Pediatric Pain : Neuroaxial Blockade for Acute Pain Management Intrathecal Administration Epidural...

Pediatric Pain :Pediatric Pain : Neuroaxial Blockade for Acute Pain Neuroaxial Blockade for Acute Pain

ManagementManagement

Intrathecal AdministrationIntrathecal Administration

Epidural AdministrationEpidural Administrationsinglesingle

continuouscontinuous

post-op managementpost-op management

“The Advantages to be gained by the use of spinal anesthesia have so far impressed me that I am convinced it will occupy an important place in the surgery

of children in the future.”

H. Tyrell-Grey

The Lancet 1909

IntroductionIntroduction

The following sessions illustrate the The following sessions illustrate the advantages for using neuro-axial advantages for using neuro-axial blockade for pediatric pain management blockade for pediatric pain management either acutely or in combination with a either acutely or in combination with a general anesthetic. The approaches general anesthetic. The approaches delineated remain designed for the delineated remain designed for the general practitioner as well as specialist. general practitioner as well as specialist. Even though perhaps still evolving, these Even though perhaps still evolving, these techniques have and continue to benefit techniques have and continue to benefit many.many.

CASECASE

A three month of age boy is to have a A three month of age boy is to have a right inguinal hernia repaired. Upon review right inguinal hernia repaired. Upon review he has had respiratory distress syndrome. he has had respiratory distress syndrome.

Wght: 3 kgWght: 3 kg

Hct: 30%Hct: 30%

Preoperative EvaluationPreoperative EvaluationEmergency? Emergency? NoNo

Why is the Surgery being performed?Why is the Surgery being performed?

PREOPERATIVE EVALUATION:PREOPERATIVE EVALUATION: ProblemsProblems1. RDS1. RDS2. Hyaline Membrane Ds2. Hyaline Membrane Ds2. Prematurity2. Prematurity3. Airway3. Airway5. Full Stomach5. Full Stomach

History & PhysicalHistory & Physicallitany of basic knowledgelitany of basic knowledge

Laboratory TestsLaboratory TestsCBCCBCElectrolytesElectrolytesCoagsCoagsCXR (ABG, FEV1/FVC, F-V loop)CXR (ABG, FEV1/FVC, F-V loop)

ANY ISSUES TO BE ADDRESSED PRIOR TO ENTERING THE O.R.ANY ISSUES TO BE ADDRESSED PRIOR TO ENTERING THE O.R.

Choice of AnesthesiaChoice of Anesthesia

General AnesthesiaGeneral Anesthesia

Regional AnesthesiaRegional Anesthesia

Peripheral Nerve BlockPeripheral Nerve Block

IV Regional IV Regional

MACMAC

LocalLocal

Techniques for General Techniques for General AnesthesiaAnesthesia

4 Concerns to Guide the Plan:4 Concerns to Guide the Plan:

Airway/ Full Stomach/ Volume Status/ Medical ProblemsAirway/ Full Stomach/ Volume Status/ Medical Problems

Is Regional an Option?Is Regional an Option?

Rapid SequenceRapid Sequence

Modified Rapid SequenceModified Rapid Sequence

Medications1. Administration sequence2. Including NMB Agent3. Analgesic Component

Concerns1. Airway2. Full Stomach3. Volume Status4. Medical Problems

How1. IV-IM2. Inhalational3. Awake Fiber Optic4. Local Trach

Intrathecal Intrathecal AdministrationAdministration

I keep six honest serving menI keep six honest serving men(They taught me all I knew);(They taught me all I knew);

Their names are What and Why and Their names are What and Why and WhenWhen

And How and Who.And How and Who.

Rudyard Kipling 1865-1936Rudyard Kipling 1865-1936--The Just-So Stories (1902). The Elephant’s --The Just-So Stories (1902). The Elephant’s

ChildChildWhatWhat

WhyWhy

WhenWhen

How How

WhoWho

WhereWhere

Efficient: What NeededEfficient: What Needed

Physiology, Safety & EfficacyPhysiology, Safety & Efficacy

Patient Centered, Timely, EquitablePatient Centered, Timely, Equitable

TreatmentTreatment

Background Demographics IntroductionBackground Demographics Introduction

AnatomyAnatomy

What?What?Anatomy : Intrathecal SpaceAnatomy : Intrathecal Space

Why?Why?

