Society for Pediatric Pain Medicine
Better Care for Children in Pain

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?

A 2.5 month-old, ex- 31 week premature infant is scheduled for an exploratory laparotomy for adhesiolysis and possible small bowel resection. The infant has a history of necrotizing enterocolitis, and underwent a small bowel resection six weeks prior to the operation. Other history includes grade I IVH. The infant was intubated for 3 weeks after birth, and for one week following her initial operation. She required significant amounts of opioid for sedation during mechanical ventilation, and recently finished weaning opioids. The surgeon requests epidural placement to facilitate immediate postoperative extubation and minimize postoperative opioids.
Preoperative lab results include an INR of 1.3 (normalized values 0.8-1.2), PTT of 45.4 (normal 28-37 seconds), fibrinogen 175 mg/dL (normal 200-400), platelets 375 K/uL.

What strategy would you select for postoperative pain management?

A 9 year old female had an epidural placement for postoperative analgesia after osteosarcoma resection and reconstruction of the left leg. The epidural placement required multiple attempts by resident and attending. Patient reported on POD 1 that she is not able to sit up without 8/10 pain described as in the occipital location, dull, and constant. Orthopedic surgery wants to mobilize her early. What are your treatment options?