Clinical Forum - Pain Catheters in Children: I’ve got it in. NOW what do I do with it?
Moderator Rita Agarwal MD, University of Colorado
Panelists: Giovanni Cucchiaro MD, CHLA, Stephan Hays MD, Vanderbilt and Julie Niezgoda MD, Cleveland Clinic
Reviewed by Rita Agarwal MD, FAAP
This highly interactive forum used 3 cases as the basis for lively discussions on a variety of pain management techniques. The ASA introduced the use of Audience Response technology this year, truly allowing every one to participate.
The first case was that of an 8 year old with cerebral palsy and mental retardation undergoing bilateral tibial osteotomies. There were several options listed for post-operative pain management including peripheral nerve blocks/catheters and epidural catheter and intrathecal morphine. The difficulty with assessing a patient like this and the challenge with ensuring that compartment syndrome was not missed were reviewed.
Dr Cucchiaro had a nice series of articles and slides that confirmed that epidurals do not mask compartment syndrome. Much attention was focused on the fact that despite the evidence, many surgeons are still reluctant to allow the placement of epidural or other regional analgesic techniques for fear of missing or masking compartment syndrome. Several of the respondents reviewed their experience and success with intrathecal morphine. The question was expanded to explore options for treatment of one-sided surgery and whether it was realistic to expect such a patient to go home the same day.
The second case was that of 14 year old girl with osteosarcoma, undergoing thoracotomy for removal of pulmonary metastasis. The majority of attendees including all 3 of the panelists agreed that they would place a thoracic epidural for post operative pain management in this patient. The majority of the discussion concerned the “best” analgesic cocktail for thoracic epidurals. Studies regarding the use of clonidine and local anesthetics were presented by Dr Cucchiaro.
Drs. Hays and Niezgoda reviewed the approach at their institutions. The majority of participants seemed to agree that they would start with a dilute concentration of local anesthetic and opioid (hydromorphone appeared to be the most popular selection, followed closely by fentanyl and morphine). Other options that were presented included intrathecal morphine, paravertebral blocks and no regional technique.
The final case of this forum was that of a 10 year old boy with hepatic dysfunction, Crohn’s disease and the need for a bowel resection. The Pros and Cons of TAP blocks and wound soaker catheters were discussed. The literature and most participants experience with wound soaker catheters has been fairly mixed and there was not any consensus their overall utility-however since they have very few side effects, most participants were in favor of trying them in the absence of any other options.
Audience Response Questions for SPA Newsletter Review
Case #1:
An 8 yo boy with severe MRCP comes to the OR for bilateral tibial osteotomies. His surgeon would ideally like to send him home the same day, but would be happy if he can go home the next day. What would be your preferred pain plan?
- Epidural Catheter
- Bilateral popliteal single shot block
- Single shot epidural
- Bilateral Popliteal catheters
- Intrathecal morphine
- No regional technique
Assume that the case ended up being a Left sided distal tibial osteotomy. What would your strategy be now?
- Epidural catheter
- Popliteal (or sciatic) nerve block/catheter
- Femoral nerve block+ Popliteal (or sciatic nerve) block/catheter
- Popliteal (sciatic) + saphenous nerve block/catheter
- No regional
- Something else
If you place a peripheral nerve catheter(s) would you be comfortable sending the patient home with it infusing?
- Yes
- Yes in certain circumstances with good family support
- No
Case #2:
A 14 yo girl with osteosarcoma comes to the OR for bilateral thoracotomy and removal of pulmonary metastases. She is very afraid of postoperative pain. You plan to use a thoracic epidural catheter for post-operative analgesia. Which of the following solutions are you most likely to use?
- Local + opioid
- local anesthetic + opioid + clonidine
- opioid + clonidine
- I would not use an epidural technique
- I would not use any regional anesthetic technique
If you would not/could not do an epidural for this patient, which of the following techniques would you be most likely to do?
- Bilateral paravertebral blocks/catheters
- Bilateral intrapleural catheters
- Intrathecal morphine
- Bilateral intercostals blocks/catheters
- Other
Case #3:
A 10 yo boy presents for bowel resection for Crohn’s. He’s had multiple procedures, and this one cannot be done laparoscopically. Chronic TPN has contributed to liver dysfunction and chronic coagulopathy. What are some options that you would consider for managing this patient’s postoperative pain?
- Intrathecal morphine
- Bilateral TAP blocks/catheters
- Wound (soaker) catheters
- No regional techniques
- Other