The spinal cord The spinal cord anatomy of the infant anatomy of the infant differs from the adult, differs from the adult, since the cord since the cord terminates at L3 in terminates at L3 in the infant not L2 as in the infant not L2 as in the adult. the adult.

When?When?

For high risk infants less than 1 year of age. These For high risk infants less than 1 year of age. These include infants with certain congenital anomalies, a include infants with certain congenital anomalies, a history of prematurity, or a history of neonatal history of prematurity, or a history of neonatal respiratory distress syndrome thereby increasing the respiratory distress syndrome thereby increasing the risk for general anesthesia.risk for general anesthesia.

How?How?Technique: 1. Suggest premedication with atropine onlyTechnique: 1. Suggest premedication with atropine only

2. ASA monitors placed while infant remains fully awake in the OR2. ASA monitors placed while infant remains fully awake in the OR

3. While receiving supplemental 02 with chin extended, the infant is placed into position3. While receiving supplemental 02 with chin extended, the infant is placed into position

4. Prepare the lumber area with iodine solution4. Prepare the lumber area with iodine solution

5. Identify the lowest palpable interspace below L35. Identify the lowest palpable interspace below L3

6. Use 1% procaine for the skin weal analgesic6. Use 1% procaine for the skin weal analgesic

7. Draw 0.2 cc of 1% tetracaine in a TB syringe and add 0.2 cc of 10% dextrose for a 7. Draw 0.2 cc of 1% tetracaine in a TB syringe and add 0.2 cc of 10% dextrose for a

hyperbaric solution. By adding 0.02 cc of epi 1:1000 the effect may increase upwards to 100 hyperbaric solution. By adding 0.02 cc of epi 1:1000 the effect may increase upwards to 100

minutesminutes

8. Have available a variety of 22 or 25 gauge pediatric Quincke or Whitacre type spinal 8. Have available a variety of 22 or 25 gauge pediatric Quincke or Whitacre type spinal needlesneedles

9. After obtaining free flow of CSF from all planes of needle rotation, 9. After obtaining free flow of CSF from all planes of needle rotation, do not aspiratedo not aspirate

10. Inject the hyperbaric solution plus 0.4cc more than needed to compensate for dead space.10. Inject the hyperbaric solution plus 0.4cc more than needed to compensate for dead space.

11. Leave the needle in place for about 5 seconds to prevent back tracking of the solution from 11. Leave the needle in place for about 5 seconds to prevent back tracking of the solution from

the CSF, thus avoiding an incomplete or failed block. the CSF, thus avoiding an incomplete or failed block.

12. Place the infant supine, while observing for the onset of lower extremity flaccidity, usually 12. Place the infant supine, while observing for the onset of lower extremity flaccidity, usually

within 2 minutes.within 2 minutes.

13. Maintain strict supine positioning until the block establishing the block, without leg 13. Maintain strict supine positioning until the block establishing the block, without leg elevation. elevation.

Such prevents potential migration of the block and a total spinalSuch prevents potential migration of the block and a total spinal

Infant Spinal Infant Spinal AnesthesiaAnesthesia

1……………………….add Tb syringe1……………………….add Tb syringe

2…………………...add spinal needle2…………………...add spinal needle

3……………………...add medication3……………………...add medication


4...use local4...use local


5………...…………..attach syringe 5………...…………..attach syringe firmlyfirmly

6………………………………...6………………………………...do not do not aspirateaspirate

7….it is ok to inject into bloody CSF7….it is ok to inject into bloody CSF


8…...load syringe sterile 8…...load syringe sterile and have surgeon inject and have surgeon inject

itit

9…….if spinal begins to 9…….if spinal begins to wear off, repeat the dosewear off, repeat the dose


10…...start IV in anesthetized ankle10…...start IV in anesthetized ankle


11…..note the placement of the drapes11…..note the placement of the drapes


close upclose up

Who?Who?High risk infants who had been born prematurely or were treated High risk infants who had been born prematurely or were treated

for neonatal respiratory distressfor neonatal respiratory distress

Infants with congenital anomalies such as laryngomalacia, Infants with congenital anomalies such as laryngomalacia, macroglossia, or microagnathiamacroglossia, or microagnathia

Most commonly the surgical indication is bilateral inguinal hernia Most commonly the surgical indication is bilateral inguinal hernia repair, but other surgery below the umbilicus is also considered:repair, but other surgery below the umbilicus is also considered:

colostomy for imperforated anuscolostomy for imperforated anus

recctal biopsyrecctal biopsy

closed reduction of hip dislocationclosed reduction of hip dislocation

circumcisioncircumcision

correction of club footcorrection of club foot

etc.etc.

