ep 1 · 4:08](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=248)
- "With erector spinal catheters, the catheters stay in for 5 days, hospital stay is 2 days, and on the 3rd day while patients are at home, the catheters are pulled out by the family." — Victor Garcia (clinical) [Ep 1 · 4:19](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=259)
- "Dr. Garcia's institution achieved 2-day hospital stays with erector spinal catheters and reduced opioid requirements both in-hospital and at home." — Victor Garcia (clinical) [Ep 1 · 4:31](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=271)
- "Erector spinal catheters achieve shorter stays than the 4-5 days seen with epidurals, though not the one-day stays achieved with cryoanalgesia." — Victor Garcia (clinical) [Ep 1 · 4:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=285)
- "Dr. Rothenberg's initial concerns about cryoanalgesia were the added operative time and concerns about neuralgia and complications." — Steven Rothenberg (opinion) [Ep 1 · 4:53](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=293)
- "After approximately 4 cases, Dr. Rothenberg observed that cryoanalgesia changed not just when patients go home but how they feel when they go home, describing the results as unbelievable." — Steven Rothenberg (opinion) [Ep 1 · 5:08](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=308)
- "Dr. Rothenberg agrees with Dr. Garcia's concerns and supports the need for a registry to track long-term cryoanalgesia outcomes." — Steven Rothenberg (opinion) [Ep 1 · 5:23](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=323)
- "Multimodal pain control options include Tylenol, NSAIDs, precedex for gentle wake-up, dexamethasone for post-anesthetic nausea, and ketamine to avoid opioids." — Justin Wagner (clinical) [Ep 1 · 5:40](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=340)
- "Non-pharmacologic multimodal approaches include child life specialists, mindfulness resources, and supportive physical therapists." — Justin Wagner (clinical) [Ep 1 · 5:55](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=355)
- "Dr. Ponsky's best multimodal treatments are preoperative counseling, gabapentin both pre and postoperatively, methadone, clonidine, bowel regimen medications, and anti-emetics." — Justin Wagner (host_summary) [Ep 1 · 6:02](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=362)
- "At the institution where Dr. Wagner trained in Nebraska, Steve Rayner achieves length of stay under 2 days with patients off opioids by 1 week." — Justin Wagner (host_summary) [Ep 1 · 6:19](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=379)
- "Bar flippage typically occurs early and is caused by the bar sitting in a funky interspace, sitting in a bad spot, not being wrapped tight enough, or not being secured well." — Shawn St. Peter (clinical) [Ep 1 · 6:39](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=399)
- "The bar must sit in a comfortable position before securing or it will not stay in place; securing alone does not prevent bar flippage." — Shawn St. Peter (clinical) [Ep 1 · 6:54](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=414)
- "Dr. Rothenberg believes bar flippage is completely a surgical issue, not related to pain management technique." — Steven Rothenberg (opinion) [Ep 1 · 6:59](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=419)
- "Physics-minded surgeons created a computational model showing that shorter flat bars have more pressure on the sternum compared to traditionally U-shaped bars, making them more stable." — Justin Wagner (host_summary) [Ep 1 · 7:36](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=456)
- "Dr. Wolon uses a sternal elevator for pectus excavatum repair at Akron Children's Hospital." — Victor Garcia (host_summary) [Ep 1 · 8:08](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=488)
- "Dr. Rothenberg uses a sternal elevator in about 10% of cases, primarily in really deep stiff pectuses where it allows less tissue damage and a better repair." — Steven Rothenberg (clinical) [Ep 1 · 8:19](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=499)
- "In average younger patients, thoracoscopy provides adequate visualization without needing a sternal elevator." — Steven Rothenberg (clinical) [Ep 1 · 8:22](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=502)
- "Dr. Garcia uses the sternal elevator in every case because it eliminates guesswork and allows entry and exit at the same interspace." — Victor Garcia (clinical) [Ep 1 · 8:35](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=515)
- "Dr. Saint Peter continues to use subxiphoid incision along with thoracoscopy, sternal elevator, or vacuum bell in the operating room as safety techniques to avoid cardiac injury." — Shawn St. Peter (clinical) [Ep 1 · 8:50](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=530)
- "Dr. Holcomb's principle is that whatever technique helps avoid injuring the heart is the technique that should be used." — Shawn St. Peter (host_summary) [Ep 1 · 9:05](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=545)
- "One surgeon passes the bar from left chest to right chest because passing right to left directs the instrument toward the ventricle." (clinical) [Ep 1 · 9:31](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=571)
- "Dr. Slater has always performed the Nuss procedure right to left and had not previously considered left to right." — Cecilia Gigena (host_summary) [Ep 1 · 9:41](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=581)
- "One surgeon learned left to right but switched to right to left and found it easier, particularly when using external elevator and thoracoscopy for safety." — Shawn St. Peter (clinical) [Ep 1 · 9:54](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=594)
- "Direction of bar passage is likely surgeon preference and does not make much difference as long as the substernal space is well dissected and everything is clear." — Shawn St. Peter (opinion) [Ep 1 · 10:12](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-5806?t=612)
- "Dr. St. Peter's hospital completed a randomized trial of 110 patients comparing epidural and PCA, and epidurals did not show superior results" — Todd Ponsky (host_summary) [Ep 3 · 1:02](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=62)
- "After implementing cryoanalgesia, the first patient went home on post-operative day one, leading Dr. St. Peter to discontinue enrollment in the epidural/PCA comparison trial" — Cecilia Gigena (host_summary) [Ep 3 · 1:21](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=81)
