Perioperative Management and In-Hospital Outcomes After Minimally Invasive Repair of Pectus Excavatum: A Multicenter Registry Report From the Society for Pediatric Anesthesia Improvement Network.

BACKGROUND: There are few comparative data on the analgesic options used to manage patients undergoing minimally invasive repair of pectus excavatum (MIRPE). The Society for Pediatric Anesthesia Improvement Network was established to investigate outcomes for procedures where there is significant management variability. For our first study, we established a multicenter observational database to characterize the analgesic strategies used to manage pediatric patients undergoing MIRPE. Outcome data from the participating centers were used to assess the association between analgesic strategy and pain outcomes. METHODS: Fourteen institutions enrolled patients from June 2014 through August 2015. Network members agreed to an observational methodology where each institution managed patients based on their institutional standards and protocols. There was no requirement to standardize care. Patients were categorized based on analgesic strategy: epidural catheter (EC), paravertebral catheter (PVC), wound catheter (WC), no regional (NR) analgesia, and intrathecal morphine techniques. Primary outcomes, pain score and opioid consumption by postoperative day (POD), for each technique were compared while adjusting for confounders using multivariable modeling that included 5 covariates: age, sex, number of bars, Haller index, and use of preoperative pain medication. Pain scores were analyzed using repeated-measures analysis of variance with Bonferroni correction. Opioid consumption was analyzed using a multivariable quantile regression. RESULTS: Data were collected on 348 patients and categorized based on primary analgesic strategy: EC (122), PVC (57), WC (41), NR (120), and intrathecal morphine (8). Compared to EC, daily median pain scores were higher in patients managed with PVC (POD 0), WC (POD 0, 1, 2, 3), and NR (POD 0, 1, 2), respectively (P < .001-.024 depending on group). Daily opioid requirements were higher in patients managed with PVC (POD 0, 1), WC (POD 0, 1, 2), and NR (POD 0, 1, 2) when compared to patients managed with EC (P < .001). CONCLUSIONS: Our data indicate variation in pain management strategies for patients undergoing MIRPE within our network. The results indicate that most patients have mild-to-moderate pain postoperatively regardless of analgesic management. Patients managed with EC had lower pain scores and opioid consumption in the early recovery period compared to other treatment strategies.

Perioperative Surgical Home: Evaluation of a New Protocol Focused on a Multidisciplinary Approach to Manage Children Undergoing Posterior Spinal Fusion Operation.

BACKGROUND: The concept of Perioperative Surgical Home has been gaining significant attention in surgical centers. This model is delivering and improving coordinated care in a cost-effective manner to patients undergoing surgical procedures. It starts with the decision for surgical intervention, continues to the intraoperative and postoperative periods, and follows into long-term recovery. Constant re-evaluation of outcomes and modifications of delivery provides a feedback loop for improvement. Children's Hospital Los Angeles initiated a new protocol in June 2014 to manage children undergoing Posterior Spinal Fusion (PSF) with the goal to improve patient experience and lower the hospital length of stay and cost. METHODS: A retrospective chart review identified patients who underwent a PSF for idiopathic scoliosis before and after initiation of a new treatment protocol designed by a team of anesthesiologists, surgeons, nurses, and physical therapists. The new protocol included preoperative teaching of parents and patients, intraoperative anesthetic and surgical management, and immediate to long-term postoperative medical management. In addition to demographics, we examined length of stay, cost of hospitalization, pain scores on discharge, length of patient-controlled analgesia use, time to first solid food intake, and time to ambulation. RESULTS: Thirty-six patients were identified preinitiation and postinitiation of the protocol (total n = 72). There was no statistically significant difference in age, sex, use of intrathecal morphine, or estimated blood loss. Patients enrolled in the new protocol had higher American Society of Anesthesiologists classification (P = .003), significantly lower duration of patient-controlled analgesia use, time to first solid food intake, and time to ambulation (P= .001). The pain scores were higher at the time of discharge, although the difference was not statistically significant. Length of stay was significantly shorter in the new protocol group (P = .001), accounting for $292,560 in cost savings for the hospital. CONCLUSIONS: These data show that the cooperation of different teams in designing new management guidelines for patients requiring a PSF can significantly decrease the total length of stay and cost of hospitalization without altering quality of care.