High Risk Infants Who Had Been High Risk Infants Who Had Been Born PrematurelyBorn Prematurely

Consider Surgery Below the Consider Surgery Below the UmbilicusUmbilicus

Where?Where?

Lowest palpable interspace below Lowest palpable interspace below L3 L3

AnatomyAnatomy

PitfallsPitfalls

Dose:Dose: 1 mg for those infants < 1 year of 1 mg for those infants < 1 year of ageage

then 0.25 mg/kg then 0.25 mg/kg

mean duration of 84 minutesmean duration of 84 minutes

with epi mean increased to 109 with epi mean increased to 109 minutesminutes

Alternates: 0.5% bupivicaine or 2.5% lidocaineAlternates: 0.5% bupivicaine or 2.5% lidocaine

ResultsResultsgroup infants proceedures attempt attempt unsuccessful spinals requiring supplementationgroup infants proceedures attempt attempt unsuccessful spinals requiring supplementation

## ## 1st 2nd # # 1st 2nd # #

high risk 36high risk 36 3636 31 31 5 5 0 0 6 6

anomaly 8anomaly 8 1111 10 10 1 1 0 0 3 3

termterm 3434 3434 22 22 4 4 8 8 5 5

totalstotals 7878 8181 63 63 10 10 8 8 14 14

SafetySafety

Most Difficulty Lies in Positioning an Awake Wiggling InfantMost Difficulty Lies in Positioning an Awake Wiggling Infant

The CSF Flow Must Remain Continuos As the Needle RotatesThe CSF Flow Must Remain Continuos As the Needle Rotates

Bloody Taps Occur More Often If Not Midline in ApproachBloody Taps Occur More Often If Not Midline in Approach

With a Bloody Tap More Difficulty Arises in Locating the CSF With a Bloody Tap More Difficulty Arises in Locating the CSF

BP and Bradycardia Less Likely With Infants Than With AdultsBP and Bradycardia Less Likely With Infants Than With Adults

The CSF Flow Must Remain The CSF Flow Must Remain Continuous as the Needle Continuous as the Needle

RotatesRotates

ReferencesReferences

Abajian JC, Mellish PWP, Browne AD, Perkins FM, Lambert Abajian JC, Mellish PWP, Browne AD, Perkins FM, Lambert DW, Mazuzan JE. Spinal Anesthesia for Surgery in DW, Mazuzan JE. Spinal Anesthesia for Surgery in Children and Infant. Anesth Anal 1984; 63:359-62.Children and Infant. Anesth Anal 1984; 63:359-62.

Gregory, GA and Steward, DJ. Life Threatening Gregory, GA and Steward, DJ. Life Threatening Perioperative Apnea in the Ex-preemie. Anesthesiology Perioperative Apnea in the Ex-preemie. Anesthesiology 59:495-498, 1983.59:495-498, 1983.

Steward, DJ. Preterm Infants are More Prone to Steward, DJ. Preterm Infants are More Prone to Complications Following Minor Surgery than are Term Complications Following Minor Surgery than are Term Infants. Anesthesiology 56:304-306, 1982.Infants. Anesthesiology 56:304-306, 1982.

PEDIATRIC PAINPEDIATRIC PAINEpidural AdministrationEpidural Administration

Kiddy CaudalsKiddy Caudals

Epidural AdministrationEpidural Administration

WhatWhat

WhyWhy

WhenWhen

How How

WhoWho

WhereWhere

I keep six honest serving menI keep six honest serving men(They taught me all I knew);(They taught me all I knew);

Their names are What and Why and Their names are What and Why and WhenWhen

And How and Who.And How and Who.

Rudyard Kipling 1865-1936Rudyard Kipling 1865-1936--The Just-So Stories (1902). The Elephant’s --The Just-So Stories (1902). The Elephant’s

ChildChildEfficient: What NeededEfficient: What Needed

Physiology, Safety & EfficacyPhysiology, Safety & Efficacy

Patient Centered, Timely, EquitablePatient Centered, Timely, Equitable

TreatmentTreatment

Background Demographics IntroductionBackground Demographics Introduction

AnatomyAnatomy

Single AdministrationSingle Administration

What?What?

