Society for Pediatric Pain Medicine
Better Care for Children in Pain

Submitted by:
Michelle S. Kars, MD, FAAP
North American Partners in Anesthesia

A 3 day-old full-term infant weighing 3.7 kg presents for thoracotomy for repair of esophageal atresia.  Echocardiogram reveals a small PFO.  Currently the infant is on nasal O2 with no pulmonary distress. Laboratory data is significant for INR of 1.4, and platelets of 60,000.  On discussion with the surgical and NICU teams, they would like to avoid prolonged intubation after surgery. Which of the following will provide thoracic dermatomal coverage and the longest duration block in order to minimize opioids and expedite extubation following surgery?

This question submitted by Timothy Casias, MD

A 15-year-old, 50-kilogram female has history of Complex Regional Pain Syndrome in her right lower extremity for the last 5 years. She presents to the operative room for an open reduction and internal fixation of a displaced distal tibial shaft fracture after falling on ice and hitting her right lower leg on the curb during the winter.  She previously is quite disabled from CRPS and spends most of the time in a wheelchair.  The decision is to place a popliteal catheter for post-operative pain control.  The operation was uneventful, and she has good analgesia with the catheter running 0.2% ropivacaine at 6 ml/hr.   Approximately 36 hours after the operation, she has increasing, severe pain.  What is your biggest concern for this patient? 

The question submitted by Franklin Chiao.

A 10-year-old patient with joint hypermobility syndrome presents with acute on chronic pain after a minor orthopedic procedure .  She frequently experiences gerd, generalized joint pain, muscle weakness, and disrupted proprioception.  She also has a history of anxiety, depression, and fears the onset of pain.  Her parents are distressed and concerned.  Which of the following would be a good immediate post-operative treatment plan?

This question submitted by Rani Sunder and Franklin Chiao.

A 6-month old boy presents for proximal hypospadias repair. The plan is to perform the surgery under general anesthesia with supplemental regional anesthesia. Which analgesic technique would best manage intraoperative and post-operative pain?

This question was submitted by Deepa Kattail and Anjana Kundu. If you would like to submit a future question, please send it to Franklin Chiao at [email protected].

A previously healthy 16 year old, 60 kg female with a diagnosis of CRPS type I after a right ankle sprain while skiing 6 months ago presents to your pain clinic. Although the edema, purplish discoloration and cold foot and ankle seen 1-2 weeks after the injury have subsided, allodynia and intense pain of the entire right lower extremity persist. She is unable to bear weight on that leg and has been wheelchair bound at this point. All imaging studies were normal after the initial injury. Despite regular physical therapy and compliance with her oral medication regimen (gabapentin, amitriptyline, acetaminophen, ibuprofen and hydromorphone as needed) she continues to have severe excruciating pain interfering with school attendance, sleep, ambulation and is limiting progress with PT. An assessment by the pediatric pain psychologist did not reveal any major mental health concerns except some reactive depression. A lumbar sympathetic block performed during earlier phase, failed to provide any analgesia despite obvious signs of sympathetic blockade. She and her family are desperate to get some pain relief, want help with being able to participate in PT more aggressively and seek other options for pain control.

Which option, supported by current guidelines, would be most appropriate at this time?