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May 2025

Poll Author:  Cheryl J. Hartzell, MD, Cincinnati Children’s Hospital Medical Center

Your pain team was consulted on a 12 yo child otherwise healthy with no history of mental health disorders who is presenting for idiopathic spinal fusion. They are placed on a multimodal pain regimen postoperative that includes a hydromorphone PCA and muscle relaxant. Despite optimizing their pain regimen, they continue to have severe 9/10 pain. They deny being anxious but in talking with parents and bedside staff, the patient has been displaying severe anxiety behaviors. You suspect their anxiety and poor pain coping are amplifying the patient’s postoperative pain. Would you:

• A.  Start a benzodiazepine 6.52% (3 votes)
• B.  Start hydroxyzine 4.35% (2 votes)
• C.  Recommend psychiatry consult 4.35% (2 votes)
• D.  Defer to primary team for anxiety management 2.17% (1 vote)
• E.  Recommend psychology consult 19.57% (9 votes)
• F.  A + psychology consult 34.78% (16 votes)
• G.  B + psychology consult 15.22% (7 votes)
• H.  Other (add comments in text area below) 13.04% (6 votes)

Total Answers:  46
Total Votes:  46

Other Answer Responses for Answer H:

1. First start gabapentin and/or ketamine low-dose infusion, as scoliosis repair inevitably results in some degree of neuropraxia or direct nerve injury that won\’t respond to opioids.. This would be much more important than making the \leap to the head\” and patient-blaming. If \”anxiety behaviours\” continue, then clinical psychology assessment may be helpful.”
2. Trial opioid rotation first
3. Start low dose Dexmedetomidine infusion as adjunct. If dex not available on floor then clonidine 1mcg/kg IV q 8hrs
4. Ask for a Child Life visit to explore coping strategies, ask for a music therapy consult to explore coping skills and a therapeutic plan.

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March 2025

Does your institution have an intensive interdisciplinary pain treatment (IIPT) program, defined as multimodal treatment focused on functional restoration and pain management delivered by a team of 3 or more health professionals, either in an inpatient or outpatient setting?

• A. No, we don’t have the resources 29. 17% (7 votes)
• B. No, we don’t have interest 4.17% (1 vote)
• C. No, but our institution is willing to provide resources to develop one 8.33% (2 votes)
• D. Yes, we only have an inpatient program 0% (0 votes)
• E. Yes, we have both an inpatient and outpatient program 12.50% (3 votes)
• F. Yes, we only have an outpatient program 25% (6 votes)
• G. If you have a program, what ages do you serve? (Use first text area below) 4.17% (1 vote)
• H. If you have a program, do you see patients with other primary functional and somatic symptom presentations (e.g., FNSD, DGBI, etc.) 4.17% (1 vote)
• I. Other comments (Use second text area below) 12.50% (3 votes)

Total Answers:  24
Total Votes:  24

Other Answer Responses for Answer G:

1.  12, 13, 14
2.  12, 13, 14
3.  13-18 yrs
4.  Yes, but is primarily adult oriented inpatient and outpatient
5.  Up to 21, older for CCHD and Oncology in system

Other Answer Responses for Answer I:

1.  Yes, for FNSD, etc. only cannot have prolonged PNES episodes.
2.  Yes
3.  Yes
4.  We have a robust outpatient clinic but other departments (psychology and PT) are spread thin and unable to support an IIPT at this time.
5. Resources thin (7 paediatric anaesthesiologists, 1 paediatrician with interest in palliative care, 4 adult chronic pain physicians with no interest in paediatric practice) – but the main issue is interest, as as anaesthesiologists are all keen to improve paediatric acute pain management infrastructure however minimal engagement from interdisciplinary colleagues. Also, hospital pharmacists lack paediatric expertise and confidence. Scarce paediatric pharmacists not very engaged with acute pain needs of paediatric patients across hospital. Paediatric pain medicine remains largely underserved and unrecognised.
6. My institution used to have an interdisciplinary pain team and ultimately funding was reduced so it no longer exists.