With very little equipment With very little equipment which includes a skin prep, which includes a skin prep, needle of choice, and desired needle of choice, and desired local anesthetic:local anesthetic:

1………………...………...alcohol 1………………...………...alcohol padpad

2…….povidone idoine solution2…….povidone idoine solution

3……….formal prep and drape3……….formal prep and drape

4……………..appropriate needle4……………..appropriate needle

5…..desired local anesthetic5…..desired local anesthetic

single shot caudals provide single shot caudals provide excellent analgesiaexcellent analgesia

11

22

33

4455

Why?Why?

Caudals provide effective Caudals provide effective adjunctive operative analgesia adjunctive operative analgesia lasting upwards of 4 to 6 hours lasting upwards of 4 to 6 hours post-surgically in pediatric post-surgically in pediatric patients. Moreover, these patients. Moreover, these techniques are relatively safe techniques are relatively safe and easy to perform. and easy to perform.

When?When?

after induction of general anesthesia but before after induction of general anesthesia but before the onset of surgical incision.the onset of surgical incision.

-the time required for placement translates into time regained post -the time required for placement translates into time regained post operatively secondary to earlier anesthetic emergenceoperatively secondary to earlier anesthetic emergence

-patients commonly remain pain free for several hours post.-patients commonly remain pain free for several hours post.

-greatly reduces the risk of laryngospasm due to surgical stimulation -greatly reduces the risk of laryngospasm due to surgical stimulation especially during perineal procedures obviating the need for especially during perineal procedures obviating the need for

intubation and the possibility of post-operative croupintubation and the possibility of post-operative croup

How?How?

1. Properly position the patient1. Properly position the patient

2. After the skin preparation, use the hypodermic 2. After the skin preparation, use the hypodermic needle of choice at a 60 degree angle to the skin needle of choice at a 60 degree angle to the skin until the sacrococygeal membrane is peirced.until the sacrococygeal membrane is peirced.

3. Note a distintive ‘pop’ upon entering the sacral 3. Note a distintive ‘pop’ upon entering the sacral canal canal

4. Then further advance the hypodermic another 2mm 4. Then further advance the hypodermic another 2mm parallel the plane of the spinal axis.parallel the plane of the spinal axis.

5. Gently aspirate to confirm neither an intravascular 5. Gently aspirate to confirm neither an intravascular nor an intrathecal injection of local anesthetic.nor an intrathecal injection of local anesthetic.

6. Introduce the agent into the caudal epidural space6. Introduce the agent into the caudal epidural space

How to Position?How to Position?

How to Proceed?How to Proceed?

1. After the skin preparation, 1. After the skin preparation, use the hypodermic use the hypodermic needle of choice at a 60 needle of choice at a 60 degree angle to the skin degree angle to the skin with the bevel down until with the bevel down until the sacrococygeal the sacrococygeal membrane is peirced.membrane is peirced.

2. Note a distintive ‘pop’ 2. Note a distintive ‘pop’ upon entering the sacral upon entering the sacral canal canal

3. Then further advance the 3. Then further advance the hypodermic another 2mm hypodermic another 2mm parallel the plane of the parallel the plane of the spinal axis.spinal axis.

Caudal EpiduralCaudal Epidural

1……….. enter membrane at 30 to 40 degrees1……….. enter membrane at 30 to 40 degrees

2…………………………..flatten toward the rectum2…………………………..flatten toward the rectum

3…………………….advance about 1/4 to 1/2 inch3…………………….advance about 1/4 to 1/2 inch

4……slip catheter off the needle into space4……slip catheter off the needle into space


5…………………….do not inject air5…………………….do not inject air

6…………………..aspirate catheter6…………………..aspirate catheter


18 gauge cathalon18 gauge cathalon

arrow caudal/epidural kitarrow caudal/epidural kit


suitable dressingsuitable dressing

tape up the side to allow for bovie tape up the side to allow for bovie padpad

Who?Who?

children having surgical procedures below the children having surgical procedures below the umbilicus:umbilicus:

circumcisionscircumcisions

orchidopexyorchidopexy

inguinal hernia repairinguinal hernia repair

hydrocelectomyhydrocelectomy

rectal dilationrectal dilation

lower extremity orthopedic procedureslower extremity orthopedic procedures

WhereWhere

Through the caudal spaceThrough the caudal space

Pediatric Acute Pain Pediatric Acute Pain Management Post-Management Post-

Operatively:Operatively:

Continuous Epidural InfusionsContinuous Epidural Infusions

Cardiothoracic SurgeryCardiothoracic Surgery

At our institution epidural remains the standard of care. At our institution epidural remains the standard of care. So much so that parents must specifically state refusal So much so that parents must specifically state refusal for this preferred method of intra-operative and for this preferred method of intra-operative and postoperative analgesia not to be provided.postoperative analgesia not to be provided.

