OPIOID ADMINISTRATION AS PREDICTOR OF PEDIATRIC EPIDURAL FAILURE.

BACKGROUND: Increasing use of regional analgesia in pediatric populations requires a better understanding of when analgesic techniques need revising or supplementation. This study was conducted to examine intra-operative opioid use as a predictor of post-operative epidural failure. METHODS: Retrospective chart review of patients having epidurals placed intra-operatively. 229 epidurals were placed during the study, with 75 excluded. Dosing and quantity of opioids used intra-operatively were compared to the primary outcome of epidural failure, as well as duration of infusions and pain scores. RESULTS: Opioid use was associated with increased epidural failure, particularly in less than 12 hours. However, no distinct point of certain epidural failure was found. CONCLUSIONS: Opioid use after epidural loading correlates with increasing risk for epidural failure. Anesthesia providers should consider replacing or supplementing epidurals with increasing use of opioids.

Safety, tolerability, and short-term efficacy of intravenous lidocaine infusions for the treatment of chronic pain in adolescents and young adults: a preliminary report.

OBJECTIVE: To provide pediatric care providers with insight into lidocaine infusions for analgesia. AIM: This retrospective review was conducted to describe lidocaine infusions for chronic refractory pain within the adolescent and young adult pain population. SETTING: Although lidocaine infusions have been used for pain management in adults, their analgesic utility in the adolescent and young adult population is limited and so is the evidence for their efficacy and safety. METHODS: After Institutional Board Review approval, a retrospective review of efficacy and safety data for analgesic use of lidocaine was conducted. RESULTS: Fifteen patients received 58 infusions with 76% receiving relief where maximum relief was seen among patients with starting pain scores ≥6/10 (mean reduction 2.3 vs. 0.5, P value = 0.006) and when a patient had three or more infusions (mean reduction 1.7 compared with 1.2). No serious side effects were encountered, but only mild or moderate side effects that did not require any intervention. Incidence of tingling or numbness and nausea or vomiting seemed to correlate with total dose of lidocaine per kilogram body weight. Patients reported reduced pain scores (6.3 ± 2.3 to 4.6 ± 2.5 before compared with after the infusion [as mean ± standard deviation]) during 80% of infusions. CONCLUSIONS: Our limited experience suggests that lidocaine infusions are well tolerated in the adolescent and young adult pain population, with side effects resolving quickly with interruption or discontinuation of the infusion if necessary. Future studies are warranted to examine safety, efficacy, mechanism of actions, and its long-term impact on a developing central nervous system.

Analysis of Soft Tissue Materials for Simulation Development.

INTRODUCTION: To meet unique demands and stretch budgets, simulations will often be made rather than purchased. Although 3-dimensional printing can be useful, there are significant physical limitations of these materials. This project is intended to begin examining the physical properties of materials used in casting/molding that may be useful for simulant soft tissue creation. METHODS: A variety of materials (foams and rubbers, urethanes and silicones, ballistic and food grade gels) were cast in standardized forms for analysis and visualized via computed tomography scanner and ultrasound (US). Each sample was also tested using 18ga and 22ga needles to determine force required for penetration. RESULTS: Silicone rubbers were generally well visualized via US, with computed tomography imaging showing between 100 and 200 Hounsfield units. Ballistic and food grade gels measured in the areas of -175 and 8 Hounsfield units, respectively, while being clear under US. Foams, particularly the urethane, demonstrated low Hounsfield units and were essentially opaque to US because of air cell artifact. Needle force requirements ranged from 0.05 to 23.34 N. Gels and foams were in the lower range, but there was overlap with the silicone. The use of additives in the silicones allowed for a wide range of needle forces and tactile experiences. CONCLUSIONS: Silicone and urethane materials can mimic soft tissues, for both imaging and interventions. Although there is significant potential for independent production of custom, high-fidelity simulants, further work is required to identify preferable combinations of materials and optimal techniques for their use.

Evaluation of Three-Dimensional Printed Materials for Simulation by Computed Tomography and Ultrasound Imaging.

