Society for Pediatric Pain Medicine
Better Care for Children in Pain

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?

Ex 34-week infant who was born to a mother with a history of severe Osteogenesis Imperfecta (OI) and chronic pain on chronic opioid therapy. Throughout her pregnancy, the mother was on methadone 15mg TID, and PRN hydrocodone/acetaminophen (dose weaned from 100 mg/day earlier in pregnancy to 30mg/day in an attempt to limit fetal exposure). The inpatient pain service was consulted for evaluation and treatment of NAS and ongoing pain issues.

Which of the following statements is true?

VentricularTachycardia in a Ten-month-old?
Jennifer Zieg MD, University of Colorado, Children’s Hospital Colorado

A 9 kg 10-month-old is undergoing thoracotomy for unilateral congenital cystic adenomatoid malformation (CCAM) resection. He was born at full term, and has had no other health problems. The patient has a thoracic epidural in place that seems to have been working well. A new nurse enters her shift and accidentally gives a 10ml bolus through the epidural. The patient develops ventricular tachycardia and hypotension. What is the MOST appropriate next step?

17 year old male with Ewing sarcoma of Left 7th rib with bilateral pulmonary metastases scheduled for chest wall resection (en bloc with 6th, 7th, and 8th ribs together with diaphragm and left lower pulmonary lobe), left upper lobe and left lower lobe pulmonary wedge resections.
PMH: pneumonia 2 months ago -resolved. Otherwise unremarkable.
Preop labs -
Hemoglobin: 10.3 (L)
Hematocrit: 30.9 (L)
Platelet Count: 193
Fibrinogen: 338
INR: 1.0
Part Thromboplastin: 59.8 (H)
Prothrombin Time: 13.4

The anesthesia team in the room has tried placing an awake thoracic epidural
without success. You are called to suggest options for pain management.

What postoperative pain management options would you then choose?