David A. David A. Rosen, MDRosen, MD

EpiduralEpidural

Dr. Chris Abajian pioneered spinal anesthesia for infants Dr. Chris Abajian pioneered spinal anesthesia for infants at the University of Vermont and maintains the largest at the University of Vermont and maintains the largest database in the world on outcomes associated with this database in the world on outcomes associated with this techniquetechnique

Chris Abajian, Chris Abajian, MDMD

18 guage cathalon18 guage cathalon


EpiduralEpidural

CaudalCaudal

22 gauge jelco catheter 22 gauge jelco catheter inserted through the inserted through the sacrococygeal ligament sacrococygeal ligament with a 24-gauge styleted with a 24-gauge styleted catheter threaded 1-3 cm catheter threaded 1-3 cm into the caudal space into the caudal space usually. usually.


suitable dressingsuitable dressing

tape up the side to allow for bovie tape up the side to allow for bovie padpad

EpiduralEpidural

CaudalCaudal

suitable bio-occlusive dressing applied suitable bio-occlusive dressing applied with a drape below and above the with a drape below and above the insertion site providing a sterile insertion site providing a sterile barrier resisting contamination from barrier resisting contamination from urine and feces. Tape the catheter urine and feces. Tape the catheter connector to a tongue blade to add connector to a tongue blade to add 1-2, 4-way stopcocks for medication 1-2, 4-way stopcocks for medication infusionsinfusions

tape up the side to allow for bovie padtape up the side to allow for bovie pad

Caudal MedicationsCaudal Medications

MorphineMorphine

HydromorphoneHydromorphone

ClonidineClonidine

Local AnestheticsLocal Anesthetics

lidocainelidocaine

bupivacainebupivacaine

ropivacaineropivacaine


MorphineMorphine

BOLUSBOLUS SIDE EFFECTSSIDE EFFECTSRATERATEINFUSIONINFUSION

0.04 mg/kg0.04 mg/kg

>14 kg 10cc PFNS >14 kg 10cc PFNS

< 1kg 3cc PFNS < 1kg 3cc PFNS

<14 kg 5cc PFNS <14 kg 5cc PFNS

0.075 mg/kg0.075 mg/kg

>14 kg 10cc PFNS >14 kg 10cc PFNS

< 1kg 3cc PFNS < 1kg 3cc PFNS

<14 kg 5cc PFNS <14 kg 5cc PFNS

0.125 mcg/kg/min0.125 mcg/kg/min

0.025 mcg/kg/min0.025 mcg/kg/min

0.5 cc/hr0.5 cc/hr

1 cc/hr1 cc/hrsomulencesomulence

nauseanausea vomitingvomitingpruritispruritis

*epidurally administered opiods require a *epidurally administered opiods require a minimum of 8 hours of continuous pulse minimum of 8 hours of continuous pulse

oximetryoximetry

MorphineMorphine

Caudal CaveatsCaudal Caveats

If only using morphine throughout the case after the bolus of If only using morphine throughout the case after the bolus of 0.04 mcg/kg infuse at 0.125 mcg/kg/min, then stop near the 0.04 mcg/kg infuse at 0.125 mcg/kg/min, then stop near the end to facilitate extubation. Restart the infusion upon the end to facilitate extubation. Restart the infusion upon the child’s awakening if placed in the caudal region as noted child’s awakening if placed in the caudal region as noted already. Or if the catheter lies in the thoracic segments, for already. Or if the catheter lies in the thoracic segments, for Down’s children or premature infants begin at half the rate Down’s children or premature infants begin at half the rate 0.0625 mcg/kg/min. Should side effects (somulence without 0.0625 mcg/kg/min. Should side effects (somulence without discomfort) arise decrease the infusion by 0.025 increments.discomfort) arise decrease the infusion by 0.025 increments.

For those individuals requiring continued ventilatory support For those individuals requiring continued ventilatory support simply maintain the above maximum infusion.simply maintain the above maximum infusion.