Sacroiliac joint pain in adolescents: Diagnostic and treatment challenges.

The aim of this review was to assess diagnostic and treatment challenges of adolescents with SI joint pain. We diagnosed 13 of the patients who were referred to our chronic pain clinic because of low back pain (30%) with SI joint pain based on provocative tests response. We performed SI joint steroid infiltration. Six patients (46%) felt better immediately after the procedure and 1 (8%) patient had a one-side only pain relief after a bilateral block. Four of these patients (31%) did not experience any further episode of pain during the follow-up and three patients reported recurring pain on average 2 months after the initial procedure. The 2nd procedure was successful in two patients and the third one experienced pain again 12 months later, requiring a third successful infiltration. Six patients (46%) experienced pain again within a few hours or days after the infiltration and their pain score were unchanged compared with what they had reported prior to the procedure. We were unable to place the needle within the joint under fluoroscopy in 1 patient; however, we were successful repeating the procedure under CT guidance. One patient experienced a motor and sensory block in the distribution of the sciatic nerve immediately after the procedure, which resolved within 24 and 48 hours, respectively. SI joint pain is a distinctive pathology that can be present in children and adolescents and is often overlooked by practitioners. Its diagnosis and management are challenging in this population as it is in adults. SI joint steroids injections may play a role in the management of these patients.

Preappointment surveys and reminder calls to improve show rate.

OBJECTIVES: To assess the impact of preappointment surveys and reminder phone calls on show rate and time spent in new patient appointments at a multidisciplinary pediatric chronic pain clinic. STUDY DESIGN: We examined show rates and appointment length during the 1-year period before and 1-year period after a preappointment survey and phone reminders were implemented. Fisher exact test was used for categorical variables and Student's t test with equal variances was used for continuous variables. METHODS: The setting was a multidisciplinary pediatric chronic pain management clinic in Florida. Participants were 362 patients scheduled for an initial pain clinic evaluation 1 year prior to and after the implementation of a preappointment survey on August 19, 2019. Our main outcome measures were show rate and appointment length. RESULTS: Patients who completed a preappointment survey were significantly more likely to attend their clinic appointment than noncompleters (97.2% vs 36.2%) and spent significantly less time in their appointment. CONCLUSIONS: With new patients, preappointment surveys can improve clinic show rate and decrease time spent in initial appointments. Clinics may consider policies targeting completion of preappointment surveys to assist with show rate, but they must consider their patients' barriers to completing surveys so access to care is not limited.

Feasibility of Conducting Long-term Health and Behaviors Follow-up in Adolescents: Longitudinal Observational Study.

BACKGROUND: Machine learning uses algorithms that improve automatically through experience. This statistical learning approach is a natural extension of traditional statistical methods and can offer potential advantages for certain problems. The feasibility of using machine learning techniques in health care is predicated on access to a sufficient volume of data in a problem space. OBJECTIVE: This study aimed to assess the feasibility of data collection from an adolescent population before and after a posterior spine fusion operation. METHODS: Both physical and psychosocial data were collected. Adolescents scheduled for a posterior spine fusion operation were approached when they were scheduled for the surgery. The study collected repeated measures of patient data, including at least 2 weeks prior to the operation and 6 months after the patients were discharged from the hospital. Patients were provided with a Fitbit Charge 4 (consumer-grade health tracker) and instructed to wear it as often as possible. A third-party web-based portal was used to collect and store the Fitbit data, and patients were trained on how to download and sync their personal device data on step counts, sleep time, and heart rate onto the web-based portal. Demographic and physiologic data recorded in the electronic medical record were retrieved from the hospital data warehouse. We evaluated changes in the patients' psychological profile over time using several validated questionnaires (ie, Pain Catastrophizing Scale, Patient Health Questionnaire, Generalized Anxiety Disorder Scale, and Pediatric Quality of Life Inventory). Questionnaires were administered to patients using Qualtrics software. Patients received the questionnaire prior to and during the hospitalization and again at 3 and 6 months postsurgery. We administered paper-based questionnaires for the self-report of daily pain scores and the use of analgesic medications. RESULTS: There were several challenges to data collection from the study population. Only 38% (32/84) of the patients we approached met eligibility criteria, and 50% (16/32) of the enrolled patients dropped out during the follow-up period-on average 17.6 weeks into the study. Of those who completed the study, 69% (9/13) reliably wore the Fitbit and downloaded data into the web-based portal. These patients also had a high response rate to the psychosocial surveys. However, none of the patients who finished the study completed the paper-based pain diary. There were no difficulties accessing the demographic and clinical data stored in the hospital data warehouse. CONCLUSIONS: This study identifies several challenges to long-term medical follow-up in adolescents, including willingness to participate in these types of studies and compliance with the various data collection approaches. Several of these challenges-insufficient incentives and personal contact between researchers and patients-should be addressed in future studies.

