1. November 2010

2. Benefits
 What are the benefits of neuraxial
anesthesia/analgesia?

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?

5. Pediatric vs. Adult
Peds Adult
Conus Medullaris L3 T12-L2 (L1)
Dural Sac S3-5 S1
CSF volume 4ml/kg 2ml/kg
SC myelinization incomplete Complete
(by 12 yo)
Epidural Fat Low/loose high
Albumin/Alpha1-acid
Glycoprotein
Low normal

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

9. Epidural Solutions:
Adjuvants
 Which adjuvants may be used?
Epinephrine
Opioids
Clonidine
Ketamine
Neostigmine

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

16. PCEA
 Usually appropriate for > 7yo
 Basal 0.15 ml/kg/hr
 Bolus 0.07 ml/kg
 Lockout 20-30 min

17. Pediatric Postoperative Pain
Management
 What tools are available for assessing
pediatric pain?
 What medications are available?
Doses?

18. Pediatric Pain Assessment Scales:
Behavioral Observation
 CRIES: cry, O2 Requirement, increased VS,
facial expression, sleep
 NIPS (<1yo): facial exp., breathing pattern,
arms, legs, state of arousal
 FLACC: Face, Legs, Activity, Crying,
Consolability
 CHEOPS (1-7yo): cry, facial expression,
verbalization, torso movement, touching
affected site, leg position.
Overall: if crying, grimacing, agitated = in pain

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.

20. Pediatric Opioid Bolus Dosing
DRUG Child<50kg Child>50kg Child<50kg Child>50kg
Morphine Bolus 0.1
mg/kg
Bolus 5-8 mg 0.3 mg/kg 15-20 mg/kg
Methadone 0.1 mg/kg 5-8 mg* 0.1-0.2 mg/kg 5-10 mg/kg
Fentanyl 0.5-1
mcg/kg
25-50 mcg N/A N/A
Hydromorphone 0.01-0.02
mg/kg
0.5-1 mg 0.04-0.08
mg/kg
2-4 mg
IV PO

21. Pediatric Acetaminophen/NSAID
Dosing
Dose<60kg Dose>60kg
Acetaminophen
(Tylenol)
10-15 mg/kg q4h 650-1000mg q4h
Naproxen
(Aleve)
5 mg/kg q12h 250-500mg q12h
Ibuprofen
(Motrin)
6-10 mg/kg q6-8h 400-600 mg q6h
Celecoxib
(Celebrex)
2-4 mg/kg q12h 100-200mg q12h
Ketorolac
(Toradol)
0.5 mg/kg q6-8h 30 mg q6h

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)

24. Case 1:
2 yo, ASA 1, presents for inguinal hernia repair, 15kg.
Considerations: mildly painful, outpatient
Options:
Ilioinguinal nerve block
Wound infiltration
Caudal
Acetaminophen or ibuprofen
Options:
bupiv 0.25% w/epi 1:200k.
0.5ml/kg(15kg) = 7.5mL
Wound infiltration - same
Caudal - 0.125% bupiv w/epi, 0.5-
0.75ml/kg(15kg) = 7-11ml
Acetaminophen (10-15mg /kg po q4-6h
prn) ibuprofen (6-10mg/kg q6h
prn)

25. Case 2:
6 month, ASA1, presents for ureteral reimplantation,
6kg.
Considerations: moderately painful, bladder spasms, pain assessment
tools
Options:
Epidural analgesia: bolus,
infusion
IV morphine infusion
Nurse controlled
analgesia
Options:
1. 10 dermatomes to cover:
bolus: 10(0.05 ml/kg/drm)(6 kg) = 3mL
infusion: bupiv 0.1% w/fent 2mcg/mL at 0.2
mL/kg/hr)=1.2mL/hr
Acetaminophen 35-40mg/kg initial, then 20mg/kg q6h
rectal (total <100mg/kg/24h)
2. Loading: 0.075-0.1 mg/kg = 0.6 mg
Infusion: 0.02 mg/kg/hr = 0.12 mg/hr +/-
acetaminophen prn
3. Loading/infusion as above. 8-15min lockout.
0.25mg/kg/4hour limit +/- acetaminophen prn
Don’t forget: apnea
monitoring, continuous
pulse oximetry, frequent
observation!!!

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