Typically the epidural infuse for 2-3 days post-op thought Typically the epidural infuse for 2-3 days post-op thought upto even 5 days are not uncommonupto even 5 days are not uncommon


HydromorphoneHydromorphone

BOLUSBOLUS SIDE EFFECTSSIDE EFFECTSPOST OP ADJUSTMENTSPOST OP ADJUSTMENTSINFUSIONINFUSION

0.1-3.5*0.1-3.5*

2xwghtx24 = mg added in PFNS for total of 48cc2xwghtx24 = mg added in PFNS for total of 48cc

0.5-1.0*0.5-1.0*

*mcg/kg/hr*mcg/kg/hr

0.1 and 0.5 increments*0.1 and 0.5 increments* akin to morphine, akin to morphine, and more and more lipophilic thus the lipophilic thus the catheter tip lies in catheter tip lies in proximity to the proximity to the desired desired dermatomal area.dermatomal area.


ClonidineClonidine

BOLUSBOLUS SIDE EFFECTSSIDE EFFECTSPOST OP ADJUSTMENTSPOST OP ADJUSTMENTSINFUSIONINFUSION

profound analgesiaprofound analgesiasedationsedation

hypotension**hypotension**bradycardia**bradycardia**

0.1-5*0.1-5*0.5-1.0*0.5-1.0*

*mcg/kg/hr*mcg/kg/hr

0.1 and 0.5 increments*0.1 and 0.5 increments*

PF Clonidine comes as 100 or 500 mcg/cc PF Clonidine comes as 100 or 500 mcg/cc reduce the concentration by tenfold to 10 or 50 mcg/ccreduce the concentration by tenfold to 10 or 50 mcg/cc

**ideal for coarctation patients**ideal for coarctation patients


Local Anesthetics: Local Anesthetics: BolusBolus

LOCALLOCAL LOADING DOSELOADING DOSETEST DOSETEST DOSE

lidocaine (L)lidocaine (L)

bupivacaine (B)bupivacaine (B)

ropivacaine (R)ropivacaine (R)

0.1cc/kg 1-1.5%L epi 1:200k0.1cc/kg 1-1.5%L epi 1:200k0.25% B 0.056 cc/kg/seg0.25% B 0.056 cc/kg/seg0.1cc/kg 0.25%B epi 1:200k0.1cc/kg 0.25%B epi 1:200k

1-1.5% L bolus to desired level1-1.5% L bolus to desired level


Local Anesthetics: MaintanenceLocal Anesthetics: Maintanence

LOCALLOCAL SIDE EFFECTSSIDE EFFECTSINFUSIONINFUSION

lidocaine (L)lidocaine (L)

bupivacaine (B)bupivacaine (B)

ropivacaine (R)ropivacaine (R)

somulencesomulencehand tinglinghand tingling

extra-dermatomal numbnessextra-dermatomal numbnesspain with adequate sympathectomypain with adequate sympathectomy

0.75% L @10-20mcg/kg/hr*0.75% L @10-20mcg/kg/hr*

0.1% R @ 10-20mcg/kg/hr0.1% R @ 10-20mcg/kg/hr

0.1-0.125%** B @0.25mg/kg/hr0.1-0.125%** B @0.25mg/kg/hr

*lidocaine level obtained 12hr post op then daily while the infusion continues*lidocaine level obtained 12hr post op then daily while the infusion continues

**0.125% B used for children reaching tanner stage 4**0.125% B used for children reaching tanner stage 4

Side EffectsSide Effects

vomiting more commonly in children > 3 yearsvomiting more commonly in children > 3 yearsfacial itching noted more often in non-infantsfacial itching noted more often in non-infants

respiratory depression rarely occurs with adherence to the dosage schedulerespiratory depression rarely occurs with adherence to the dosage schedule

Nalbuphene 0.025 mg/kg q 2hr prn nausea, vomiting, pruritisNalbuphene 0.025 mg/kg q 2hr prn nausea, vomiting, pruritisshould vomiting persist decrease the narcotic infusionshould vomiting persist decrease the narcotic infusion

failing two trials of nubain, ondensatron failing two trials of nubain, ondensatron 0.15 mg/kg up to 4mg iv q 4hr prn 0.15 mg/kg up to 4mg iv q 4hr prn

nausea, vomiting, pruritisnausea, vomiting, pruritis

prophylactic low dose propofol infusion starting atprophylactic low dose propofol infusion starting at 1 titrating upto 10 mcg/kg/min might be considered1 titrating upto 10 mcg/kg/min might be considered

if these measures prove ineffective consider if these measures prove ineffective consider metaclopramide 0.1mg/kg or dexamethasone 0.5mg/kg metaclopramide 0.1mg/kg or dexamethasone 0.5mg/kg