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January 2025

A 15 y.o patient with sickle cell disease is hospitalized for severe chest pain, related to sickle cell crises. He has been successfully treated in the past with a combination of a morphine PCA, lidocaine, and ketamine infusions. He is currently admitted to the floor. Which of the following best describes the practice at your institution? (Choose all that apply):

• A.  We routinely run PCAs with opioids and infusions with lidocaine and/or ketamine on the floor. 33.33% (20 votes)
• B.  PCA, lidocaine and ketamine infusions have to be run in the ICU. 1.67% (1 vote)
• C.  PCA can be on the floor, lidocaine and ketamine infusions can only run in the PICU. 10% (6 votes)
• D.  PCA, and ketamine infusions can be run on the floor, lidocaine can only be run in the ICU. 25% (15 votes)
• E.  Lidocaine infusions can be run on the floor, but PCA and ketamine have to be in the ICU. 3.33% (2 votes)
• F.  Ketamine infusions can be run on floor, but PCA and Lidocaine have to be run in the ICU. 1.67% (1 vote)
• G.  We do not offer PCA. 6.67% (4 votes)
• H.  We do not offer lidocaine infusions. 11.67% (7 votes)
• I.  We do not offer ketamine infusions. 1.67% (1 vote)
• J.  Other-please explain in text area. 5% (3 votes)

Total Answers:  60
Total Votes:  47

Other Answer Responses for Answer J:

1.  We also do acupuncture for the sickle cell patients as needed.
2.  We can run all infusions on the floor. We have specific order sets for all of these infusions.
3.  Ketamine is limited to 5mcg/kg/min for floor dosing.
4.  We just started using lidocaine infusion on the floor for 6 hrs. Longer duration is still in the ICU unless it is palliative.
5.  Ketamine gtt can be run on the floor up to 3 mcg/kg/min. We do not offer lidocaine infusions or opioid PCA.

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November 2024

What is your usual practice with regards to the performance of acupuncture in the medical setting? Please choose all options that apply:

• A. We provide acupuncture to inpatients 19.05% (8 votes)
• B. We provide acupuncture to outpatients 14.29% (6 votes)
• C. We provide acupuncture for oncology patients 11.90% (5 votes)
• D. We provide acupuncture for chronic pain/chronic medical problems 14.29% (6 votes)
• E. We provide acupuncture for acute pain 7.14% (3 votes)
• F. We provide acupuncture in the perioperative period 4.76% (2 votes)
• G. We provide acupuncture for patients who have been on long term opioids or sedatives to help with weaning 4.76% (2 votes)
• H. We provide acupuncture for any symptom requested 7.14 % (3 votes)
• I. We do not provide acupuncture services in our institution 14.29% (6 votes)
• J. Other-please explain in text area 2.38% (1 vote)

Other Answer Responses for Answer J:

1. No trained practitioner.
2. Physician acupuncture offered as indicated.
3. No acupuncture at our institution, but do recommend acupuncture.
4. It is provided by our physiotherapists.
5. Our acupuncturists are encouraged to use a pain diagnosis code for billing, but I know that they do include acupuncture points for nausea, agitation etc as needed.
6. We provide acupuncture, acupressure, aromatherapy, massage, and yoga services to our patients.
7. Have in the past, but no provider currently.
8. Have acupuncture clinic and provide acupuncture for hospital patients.

Total Answers:  42
Total Votes:  14

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September 2024

A 9-year-old otherwise healthy male presents with 2-week history of severe post-prandial pain and starvation ketosis from decreased PO intake. He has never had this occur before and has no history of GI problems. Per his parents he is not an anxious child. A CT-angiography of abdomen shows mild narrowing at trunk of celiac artery suggestive of possible median arcuate ligament syndrome (MALS). MALS ultrasound is unequivocal. EGD and biopsies were normal. Remaining work-up has been unrevealing. Surgery is requesting a celiac plexus block for MALS. Which of the following would you likely choose:

• A. Agree to celiac plexus block for diagnostic purposes and/or therapeutic purposes 20.83% (10 votes)
• B. Ask the GI service to place an endoscopic ultrasound guided celiac plexus block 18.75% (9 votes)
• C. I would not recommend celiac plexus block due to lack of high-quality studies to support use of this block for diagnostic or therapeutic purposes for MALS 33.33% (16 votes)
• D. I would request a psychological evaluation of patient prior to deciding 25% (12 votes)
• E. Other: Please specify in text area 2.08% (1 vote)

Other Answer Responses for Answer E:

