Pediatric Pain : Neuroaxial Blockade for Acute Pain Management

2. Pediatric Pain :Neuroaxial Blockade for Acute Pain Management Intrathecal Administration Epidural Administration single continuous post-op management

3. “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

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

5. CASE A three month of age boy is to have a right inguinal hernia repaired. Upon review he has had respiratory distress syndrome. Wght: 3 kg Hct: 30%

6. Preoperative Evaluation Emergency? No Why is the Surgery being performed? PREOPERATIVE EVALUATION: Problems 1. RDS 2. Hyaline Membrane Ds 2. Prematurity 3. Airway 5. Full Stomach Laboratory Tests CBC Electrolytes Coags CXR (ABG, FEV1/FVC, F-V loop) History & Physical litany of basic knowledge ANY ISSUES TO BE ADDRESSED PRIOR TO ENTERING THE O.R.

7. Choice of Anesthesia General Anesthesia Regional Anesthesia Peripheral Nerve Block IV Regional MAC Local

8. Techniques for General Anesthesia 4 Concerns to Guide the Plan: Airway/ Full Stomach/ Volume Status/ Medical Problems Is Regional an Option? Rapid Sequence Modified Rapid Sequence Concerns 1. Airway 2. Full Stomach 3. Volume Status 4. Medical Problems How 1. IV-IM 2. Inhalational 3. Awake Fiber Optic 4. Local Trach Medications 1. Administration sequence 2. Including NMB Agent 3. Analgesic Component

9. Intrathecal Administration I keep six honest serving men (They taught me all I knew); Their names are What and Why and When And How and Who. Rudyard Kipling 1865-1936 --The Just-So Stories (1902). The Elephant’s Child What Why When How Who Where Efficient: What Needed Physiology, Safety & Efficacy Patient Centered, Timely, Equitable Treatment Background Demographics Introduction Anatomy

10. What? Anatomy : Intrathecal Space

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

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

13. How? Technique: 1. Suggest premedication with atropine only 2. ASA monitors placed while infant remains fully awake in the OR 3. While receiving supplemental 02 with chin extended, the infant is placed into position 4. Prepare the lumber area with iodine solution 5. Identify the lowest palpable interspace below L3 6. 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 hyperbaric solution. By adding 0.02 cc of epi 1:1000 the effect may increase upwards to 100 minutes 8. Have available a variety of 22 or 25 gauge pediatric Quincke or Whitacre type spinal needles 9. After obtaining free flow of CSF from all planes of needle rotation, do not aspirate 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 the CSF, thus avoiding an incomplete or failed block. 12. Place the infant supine, while observing for the onset of lower extremity flaccidity, usually within 2 minutes. 13. Maintain strict supine positioning until the block establishing the block, without leg elevation. Such prevents potential migration of the block and a total spinal

14. Infant Spinal Anesthesia 1……………………….add Tb syringe 2…………………...add spinal needle 3……………………...add medication

15. Infant Spinal Anesthesia 4...use local

16. Infant Spinal Anesthesia 5………...…………..attach syringe firmly 6………………………………...do not aspirate 7….it is ok to inject into bloody CSF

17. Infant Spinal Anesthesia 8…...load syringe sterile and have surgeon inject it 9…….if spinal begins to wear off, repeat the dose

18. Infant Spinal Anesthesia 10…...start IV in anesthetized ankle

19. Infant Spinal Anesthesia 11…..note the placement of the drapes

20. Infant Spinal Anesthesia close up

21. Infant Spinal Anesthesia close up

22. Who? High risk infants who had been born prematurely or were treated for neonatal respiratory distress Infants with congenital anomalies such as laryngomalacia, macroglossia, or microagnathia Most commonly the surgical indication is bilateral inguinal hernia repair, but other surgery below the umbilicus is also considered: colostomy for imperforated anus recctal biopsy closed reduction of hip dislocation circumcision correction of club foot etc.