IncidenceIncidence

5 %5 %

<1%<1%

.05%.05%

once only (no sequalae)once only (no sequalae)

00

once only*once only*

twice**twice**

ComplicatiComplicationsons

16 years of experience & over 5000 cases:16 years of experience & over 5000 cases:

Problems Problems

Insertional bleedingInsertional bleeding

Catheter bleedingCatheter bleeding

Intrathecal migrationIntrathecal migration

Catheter Shearing Catheter Shearing

Durocutaneous fistulaDurocutaneous fistula

Cauda-equina syndromeCauda-equina syndrome

MeningitisMeningitis

* resolved spontaneously after 1 week* resolved spontaneously after 1 week

**developed weeks later following catheter **developed weeks later following catheter removal and no evidence relating to the removal and no evidence relating to the

epiduralepidural

CaveatCaveatss

select those with optimal select those with optimal anatomy, remain reluctant for anatomy, remain reluctant for those without a base despite a those without a base despite a caudal dimple in such caudal dimple in such circumstances consider a low circumstances consider a low lumbar approach instead. lumbar approach instead.

remember the ‘circle of errors’remember the ‘circle of errors’

place the non-dominant hand place the non-dominant hand across the sacral region across the sacral region dorsally palpating for an dorsally palpating for an inadvertent subcutaneous inadvertent subcutaneous injection by noting a “bulge” injection by noting a “bulge” midline.midline.

EpiduralEpidural

X-ray showingX-ray showing wrongwrong catheter placementcatheter placement

EpiduralEpidural

X-ray showingX-ray showing correctcorrect catheter placementcatheter placement

ReferencesReferencesAbajian JC, Mellish PWP, Browne AD, Perkins FM, Lambert DW, Mazuzan JE. Abajian JC, Mellish PWP, Browne AD, Perkins FM, Lambert DW, Mazuzan JE.

Spinal Anesthesia for Surgery in Children and Infant. Anesth Anal 1984; Spinal Anesthesia for Surgery in Children and Infant. Anesth Anal 1984; 63:359-62.63:359-62.

Broadman, Lynn M. Regional Anesthesia in Children. West Virginia Broadman, Lynn M. Regional Anesthesia in Children. West Virginia University, 1994.University, 1994.

Gregory, GA and Steward, DJ. Life Threatening Perioperative Apnea in the Gregory, GA and Steward, DJ. Life Threatening Perioperative Apnea in the Ex-preemie. Anesthesiology 59:495-498, 1983.Ex-preemie. Anesthesiology 59:495-498, 1983.

Rosen, A. David. Continuous Caudal Morphine Postoperatively. January Rosen, A. David. Continuous Caudal Morphine Postoperatively. January 2626thth, 2004., 2004.

Steward, DJ. Preterm Infants are More Prone to Complications Following Steward, DJ. Preterm Infants are More Prone to Complications Following Minor Surgery than are Term Infants. Anesthesiology 56:304-306, 1982.Minor Surgery than are Term Infants. Anesthesiology 56:304-306, 1982.

QuestionsQuestionsT or FT or F 1. In the infant the spinal cord terminates at L2 as in the adult. 1. In the infant the spinal cord terminates at L2 as in the adult.

T or F T or F 2. Infants with a history of prematurity are excellent candidates 2. Infants with a history of prematurity are excellent candidates for pediatric spinals especially for surgery above the for pediatric spinals especially for surgery above the

umbilicus.umbilicus.

T or FT or F 3. As with most local anesthetic administration one should 3. As with most local anesthetic administration one should aspirate aspirate prior to injection for the infant spinal. prior to injection for the infant spinal.

T or FT or F 3. Should bloody CSF appear one should immediately abandon 3. Should bloody CSF appear one should immediately abandon the the pediatric spinal. pediatric spinal.

T or FT or F 4. BP and bradycardia are less likely with infants than with 4. BP and bradycardia are less likely with infants than with adults.adults.

QuestionsQuestionsT or T or FF 1. In the infant the spinal cord terminates at L2 as in the adult. 1. In the infant the spinal cord terminates at L2 as in the adult.

