Society for Pediatric Pain Medicine
Better Care for Children in Pain

JUNE 2025 VISUAL PEARL
Visual Pearl created by Carole Lin, MD with editing assistance from Rita Agarwal, MD, FAAP, Andrew Dinh, MD and Rachel Pedreira, MD - All from Stanford University

JUNE 2025 QUESTION OF THE MONTH
Question Authors:  Blossom Dharmaraj, Medical Student, McMaster University and Deepa Kattail, MD, MHS, FAAP, The Hospital for Sick Children
Question Editor:  Rita Agarwal, MD, FAAP, Stanford University

A 12‑year‑old male with a known history of congenital methemoglobinemia presents for bilateral inferior alveolar nerve blocks to facilitate extraction of multiple impacted molars. He has no prior anesthetic history and is otherwise healthy. His preoperative hemoglobin is 14.6 g/dL, and his baseline methemoglobin level ranges from 2 % to 14 %. Which of the following is the most appropriate anesthetic management strategy for this patient?

A. Proceed with bilateral inferior alveolar nerve blocks using 4 % prilocaine with epinephrine, without additional monitoring.
B. Avoid all local anesthetics and use GA with volatile anesthetics.
C. Perform the nerve blocks under ultrasound guidance using ropivacaine, implement continuous or serial methemoglobin monitoring, and have methylene blue immediately available.
D. Use topical benzocaine spray to supplement a single-shot inferior alveolar block to minimize injection volume.

Answer the Question