Pediatric Pain Management - Final Wrap Up

Question 1

What are the Advantages of using Regionals on Kids?

Answer 1

↓Gas & Opioid Use

↓Post-Op Apnea

↓Vascular Insufficiency

↓Clots

Supresses Neuroendocrine Response

↑GI Function

Question 2

What are Contraindications for Neuraxial Blocks on Kids?

Answer 2

Parent Refuse

Coagulopathy

Severe Infection

Neuro Problems

Hemodynamic Instability

On Chemo

Question 3

What are the concerns r/t Neuraxial Blocks on Kids?

Answer 3

Neurotoxicity

Infection

Masking of Compartment Syndrome

Kid Needs to be Anesthetized/Held for Placement

Question 4

Why must a test dose be used when placing a Neuraxial Block on kids?

Answer 4

Anesthetized kids CANNOT tell you symptoms of intravascular injection

Question 5

What precautions are needed when prepping a kid w/ Iodine or Chlorhexidine?

Answer 5

Iodine can be harmful to neonatal skin - must let dry & wash off when done

&

CHG good for indewlling catheters, but dont use if kid < 2 months old

Question 6

What meds can prolong Post-Op pain relief to a Spinal?

Answer 6

Epi Wash

Morphine: 5-10 mcg/kg

Clonidine: 1-2 mcg/kig

Question 7

Which procedures are Spinals indicated?

Answer 7

Hernia Repair

Genital Procedures

Ex-Lap

Muscle Biopsy

Lower Extremity Surgery

Question 8

Where is the Conus Medellaris & Dural Sac of an Infant vs. an Adult?

Answer 8

Infant:
Conus - L3
Dural Sac - S3

Adult:
Conus - L1
Dural Sac - S1

Question 9

How much CSF is Neonates?

Answer 9

> 10 mL/kg

Question 10

How much CSF is in Infants < 15kg?

Answer 10

4 mL/kg

Question 11

How much CSF is in children?

Answer 11

3 mL/kg

Question 12

How much CSF is in Adolescents & Adults?

Answer 12

1.5 - 2 mL/kg

Question 13

What position should the kid be in for placing a Neuraxial Block?

Answer 13

Sitting or Lateral w/ Neutral Neck to maintain airway

Question 14

Where should the LA be injected for kids?

Answer 14

L4-L5 Space @ the Iliac Crest using a 1.5 in. needle

Question 15

What is the Pediatric Spinal Dosing of Tetracaine or Bupivacaine?

Answer 15

0.5 - 1 mg/kg

Question 16

What are the complications w/ Pediatric Spinals?

Answer 16

Difficult to Place

10-25% Failure

Short Duration w/o Morphine

Total Spinal

Question 17

In regards to Spinals, PDPH is very _____ in kids younger than 8

Answer 17

In regards to Spinals, PDPH is very RARE in kids younger than 8

Question 18

What is the most common regional used in kids?

Answer 18

Caudal Blocks - good for lower thoracic to lower extremities

Question 19

What are the Contraindications for Caudals?

Answer 19

Pilonidal Cyst

Abnormal Superficial Landmarks

Neuro Problems

Parent Refuse

Question 20

What forms the Sacral Hiatus?

Answer 20

Lack of fusion of S4 & S5 Arches

Question 21

What is the Sacral Hiatus?

Answer 21

V-shaped Aperture covered by sacrococcygeal membrane

Question 22

What type of needles are used for Pediatric Caudals?

Answer 22

Blunt Caudal Needle

Tuohy

22g Angiocath

Question 23

What is the positioning for Caudal Placement?

Answer 23

Lateral in Fetal Position

or

Prone

Question 24

What is the goal of Single Shot Caudals?

Answer 24

To provide intraoperative & prolonged post-operative analgesia

Question 25

The caudal epidural space in children need a _____ volume to fill the packed space & spread to the appropriate dermatomes

Answer 25

The caudal epidural space in children need a **HIGH** volume to fill the packed space & spread to the appropriate dermatomes

Question 26

How much LA is needed for the Pediatric Sacral Level?

Answer 26

0.5 - 0.75 mL/kg

Question 27

How much LA is needed for the Pediatric Lumbar Level?

Answer 27

1 - 1.2 mL/kg

Question 28

How much LA is needed for the Pediatric Low Thoracic Level?

Answer 28

1.2 - 1.5 mL/kg

Question 29

What is the Max Volume & Dose of LA for kids?

Answer 29

Max Volume: 25 mL Max Dose: 3 mg/kg

Question 30

What is the treatment for LA Toxicity in Kids?

Answer 30

20% Intralipid Bolus 1.5 mL/kg x 3 if needed Then Infuse @ 0.25 mL/kg/min x 30-60 min

Question 31

True or False: When placing a Caudal, the absence of blood is a reliable indicator of not being in a blood vessel.

Answer 31

FALSE

Question 32

What is the Caudal Test dose of Epinephrine w/ Sevoflurane?

Answer 32

0.1 mL/kg of LA + 5 mcg/mL of Epi Max: 3 mL

Question 33

When using a Test dose for Caudals, what indicates changes indicate Intravascular Injection?

Answer 33

↑HR by 10 bpm ↑BP by 15 mmHg ↑T-Wave by 25% Bradycardia

Question 34

Why are kids more at risk for LA Toxicity?

Answer 34

They have ↑CO & ↑Systemic Uptake

Question 35

What are signs of LA Neurotoxicity?

Answer 35

HA Somnolence Vertigo Paresthesias Tremors/Twitching Shivering Convulsions

Question 36

What are signs of LA CV Toxicity?

Answer 36

Dysrhythmias Wide QRS Torsades V-Tach CV Collapse

Question 37

What should be avoided to prevent LA Toxicity?

Answer 37

Hypothermia Hypercarbia Acidosis Hyperkalemia Fast Injection

Question 38

How should the Max Infusion Rate of LA be adjusted for Neonates & Infants younger than 3-5 months?

Answer 38

Reduce by 50% of recommended dose for Older Infants & Children

Question 39

Besides Opioids, what meds can be used for Pediatric Pain Control?

Answer 39

Oral/Rectal Tylenol & Toradol

Question 40

What is the concern when giving Codeine to kids w/ abnormal levels of CYP2D6?

Answer 40

Too Little CYP2D6 = No Analgesia Too Much CYP2D6 = Respiratory Depression & Death

Question 41

What is the result of using a PCA for kids 7 and older for Post-Op Pain, Vaso-Occlusive Crises, & Cancer Pain?

Answer 41

Safe & Effective

Question 42

What can Topical Eutectic Mixture of Lidocaine + Prilocaine be used for?

Answer 42

Reduces pain for Venepunctures More = More Pain Relief

Question 43

What is a S-Caine (Synera) Patch?

Answer 43

Lidocaine + Tetracaine + Oyxgen-Activated Heat used for Venous Cannulation pain

Question 44

What is the main indication for an Ilio-Inguinal Iliohypograstric Block?

Answer 44

Hernia Repairs