1. We do not perform these ourselves, so would refer to IR and consult as a team if needed. If IR not in favor, then refer.
2. Would also like to assure he has adequate hydration, nutrition first before intervention, as well as good follow up for functional rehabilitation of eating/abd pain (if block is offered it is placed in context of multidisciplinary chronic pain management and close monitoring for refeeding, not assuming a block is going to be a fix by itsself)

Total Answers:  48
Total Votes:  48

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July 2024

A 16-year-old female with history of anxiety and urinary tract infection 4 months ago is admitted with continued intermittent severe bladder spasms. Work-up with urology, including cystoscopy, has been reassuring and unrevealing. Urology has patient on oxybutynin XL with little improvement. Pain service is consulted for help with inpatient and outpatient pain management. Which of the following options would you consider for additional treatment?

• A. IV and or PO diazepam while inpatient and discharge with PO diazepam 16.90% (12 votes)
• B. IV and/or PO diazepam while inpatient, but wean off prior to discharge 14.08% (10 votes)
• C. Start tamulosin (Flomax) daily 7.04% (5 votes)
• D. Conservative therapy: pain and anxiety focused psychology, pelvic floor therapy 46.48% (33 votes)
• E. Superior hypogastric block to help with bladder pain/spasms 9.86% (7 votes)
• F. Other muscle relaxant or approach Please specify (free text) 5.63% (4 votes)

Other Answer Responses for Answer F:

1. Would also probably try C (tamsulosin)

Total Answers:  71
Total Votes:  71

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May 2024

Please choose the statement(s) below that most closely describes your practice (select all that apply): I typically give intraoperative methadone…

• A. To patients undergoing surgery who will remain inpatient postoperatively 21.34% (35 votes)
• B. To patients undergoing surgery who will be discharged to the outpatient setting (ambulatory/same day surgery) 5.49% (9 votes)
• C. To opioid tolerant patients (i.e. those on chronic opioid therapy) 16.46% (27 votes)
• D. To opioid naïve infants (full term 1 month -1 yr.) 2.44% (4 votes)
• E. To opioid naïve neonates (<1 month, premature infants < 56 weeks PCA/PMA) 0% (0 votes)
• F. To patients who also receive regional anesthesia 5.49% (9 votes)
• G. Along with, other opioids or sedatives 9.76% (16 votes)
• H. When I do administer a single dose methadone I use: 0.1mg/kg 7.32% (12 votes)
• I. When I do administer a single dose methadone I use: 0.15mg/kg 6.10% (10 votes)
• J. When I do administer a single dose methadone I use: 0.2mg/kg 11.59% (19 votes)
• K. When I do administer a single dose methadone I use: 0.25mg/kg 0% (0 votes)
• L. When I do administer a single dose methadone I use: use multiple doses. 2.44% (4 votes)
• M. A dose based on their current opioid therapy. 6.10% (10 votes)
• N. I don’t give methadone intraoperatively. 1.83% (3 votes)
• O. Comments (use text box for comments) 3.66% (6 votes)

Other Answer Responses for Answer O:

1. I used methadone for all patients (inpatient or outpatient) with expected multiple days of moderate-severe post-operative pain. I typically dose at least 0.15mg/kg on incision, and give additional doses of 0.05mg/kg towards the last 1/3 of the case, or in the PACU if patient is still haven\’t significant pain. I do not mix with other opioids.
2. IV not available in Canada except by complex special arrangement.
3. We use methadone in single dose mostly for spine fusion and major orthopedics
4. I use methadone fairly routinely in patients who I expect will have moderate to severe pain post op
5. Not ready to use methadone as recommended in some recent studies ( 0.25mg/kg) for outpatients

Total Answers:  164
Total Votes:  46

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March 2024

Which of the following postoperative analgesic options do you use in your practice for a child with a tibial long bone fracture at risk for acute compartment syndrome (ACS)?