INTRODUCTION: The use of three-dimensional (3D) printing allows for creation of custom models for clinical care, education, and simulation. Medical imaging, given the significant role it plays in both clinical diagnostics and procedures, remains an important area for such education and simulation. Unfortunately, the materials appropriate for use in simulation involving radiographic or ultrasound imaging remains poorly understood. Therefore, our study was intended to explore the characteristics of readily available 3D printing materials when visualized by computed tomography (CT) and ultrasound. METHODS: Seven 3D printing materials were examined in standard shapes (cube, cylinder, triangular prism) with a selection of printing methods ("open," "whole," and "solid" forms). For CT imaging, these objects were suspended in a gelatin matrix molded to match a standard human CT phantom. For ultrasound imaging, the objects were placed in acrylic forms filled with a gelatin matrix. All images were examined using OsiriX software. RESULTS: Computed tomography imaging revealed marked variation in materials' Hounsfield units as well as patterning and artifact. The Hounsfield unit variations revealed a number of materials suitable for simulation various human tissues. Ultrasound imaging showed echogenicity in all materials, with some variability in shadowing and posterior wall visualization. CONCLUSIONS: We were able to demonstrate the potential utility for 3D printing in the creation of CT and ultrasound simulation models. The similar appearance of materials via ultrasound supports their broad utility for select tissue types, whereas the more variable appearance via CT suggests greater potential for simulating differing tissues but requiring multiple printer technologies to do so.

Intraoperative Presentation of Malignant Hyperthermia (Confirmed by RYR1 Gene Mutation, c.7522C>T; p.R2508C) Leads to Diagnosis of King-Denborough Syndrome in a Child With Hypotonia and Dysmorphic Features: A Case Report.

We present the novel case report of a child with hypotonia and dysmorphic features who developed malignant hyperthermia (MH) intraoperatively. Neurology workup revealed the presence of a known causative ryanodine receptor (RYR1) mutation for MH, c.7522C>T; p.R2508C. Furthermore, the neurology workup diagnosed the child with King-Denborough syndrome (KDS). This particular mutation has never been documented in a patient with KDS. Atypical presentation of MH is more likely in patients with RYR1-related myopathy. A high index of suspicion for MH in children with myopathy is important. The MH hotline was helpful in the management of this patient when it was called after the initial dose of dantrolene. A neurology consult was essential for the diagnosis of KDS and future care.

Epidural Steroid Injections for Radiculopathy and/or Back Pain in Children and Adolescents: A Retrospective Cohort Study With a Prospective Follow-Up.

BACKGROUND AND OBJECTIVES: Epidural steroid injections (ESIs) are commonly performed for adults with spinal pain and/or radiculopathy. Previous pediatric ESI case series were not identified by literature review. The primary aim of this study was to examine the safety and provisional outcomes of pediatric ESIs. METHODS: With institutional review board approval, medical records were reviewed for patients aged 9 to 20 years receiving a first ESI at Boston Children's Hospital from 2003 through 2013. A subset of patients completed a Web-based follow-up questionnaire. Descriptive statistics included frequencies, medians, interquartile ranges, and Kaplan-Meier methods. Statistical comparisons were made using Wilcoxon rank sum, χ2, Fisher exact, and Cox proportional hazards regression analyses. RESULTS: A total of 224 patients aged 9 to 20 years underwent 428 ESIs. One hundred seventy-four (76.0%) patients had a lumbar disc herniation with radiculopathy; the others had a spectrum of other spinal disorders. There were no serious adverse events, hospitalizations, dural punctures, or nerve injuries. During follow-up, 69 (41.6%) of 166 previously nonoperated lumbar disc plus radiculopathy patients underwent discectomy at a median time of 128 days (interquartile range, 76-235 days) after first injection. Degrees of straight-leg raising at presentation was significantly associated with subsequent discectomy. On follow-up, patients who did and did not undergo discectomy had low pain scores and high function scores. CONCLUSIONS: Children and adolescents can receive ESIs under conscious sedation with good safety. Further prospective studies may better define the role for these injections in the comprehensive management of pediatric spinal pain disorders.