3. Benefits
enhanced hemodynamic stability
decreased anesthetic requirement
earlier ambulation
rapid weaning from ventilator
reduced time spent in a catabolic state
lowered circulating stress hormone
levels
superior pain relief vs. IV opioids
4. Pediatric vs. Adult Spine
What are the anatomic and physiologic
differences between the pediatric and
the adult spine?
6. Pediatric vs. Adult
Higher volume of CSF + lower epidural fat
content = increased spread of LA
Incomplete myelinization (increased
endoneurial permeabiliy) = decreased
Duration and Latency of LA
Decreased plasma proteins (and
decreased liver metabolism) = increased
unbound LA fraction (CNS/CV toxicity)
Peds epidural space depth: 1mm/kg (high
variability), 1+0.15(yrs), 0.8+0.05(kg)
7. Epidural Solutions
What dose of LA is used for
intraoperative analgesia?
Postoperative?
What is the maximal bolus dose of
Bupivacaine? Infusion dose?
8. Epidural Solutions
body weight is a better correlate than patient
age in predicting spread of local anesthetic
following a caudal block: 0.5 - 1 ml/kg - T10; 1
-1.25 ml/kg - T4
caudal: optimum concentration of bupivacaine
is 0.125-0.175% (still 4-8h, less motor block)
maximal safe dose of bupivacaine is 2.5
mg/kg
continuous epidural infusion: bupivacaine 0.2
mg/kg/h for neonates (or 2-chloroprocaine)
and 0.4 mg/kg/h for older children
10. Adjuvants
Epinephrine: 1:200k
Opioids: fentanyl 1-2mcg/kg bolus (or
infuse 2mcg/ml),
hydromorphone/sufenta/morphine.
Clonidine: 2mcg/kg bolus. Infuse
0.1mcg/kg/hr. Sedation, hypotension,
blocks ventilatory resonse to CO2
Ketamine: works well alone, with clonidine,
or LA - however, must be PF S-Ketamine
Neostigmine: bolus 2mcg/kg with LA. 25%
N/V.
11. Complications
Direct Neurologic Injury: extremely rare. Thoracic
placement: experienced practitioner (esp.
paramedian), avoid in <2yo, reserve for major
procedures, trauma in awake and asleep
Hematoma: extremely rare. Follow ASRA
guidelines.
Infection: use chlorxehidine prep and dressing
PDPH: Rx same as adult. EPB 0.3ml/kg.
Hypotension: rare. Consider total spinal.
LA toxicity: use dilute solutions
12. Side-effects
N/V
Pruritis
Sedation
Hypoventilation - hallmark of impending
OD is increased sedation and
DECREASED DEPTH and RATE (not just
rate, as TV often first to decrease)
Ileus
Urinary Retention
Naloxone 0.5-1mcg/kg boluses.
13. Postoperative Epidural Analgesia
Chloroprocaine test/lidocaine bolus can provide
catheter tip position and rapid analgesia
always use a mix of LA/opioid, unless
contraindicated
if there is inadequate analgesia when the local
anesthetic infusion is titrated upwards to more
than 12 ml/hour (adolescents), consider increasing
LA concentration
lumbar catheter/one sided block and the surgery is
thoracic or upper abdominal - add a hydrophilic
opioid (hydromorphone or morphine)
Fluid under catheter dressing is likely edema or
infused solution tracking from epidural space to
skin. Clean site and reinforce dressing.
14. Confirmation of Epidural Catheter
Position
Radiography with contrast - indwelling
catheters for cancer pain
Electrical Stimulation
ECG
Chloroprocaine Test - Postop
15. Chloroprocaine Test
Bolus 5 doses q 1-2 min.
Stop if LE motor block, decrease in HR> 30bpm, BP>25 mmHg, clear
decrease in pain
If positive test, switch from bupiv/fent to bupiv/hydromorphone (load 2
mcg/kg) - this will provide good pain relief >90% of these cases
Wt (kg) Increment Vol
(1/5 total)
Total Vol
0-10 0.125 mL/kg 0.6 mL/kg
10-20 0.1 mL/kg 0.5 mL/kg
20-35 2.5 mL fixed volume 12.5 mL
35-60 3 mL fixed volume 15 mL
>60 3.5 mL fixed volume 17.5 mL
19. Pediatric Pain Assessment Scales:
Self Report (>3 yo)
Wong-Baker Faces
Bieri-Modified
Visual Analogue Scale (VAS)
QuickTime™ and a
decompressor
are needed to see this picture.
