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?