Case Report: The Role of Spatial Repellant Devices to Prevent Malaria in Low-Income Countries.

Malaria is the leading cause of morbidity and mortality in Uganda. The role of spatial repellent devices in preventing malaria is controversial. The goal of this study was to evaluate the populations' acceptability of a newly designed insecticide diffuser. We distributed to three families living in southern Uganda a device commercially available, the VAPE® portable set. This spatial repellent device offers several advantages compared with other traditional products. It is powered by lithium batteries that guarantee 20 days of uninterrupted delivery of insecticide; it contains two insecticides: empenthrin and transfluthrin; and it is simple to use, one switch to turn it "on" and/or "off." It is odorless, and it can be placed anywhere in the living/sleeping area. People can also carry it outside the house. We planned to evaluate people's compliance with its usage, its reliability, and its overall costs. We conducted a 5-month survey. We distributed the devices to three households, one device per bedroom. Ten males and 11 females, with a mean age of 26 ± 16 (range 10-51) years, lived in these houses. The compliance with the use of the device and its acceptability were high. No side effects were reported. No individual contracted malaria during the 5-month period. The major obstacle we found was the timely delivery of the devices to the evaluation area and initial compliance with the instructions on how to use the device. Larger randomized studies are needed to clarify whether there is a role for this type of spatial repellent devices in the global efforts to prevent malaria.

Occipital Nerve Blocks for Relief of Headaches in Patients With Ventriculoperitoneal Shunts: A Case Series.

Pediatric patients with ventriculoperitoneal shunts commonly present with headaches. We report 7 children with ventriculoperitoneal shunts and occipital headaches who received occipital nerve blocks. Eighty-six percent of patients had a history of at least 1 ventriculoperitoneal shunt revision. Headaches improved in every patient after the block. Two patients (29%) were symptom free 11 and 12 months after the block. Four patients (57%) required repeat occipital nerve blocks. Two underwent pulsed radiofrequency ablation. No complications were noted. When patients with ventriculoperitoneal shunts present with headaches, a detailed physical examination is necessary. Persistent occipital headaches with tenderness and radiation in the path of the occipital nerves can be indicative of occipital neuralgia resulting from the shunt having crossed over the path of the greater or lesser occipital nerve. Occipital nerve blocks can help as both diagnostic and therapeutic interventions in these patients.

The Association Between Opioid Use and Outcomes in Infants Undergoing Pyloromyotomy.

PURPOSE: The purpose of this study was to describe the frequency and variation of opioid use across hospitals in infants undergoing pyloromyotomy and to determine the impact of opioid use on postoperative outcomes. METHODS: A retrospective cohort study (2005-2015) was conducted by using the Pediatric Health Information System (PHIS) database, including infants (aged <6 months) with pyloric stenosis who underwent pyloromyotomy. Infants with significant comorbidities were excluded. Opioid use was classified as a patient receiving at least 1 opioid medication during his or her hospital stay and categorized as preoperative, day of surgery, or postoperative (≥1 day after surgery). Outcomes included prolonged hospital length of stay (LOS; ≥3 days) and readmission within 30 days. FINDINGS: Overall, 25,724 infants who underwent pyloromyotomy were analyzed. Opioids were administered to 6865 (26.7%) infants, with 1385 (5.4%) receiving opioids postoperatively. In 2015, there was significant variation in frequency of opioid use by hospital, with 0%-81% of infants within an individual hospital receiving opioids (P < 0.001). Infants only receiving opioids on the day of surgery exhibited decreased odds of prolonged hospital LOS (odds ratio [OR], 0.85; 95% CI, 0.78-0.92). Infants who received an opioid on both the day of surgery and postoperatively exhibited increased odds of a prolonged hospital LOS (OR, 1.71; 95% CI, 1.33-2.20). Thirty-day readmission was not associated with opioid use (OR, 1.03; 95% CI, 0.93-1.14). IMPLICATIONS: There is national variability in opioid use for infants undergoing pyloromyotomy, and postoperative opioid use is associated with prolonged hospital stay. Nonopioid analgesic protocols may warrant future investigation.

