Society for Pediatric Pain Medicine
Better Care for Children in Pain

December's question is written by:  

Ashlee Holman, MD
Assistant Professor of Anesthesiology
University of Michigan Health System

A 16-year old male with sickle cell disease presents to the hospital in acute pain crisis. His sickle cell disease has worsened over the last few years, and optimal pain control during acute crises has been difficult to achieve. His analgesic regimen is complex and includes non-pharmacological methods (e.g. distraction techniques, behavioral modification therapy) as well as acetaminophen, NSAIDs, hydromorphone, methadone, and most recently, initiation of a lidocaine infusion. He reports low pain scores on the intravenous lidocaine and wonders if he can continue lidocaine in some form as an outpatient. The patient’s care team suggests transition to oral mexiletine as a replacement for intravenous lidocaine. Which of the following is false?

This month’s question was jointly written by a team from the Lucile Salter Packard Children's Hospital at Stanford University, Palo Alto, CA. Catherine A. Dietrich, MD is currently a pediatric anesthesiology fellow who completed both her medical training and residency in anesthesiology at the University of Florida College of Medicine in Gainesville, FL. Christina M. Almgren, MS, RN, CPNP, is a pediatric nurse practitioner, practicing in the hospital’s pediatric pain management service since 2000 following her graduation from the University of California, San Francisco.    

Christina Almgren, RN, CPNP (Pediatric Nurse Practitioner)

Catherine Dietrich, MD (Pediatric Anesthesiology Fellow) 

A 9-year-old male is scheduled for staged washout and internal fixation of a severe right tibia/fibula compound fracture. The trauma occurred initially 3 days ago and involved degloving of the lower extremity followed by lake water contamination.  He was transferred to your tertiary care facility for definitive management. His surgeons plan for a flap for delayed closure of his lower extremity wound, to occur at least 5-7 days from the currently planned procedure. While in the ICU, pain control has only been moderately successful, with severe opioid dose-limiting side effects (opioid-induced myoclonus, nausea, and somnolence). The surgeons request a plan for postoperative pain control, concerned especially about pain with daily dressing changes for at least the next two weeks.  What would your primary plan for postop pain management entail?

Ingy Iskander MD
Assistant Instructor 
UT Southwestern Medical Center and Children's Medical Center

You have been asked to perform a stellate ganglion block on a 17-year-old male with complex regional pain syndrome.  To avoid radiation exposure and in order to visualize the neurovascular anatomy you decide to perform the block under ultrasound guidance.  Below is the image you obtain:

Which letter represent the best location for local anesthetic deposition:

Petrus Paulus Steyn, MD 
Fellow, Department of Anesthesiology and Critical Care Medicine
Children's Hospital of Philadelphia

A 6-month old boy with isolated cleft palate repair  presents for surgical repair by the plastic surgery team. His mother is well prepared for the preoperative conversation and asks that her boy’s anesthesia team use an opioid sparing technique. The patient has a 1x1cm congenital melanocytic nevus under his left eye. You elect to do a suprazygomatic maxillary nerve block. After inducing the patient with sevoflurane, placing an IV and securing the airway with an oral right angle endotracheal tube, you obtain an image of the pterygopalatine fossa with a linear probe positioned bellow the zygomatic arch.

Please choose the option that most correctly represents the anatomical structures identified on this ultrasound imaging of the pterygopalatine fossa.

Mo Esfahanian, MD
Clinical Instructor, Pediatric Anesthesiology

                                                   
Your patient is an 8-year-old girl presenting with Ewing's sarcoma of the left scapula (Figure 1). She is scheduled for left chest wall wide resection, left scapula wide resection, multiple muscle transfers and muscle-skin flaps involving the shoulder and arm, along with neurolysis and vessel mobilization. The surgical team is unsure how far they will need to extend the chest wall wide resection. She has a history of severe nausea with opioids. You plan to use a regional anesthetic technique for post-operative pain control as part of your multi-modal regimen.

What is the sensory innervation of the scapula bone (i.e. osteotome)?