Pediatric Neuraxial Anesthesia and Postoperative Pain Management


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Pediatric Neuraxial Anesthesia and Postoperative Pain Management

  1. 1. November 2010
  2. 2. Benefits  What are the benefits of neuraxial anesthesia/analgesia?
  3. 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. 4. Pediatric vs. Adult Spine  What are the anatomic and physiologic differences between the pediatric and the adult spine?
  5. 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. 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. 7. Epidural Solutions  What dose of LA is used for intraoperative analgesia? Postoperative?  What is the maximal bolus dose of Bupivacaine? Infusion dose?
  8. 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. 9. Epidural Solutions: Adjuvants  Which adjuvants may be used? Epinephrine Opioids Clonidine Ketamine Neostigmine
  10. 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. 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. 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. 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. 14. Confirmation of Epidural Catheter Position  Radiography with contrast - indwelling catheters for cancer pain  Electrical Stimulation  ECG  Chloroprocaine Test - Postop
  15. 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. 16. PCEA  Usually appropriate for > 7yo  Basal 0.15 ml/kg/hr  Bolus 0.07 ml/kg  Lockout 20-30 min
  17. 17. Pediatric Postoperative Pain Management  What tools are available for assessing pediatric pain?  What medications are available? Doses?
  18. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.  accessed 11/22/10