23. High Risk Infants Who Had Been Born Prematurely

24. Consider Surgery Below the Umbilicus

25. Where? Lowest palpable interspace below L3

26. Anatomy

27. Pitfalls Dose: 1 mg for those infants < 1 year of age then 0.25 mg/kg mean duration of 84 minutes with epi mean increased to 109 minutes Alternates: 0.5% bupivicaine or 2.5% lidocaine

28. Results group infants proceedures attempt attempt unsuccessful spinals requiring supplementation # # 1st 2nd # # high risk 36 36 31 5 0 6 anomaly 8 11 10 1 0 3 term 34 34 22 4 8 5 totals 78 81 63 10 8 14

29. Safety Most Difficulty Lies in Positioning an Awake Wiggling Infant The CSF Flow Must Remain Continuos As the Needle Rotates Bloody Taps Occur More Often If Not Midline in Approach With a Bloody Tap More Difficulty Arises in Locating the CSF BP and Bradycardia Less Likely With Infants Than With Adults

30. The CSF Flow Must Remain Continuous as the Needle Rotates

31. References Abajian JC, Mellish PWP, Browne AD, Perkins FM, Lambert DW, Mazuzan JE. Spinal Anesthesia for Surgery in Children and Infant. Anesth Anal 1984; 63:359-62. Gregory, GA and Steward, DJ. Life Threatening Perioperative Apnea in the Ex-preemie. Anesthesiology 59:495-498, 1983. Steward, DJ. Preterm Infants are More Prone to Complications Following Minor Surgery than are Term Infants. Anesthesiology 56:304-306, 1982.

32. PEDIATRIC PAINEpidural Administration Kiddy Caudals

33. Epidural Administration I keep six honest serving men (They taught me all I knew); Their names are What and Why and When And How and Who. Rudyard Kipling 1865-1936 --The Just-So Stories (1902). The Elephant’s Child What Why When How Who Where Efficient: What Needed Physiology, Safety & Efficacy Patient Centered, Timely, Equitable Treatment Background Demographics Introduction Anatomy

34. Single Administration

35. What? With very little equipment which includes a skin prep, needle of choice, and desired local anesthetic: 1………………...………...alcohol pad 2…….povidone idoine solution 3……….formal prep and drape 4……………..appropriate needle 5…..desired local anesthetic single shot caudals provide excellent analgesia 1 3 4 5 2

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

37. When? after induction of general anesthesia but before the onset of surgical incision. -the time required for placement translates into time regained post operatively secondary to earlier anesthetic emergence -patients commonly remain pain free for several hours post. -greatly reduces the risk of laryngospasm due to surgical stimulation especially during perineal procedures obviating the need for intubation and the possibility of post-operative croup

38. How? 1. Properly position the patient 2. After the skin preparation, use the hypodermic needle of choice at a 60 degree angle to the skin until the sacrococygeal membrane is peirced. 3. Note a distintive ‘pop’ upon entering the sacral canal 4. Then further advance the hypodermic another 2mm parallel the plane of the spinal axis. 5. Gently aspirate to confirm neither an intravascular nor an intrathecal injection of local anesthetic. 6. Introduce the agent into the caudal epidural space

39. How to Position?

40. How to Proceed? 1. After the skin preparation, use the hypodermic needle of choice at a 60 degree angle to the skin with the bevel down until the sacrococygeal membrane is peirced. 2. Note a distintive ‘pop’ upon entering the sacral canal 3. Then further advance the hypodermic another 2mm parallel the plane of the spinal axis.

41. Caudal Epidural 1……….. enter membrane at 30 to 40 degrees 2…………………………..flatten toward the rectum 3…………………….advance about 1/4 to 1/2 inch 4……slip catheter off the needle into space

42. Caudal Epidural 5…………………….do not inject air 6…………………..aspirate catheter

43. Caudal Epidural 18 gauge cathalon arrow caudal/epidural kit

44. Caudal Epidural suitable dressing tape up the side to allow for bovie pad

45. Who? children having surgical procedures below the umbilicus: circumcisions orchidopexy inguinal hernia repair hydrocelectomy rectal dilation lower extremity orthopedic procedures

46. Where Through the caudal space

47. Pediatric Acute Pain Management Post-Operatively: Continuous Epidural Infusions

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