Society for Pediatric Pain Medicine
Better Care for Children in Pain

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?

Spinal anesthesia in infants is a viable anesthesia technique for surgeries such as inguinal hernia. A 2 month-old former 30 week gestation female is scheduled for a unilateral inguinal hernia repair. The resident on the case has a strong desire to perform the spinal. How does practitioner level (Attending/CRNA/Resident) matter in terms of success/failure of placement of an infant spinal?

According to a study by Ivani and colleagues, the optimum concentration of levobupivacaine at 1 ml/kg in a single shot caudal without any additive was 0.2%. What advantage did the 0.2% concentration have over the 0.25% concentration? Was there any impact on analgesia duration?