T or T or FF 2. Infants with a history of prematurity are excellent candidates 2. Infants with a history of prematurity are excellent candidates for pediatric spinals especially for surgery above the for pediatric spinals especially for surgery above the

umbilicus.umbilicus.

T or T or FF 3. As with most local anesthetic administration one should 3. As with most local anesthetic administration one should aspirate aspirate prior to injection for the infant spinal. prior to injection for the infant spinal.

T or T or FF 3. Should bloody CSF appear one should immediately abandon 3. Should bloody CSF appear one should immediately abandon the the pediatric spinal. pediatric spinal.

TT or F or F 4. BP and bradycardia are less likely with infants than with 4. BP and bradycardia are less likely with infants than with adults.adults.

QuestionsQuestionsT or FT or F 5. Single administration caudals provide excellent 5. Single administration caudals provide excellent

analgesia.analgesia.

T or FT or F 6. “Kiddie Caudals” reduce the risk of laryngospasm due to 6. “Kiddie Caudals” reduce the risk of laryngospasm due to surgical surgical stimulation. stimulation.

T or F T or F 7. The bevel of the hypodermic needle used for injection 7. The bevel of the hypodermic needle used for injection should be should be pointing upwards as with placement of a pointing upwards as with placement of a peripheral intravenous.peripheral intravenous.

T or F T or F 8. As with most local anesthetics one should aspirate the 8. As with most local anesthetics one should aspirate the epidurally epidurally placed catheter prior to injection. placed catheter prior to injection.

QuestionsQuestionsTT or F or F 5. Single administration caudals provide excellent 5. Single administration caudals provide excellent

analgesia.analgesia.

TT or F or F 6. “Kiddie Caudals” reduce the risk of laryngospasm due to 6. “Kiddie Caudals” reduce the risk of laryngospasm due to surgical surgical stimulation. stimulation.

T orT or F F 7. The bevel of the hypodermic needle used for injection 7. The bevel of the hypodermic needle used for injection should be should be pointing upwards as with placement of a pointing upwards as with placement of a peripheral intravenous.peripheral intravenous.

TT or F or F 8. As with most local anesthetics one should aspirate the 8. As with most local anesthetics one should aspirate the epidurally epidurally placed catheter prior to injection. placed catheter prior to injection.

QuestionsQuestionsT or FT or F 9. Post-op pain relief requires an institutional commitment.9. Post-op pain relief requires an institutional commitment.

T or FT or F 10. Any dressing will suffice for protection of the epidural catheter 10. Any dressing will suffice for protection of the epidural catheter insertion site from urine and fecal contamination. insertion site from urine and fecal contamination.

T or FT or F 11. Epidurally administered opiods require a minimum of 8 hours of 11. Epidurally administered opiods require a minimum of 8 hours of continuous pulse oximetry. continuous pulse oximetry.

T or FT or F 12. In general once the infusion rates are set for post-op epidurally 12. In general once the infusion rates are set for post-op epidurally administered analgesics no further adjustments are required. administered analgesics no further adjustments are required.

T or FT or F 13. Careful titration to side effects and adequacy of post-op 13. Careful titration to side effects and adequacy of post-op analgesia is required for optimum results using epidurally given analgesia is required for optimum results using epidurally given medication.medication.

QuestionsQuestionsTT or F or F 9. Post-op pain relief requires an institutional commitment.9. Post-op pain relief requires an institutional commitment.

T orT or F F 10. Any dressing will suffice for protection of the epidural catheter 10. Any dressing will suffice for protection of the epidural catheter insertion site from urine and fecal contamination. insertion site from urine and fecal contamination.

T T or For F 11. Epidurally administered opiods require a minimum of 8 hours of 11. Epidurally administered opiods require a minimum of 8 hours of continuous pulse oximetry. continuous pulse oximetry.

T or T or FF 12. In general once the infusion rates are set for post-op epidurally 12. In general once the infusion rates are set for post-op epidurally administered analgesics no further adjustments are required. administered analgesics no further adjustments are required.

TT or F or F 13. Careful titration to side effects and adequacy of post-op 13. Careful titration to side effects and adequacy of post-op analgesia is required for optimum results using epidurally given analgesia is required for optimum results using epidurally given medication.medication.

Pediatric Pain : Neuroaxial Blockade for Acute Pain Management Intrathecal Administration Epidural...

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