• A) Perform a single injection popliteal nerve block (+/- adductor canal single injection) 7.69% (4 votes)
• B) Place a popliteal sciatic nerve catheter (+/- adductor canal single injection) 3.85% (2 votes)
• C) Multimodal analgesia with no regional because I am concerned about ACS postoperatively 9.62% (5 votes)
• D) Multimodal analgesia with no regional because our orthopedic surgeons are concerned about ACS 67.31% (35 votes)
• E) Epidural catheter with low concentration LA or opioid only 3.85% (2 votes)
• F) Something else ( please specify-free text) 7.69% (4 votes)

Other Answer Responses for Answer F:

1.  Limit concentration of local anesthetic.
2.  Probably no regional because the ‘surgeon’ is concerned about compartment syndrome. There is a case to be made for multimodal with continuous opioid infusion rather than PCA, so that changes in pain level can be identified more quickly against a steady-state opioid background level.
3.  Our surgeons no longer want any blocks.

Total Answers: 52
Total Votes: 52

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January 2024

An 8kg 5-month-old male infant with history of bladder extrophy presents for primary repair with request for postoperative epidural analgesia. Orthopedics is assisting with pelvic osteotomies with postoperative traction, and the surgical team anticipates at least 10-day hospitalization. Assuming an uneventful epidural catheter placement and no associated complications, how many days would you USUALLY continue the infusion? Pick the answer that best fits your practice, assume untunneled catheter unless answer specifies that it is tunneled.

• A) 5 28.28% (28 votes)
• B) 7 17.17% (17 votes)
• C) 7 only if catheter is tunneled 11.11% (11 votes)
• D) 10 2.02% (2 votes)
• E) 10 only if catheter is tunneled 6.06% (6 votes)
• F) >10 no associated complications and surgical team requests 7.07% (7 votes)
• G) >10 if catheter is tunneled and no associated complications and surgical team requests 18.18% (18 votes)
• H) other – specify in text area 10.10% (10 votes)

Other Answer Responses for Answer H:

1.  If tunneled, longer 7-10 days.
2.  5-10 days, depending on how the patient is doing postoperatively and how the patient is tolerating a oral diet.
3.  4 days.
4.  4.
5.  2 days maximum three if not contaminated by stool.

Total Answers:  99
Total Votes:  99

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November 2023

What is your go to pain plan for healthy cooperative adolescents undergoing ACL repair with hamstring autograft? Choose all options that apply.

• A. Femoral or adductor nerve catheter 15% (21 votes)
• B. Adductor or femoral single shot 21.43% (30 votes)
• C. Sciatic/popliteal block 10.71% (15 votes)
• D. iPack 7.86% (11 votes)
• E. Block performed Awake/sedated 9.29% (13 votes)
• F. Block performed under GA before surgical incision 26.43% (37 votes)
• G. Block performed under GA at end of surgery 1.43% (2 votes)
• H. No block 3.57% (5 votes)
• I.  Other preferred analgesic techniques: specify in text area 4.29% (6 votes)

Other Answer Responses for Answer I –

1. Adductor canal, iPACK and genicular blocks performed once under GA.
2.  Genicular nerve blocks
3.  Multimodal analgesia

Total Answers:  140
Total Votes:  58

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September 2023

July 2023

An 11-month infant under goes a Left sided thoracotomy for a large benign mass resection. The incision level is at T4 and the child has 2 chest tubes in place at T6 and T7. Hemoglobin, platelets and coagulation factors are normal. Which of the following approaches to postoperative pain management are you most likely to take?

• 1. Place at thoracic epidural at a low to mid thoracic level 45.45% ( 40 votes )
• 2. Thread a catheter to the thoracic level from the caudal space using only US for confirmation 10.23% ( 9 votes )
• 3. Thread a catheter to the thoracic level from the caudal space using fluoroscopy for confirmation ( +/- US) 5.68% ( 5 votes )
• 4. Perform an ESP block ( single shot or catheter) 15.91% ( 14 votes )
• 5. Perform a Paravertebral block ( single shot or catheter) 11.36%  (10 votes )
• 6. Multimodal analgesia with no regional 4.55% ( 4 votes )
• 7. Something else 6.82% ( 6 votes )

Other Answer Responses For Answer 7: 

1. cryotherapy.
2.  Mid thoracic epidural after induction, if need for 1 lung ventilation would do,after epidural placement.
3.  Multimodal analgesia Intraoperative Dexmedetomidine infusion and IV Paracetamol 10mg/kg along with Caudal epidural catheter for Regional.
4.  Single shot paravertebral at Th4 and Th6.

Total Answers:  88
Total Votes:  88 

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May 2023