- "Cryoanalgesia uses cold temperatures to cause a conduction block that interrupts pain impulses to the brain" — Todd Ponsky (host_summary) [Ep 3 · 1:56](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=116)
- "The cryoanalgesia technique involves freezing ribs 4 through 7 for two minutes per rib" — Todd Ponsky (host_summary) [Ep 3 · 2:09](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=129)
- "Cryoanalgesia should not be performed on rib 8 or below because it can cause abdominal wall paralysis" — Todd Ponsky (host_summary) [Ep 3 · 2:09](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=129)
- "With cryoanalgesia, length of stay decreased from four days (baseline) to one day" — Cecilia Gigena (host_summary) [Ep 3 · 2:33](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=153)
- "Cryoanalgesia dramatically reduced median morphine equivalents compared to previous pain control methods" — Todd Ponsky (host_summary) [Ep 3 · 2:43](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=163)
- "Dr. Garcia expressed concern that there are no long-term studies of cryoanalgesia and potential for chronic neuropathic pain" — Cecilia Gigena (host_summary) [Ep 3 · 2:52](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=172)
- "Medical devices and implants are not required to undergo clinical trials before introduction to market, unlike medications which require FDA clinical trials with long-term results" — Todd Ponsky (host_summary) [Ep 3 · 3:14](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=194)
- "Dr. Garcia's hospital uses erector spinae catheters placed by the pain team with ultrasound guidance, positioned juxtaposed to but not in the vertebral space" — Cecilia Gigena (host_summary) [Ep 3 · 3:50](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=230)
- "With erector spinae catheters, hospital stay is two days, catheters remain in place for five days total (three days at home on automated pump), and families remove catheters at home on day five" — Cecilia Gigena (host_summary) [Ep 3 · 4:08](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=248)
- "Erector spinae catheters reduced opioid requirements both in hospital and outside the hospital, achieving two-day length of stay compared to four or five days with epidurals" — Todd Ponsky (host_summary) [Ep 3 · 4:30](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=270)
- "Dr. Rothenberg initially had concerns about cryoanalgesia including added operative time and risk of neuralgia, but after four cases observed that patients not only went home earlier but felt significantly better at discharge" — Cecilia Gigena (host_summary) [Ep 3 · 4:52](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=292)
- "Multimodal pain control components include Tylenol, NSAIDs, precedex for gentle wake-up, dexamethasone for post-anesthetic nausea, ketamine to avoid opioids, and support from child life specialists, mindfulness resources, and physical therapists" — Todd Ponsky (host_summary) [Ep 3 · 5:34](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=334)
- "Dr. Ponsky's multimodal regimen includes preoperative counseling, gabapentin pre and postoperatively, methadone, clonidine, bowel regimen medications, and antiemetics" — Cecilia Gigena (host_summary) [Ep 3 · 5:34](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=334)
- "At Nebraska where Dr. Rayner practices, length of stay is under two days and patients are off opioids by one week using multimodal pain control" — Cecilia Gigena (host_summary) [Ep 3 · 6:15](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=375)
- "Bar flippage typically occurs early and is caused by the bar sitting in an incorrect intercostal space, poor positioning, inadequate wrapping, or insufficient securing" — Todd Ponsky (host_summary) [Ep 3 · 6:26](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=386)
- "Bar flippage is a surgical technique issue; the bar must sit in a comfortable position before securing or it will not remain stable" — Todd Ponsky (host_summary) [Ep 3 · 6:26](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=386)
- "Computational modeling by physics-minded surgeons showed that shorter flat bars create more pressure on the sternum compared to traditional U-shaped bars, potentially increasing stability" — Cecilia Gigena (host_summary) [Ep 3 · 7:35](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=455)
- "Bar length selection is not standardized, though there is a trend toward shorter bars based on computational stress modeling" — Todd Ponsky (host_summary) [Ep 3 · 7:49](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=469)
- "Dr. Wolkine uses sternal elevator in about 10% of cases, primarily in younger patients where thoracoscopy provides adequate visualization" — Todd Ponsky (host_summary) [Ep 3 · 8:01](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=481)
- "Sternal elevation in deep, stiff pectus cases allows less tissue damage and better repair" — Todd Ponsky (host_summary) [Ep 3 · 8:01](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=481)
- "Dr. St. Peter uses sternal elevator in every case because it eliminates guesswork and facilitates entering and exiting at the same intercostal space" — Todd Ponsky (host_summary) [Ep 3 · 8:01](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=481)
- "Techniques to avoid cardiac injury during introducer passage include thoracoscopy, sternal elevator, vacuum bell in the operating room, and sub-xiphoid incision" — Cecilia Gigena (host_summary) [Ep 3 · 8:58](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=538)
- "Some surgeons pass the bar from left chest to right chest because passing right to left directs the introducer toward the ventricle" — Todd Ponsky (host_summary) [Ep 3 · 9:20](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=560)
- "Bar passage direction (left-to-right versus right-to-left) is surgeon preference; as long as the sub-sternal space is well dissected and visualization is clear, direction likely does not make a significant difference" — Todd Ponsky (host_summary) [Ep 3 · 9:20](https://qa.library.globalcastmd.com/watch/update-course-rewind-pectus-excavatum-2021-13668?t=560)

## Changelog
- Sep 16: 2 items no longer name shortness of breath on exertion
- Sep 7: 5 items added automatically

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