QuickTime™ and a
decompressor
are needed to see this picture.
QuickTime™ and a
decompressor
are needed to see this picture.
QuickTime™ and a
decompressor
are needed to see this picture.
22. Mount Sinai Pediatric Pain Algorithm
Upward titration ?
Adjuvant Meds ?
Give before activities?
Adjust time interval ?
Pain Team
Consult
Anesthesia
Pediatric
0 1-3 4-6 7-10
Pain Free Me Algorithm
Patient Complains of Pain ..or.. Parent is Concerned
Pain Score > 0
Mild 1-3 Moderate 4-6 Severe 7-10
Acetaminophen
po / pr Ketorolac iv * Morphine ( 0.1 mg/kg)
Ibuprofen po* Codeine PO Morphine PCA
Basal &/or hi dose
Oxycodone/
acetaminophen
Hydromorphone iv
or PCA
Hydromorphone po Fentanyl PCA
Morphine iv (0.05 mg/kg) Methadone
PCA : Morphine,
Hydromorphone, Fentanyl Epidural analgesia
*Assess for bleeding risks
Consider Non-Pharmacologic Intervention
ReAssess / Consider Time to Onset of Medication Used
23. Patient Satisfaction
QuickTime™ and a
decompressor
are needed to see this picture.• increased compliance, better treatment response,
fewer malpractice suits, increased staff satisfaction,
fiscal improvement.
• 5 MAJOR FACTORS: timeliness of care, empathy,
technical competence, information dispensation, pain
management (especially in children)
26. Case 3:
6 week, ASA 3, presents for thoracoabdominal incision
for excision of Wilms tumor, 3kg.
Considerations: painful, impairment of respiration, multiple
dermatomes, pain assessment tools (FLACC)
Options:
Epidural analgesia: bolus,
infusion
Nurse controlled
analgesia
Options:
1. 16 dermatomes to cover:
bolus: 16(0.05 ml/kg/drm)(3 kg) = 2.4mL
infusion: Chloroprocaine 1.5% w/fent 0.4mcg/mL or
clonidine 0.2mcg/mL at 0.3-1.2ml/kg/hr
Acetaminophen 35-40mg/kg initial, then 20mg/kg q6h
rectal (total <100mg/kg/24h)
2. Loading: 0.075-0.1 mg/kg = 0.3 mg
Infusion: 0.02 mg/kg/hr = 0.06 mg/hr +/-
acetaminophen prn
Don’t forget: apnea
monitoring, continuous
pulse oximetry, frequent
observation!!!
27. Case 4:
8 yo, ASA 3, cerebral palsy, severe cognitive
impairment presents for femoral osteotomy, 18kg.
Considerations: painful, may need benzodiazepines for muscle
spasm, pain assessment tools (FLACC)
Options:
Epidural analgesia: bolus,
infusion
Femoral nerve, fascia
iliaca, lumbar plexus
block
Continuous IV opioid
Nurse-controlled opioids
analgesia
Options:
1. 10 dermatomes to cover:
bolus: 10(0.05 mL/kg/drm)(18 kg) = 9mL
infusion: bupiv 0.1% w/fent 2mcg/mL at 0.2
mL/kg/hr)= 3.6mL/hr (may titrate to
0.4mL/kg/hr)
2. Bupiv 0.125-0.25% initial dose 0.3ml/kg = 5.4mL
Infusion: 0.2mL/kg/hr = 3.6mL
3. As in previous cases. Consider adding diazepam
0.05mg/kg for muscle spasm
28. Summary
Epidural Depth: 1mm/kg (high variability),
1+0.15(yrs), 0.8+0.05(kg)
Caudal Epidural: Bolus Bupivacaine 0.125% -
1mL/kg
Lumbar Epidural: 0.05(kg)(#dermatomes)
Infuse 0.2-0.4mL/kg/hr bupivacaine 0.1% with
2mcg/mL fentanyl (0.2-0.4mg/kg/hr Bupivacaine
limit)
Use Acetaminophen and NSAIDS unless
contraindicated
Use Pediatric Pain Assessment Tools
Empathy and Patient/Parent Education are as
critical to Patient Satisfaction as pain control
29. References
Malviya S, Polaner DM, Berde C. Acute Pain (ed.
Cote CJ, Lerman J, Todres ID) in A Practice of
Anesthesia for Infants and Children. Saunders
Elsevier. Philadelphia. 2009. P. 939-976.
http://www.nysora.com/regional_anesthesia/sub-specialties/p
accessed 11/22/10