Society for Pediatric Pain Medicine
Better Care for Children in Pain

Submitted by:
Michelle S. Kars, MD, FAAP
North American Partners in Anesthesia

A 3 day-old full-term infant weighing 3.7 kg presents for thoracotomy for repair of esophageal atresia.  Echocardiogram reveals a small PFO.  Currently the infant is on nasal O2 with no pulmonary distress. Laboratory data is significant for INR of 1.4, and platelets of 60,000.  On discussion with the surgical and NICU teams, they would like to avoid prolonged intubation after surgery. Which of the following will provide thoracic dermatomal coverage and the longest duration block in order to minimize opioids and expedite extubation following surgery?

This question submitted by Timothy Casias, MD

A 15-year-old, 50-kilogram female has history of Complex Regional Pain Syndrome in her right lower extremity for the last 5 years. She presents to the operative room for an open reduction and internal fixation of a displaced distal tibial shaft fracture after falling on ice and hitting her right lower leg on the curb during the winter.  She previously is quite disabled from CRPS and spends most of the time in a wheelchair.  The decision is to place a popliteal catheter for post-operative pain control.  The operation was uneventful, and she has good analgesia with the catheter running 0.2% ropivacaine at 6 ml/hr.   Approximately 36 hours after the operation, she has increasing, severe pain.  What is your biggest concern for this patient? 

The question submitted by Franklin Chiao.

A 10-year-old patient with joint hypermobility syndrome presents with acute on chronic pain after a minor orthopedic procedure .  She frequently experiences gerd, generalized joint pain, muscle weakness, and disrupted proprioception.  She also has a history of anxiety, depression, and fears the onset of pain.  Her parents are distressed and concerned.  Which of the following would be a good immediate post-operative treatment plan?

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?

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?