Society for Pediatric Pain Medicine
Better Care for Children in Pain

Written by:
  Sam Nia, MD
UMass Memorial Medical Center, Worcester, MA

You are covering the pediatric acute pain/ regional service and are called to the bedside in the holding area to evaluate a 7 month old female who is scheduled to undergo a right cleft lip and cleft palate repair. The patient’s parents are extremely concerned about perioperative opiate use for this patient and would prefer the patient receive the least amount of opiates possible. The patient has no other significant medical and prenatal history. You are asked if there are any regional anesthesia options available for their child. Which regional technique, if any, could be used in this case?

Written by:

 Bob Wilder, MD

The Mayo Clinic, Rochester, MN

A 15-year-old girl developed an acute viral intestinal illness several months ago with nausea, vomiting and diarrhea.  These symptoms resolved in 7 – 10 days, but she has had postprandial right upper quadrant abdominal pain since.  She notes that she also hurts with exercise.  A pediatric gastroenterologist has seen her and has completed a workup consisting of a normal abdominal ultrasound, an EGD that was normal both visually and by pathology.  Disaccharidase levels are normal.  Gastric emptying studies were also normal.  Fructose breath test was normal.  Abdominal radiograph shows “non-obstructive pattern with mild to moderate stool in the colon.” She may have increased pain with bearing down to have a bowel movement, but it returns to baseline thereafter.   On exam the gastroenterologist states she has a “positive Carnett’s sign” in the right upper quadrant. 

What is a Carnett’s sign? 

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?