Efficacy of addition of fentanyl to epidural bupivacaine on postoperative analgesia after thoracotomy for lung resection in infants.

BACKGROUND: The authors evaluated the efficacy of adding fentanyl to epidural bupivacaine in infants up to 6 months of age after a thoracotomy in a prospective, randomized, double-blind study. The primary outcome was the total amount of rescue doses of intravenous nalbuphine in the first 24 h after surgery. Secondary outcomes included (1) time to first rescue dose of nalbuphine, (2) pain scores, and (3) behavior scores. METHODS: Thirty-two infants were randomly assigned to receive an epidural infusion containing 0.1% bupivacaine (group B; n = 16) or 0.1% bupivacaine and 2 microg/ml fentanyl (group BF; n = 16). Patients were evaluated up to 24 h after surgery for pain; amount of analgesic rescues and time to first rescue; pain scores; behavior scores (five-item behavior score); and complications, including respiratory depression, oxygen requirement, vomiting, and urinary retention. RESULTS: The two groups had similar demographics. Nalbuphine consumption (P = 0.001) and pain scores (P < 0.001) in the first 24 h were significantly decreased in group BF compared with group B. The time to first analgesic rescue was significantly longer in group BF (P = 0.005). The five-item behavior score was significantly better in group BF than in group B (P = 0.01). The incidence of side effects, the time to first successful feeding, and the time to discharge were similar in both groups. CONCLUSIONS: Addition of 2 microg/ml epidural fentanyl to 0.1% bupivacaine results in improved postthoracotomy analgesia without any increase in side effects, compared with 0.1% bupivacaine, in infants up to 6 months of age.

Analgesic effects of Sazetidine-A, a new nicotinic cholinergic drug.

BACKGROUND: The use of nicotinic agonists for analgesia is limited by their unacceptable side effects. Sazetidine-A is a new partial agonist nicotinic ligand that has very high selectivity for beta2-containing nicotinic acetylcholine receptors. It potently and selectively desensitizes alpha4beta2 nicotinic acetylcholine receptors without measurable effects on alpha3beta4 receptors. The authors investigated the analgesic effects of Sazetidine-A using the formalin model of chronic inflammatory pain. METHODS: The formalin test was conducted after rats received intraperitoneal saline, Sazetidine-A (0.125, 0.25, 0.5, 1, 2 mg/kg), or subcutaneous epibatidine (2.5-5-10 mug/kg). In other experiments, Sazetidine-A was preceded by naloxone (0.5 mg/kg) or mecamylamine (10 mg). Effects of Sazetidine-A and epibatidine on locomotor were tested in an open field, and seizure activity was measured using the Racine scale. Locus coeruleus neuron extracellular single-unit spontaneous discharge was recorded in anesthetized animals after Sazetidine-A and epibatidine. RESULTS: Higher doses of Sazetidine-A (0.5, 1, or 2 mg/kg) induced analgesia, with pain scores significantly lower than those seen after saline, lower doses of Sazetidine-A, and epibatidine (P < 0.001). Naloxone did not antagonize the effects of Sazetidine-A, and mecamylamine had partial, dose-dependent antagonistic effects. Epibatidine excited locus coeruleus neurons, whereas Sazetidine-A had no effect on these neurons. Epibatidine and Sazetidine-A affected animals' locomotor activity for the initial 20 min. While analgesic doses of epibatidine caused seizures, no seizure activity or other neurologic complications were seen in animals that received as much as four times the minimum analgesic dose of Sazetidine-A. CONCLUSIONS: Sazetidine-A seems to be a potent analgesic without causing neurologic side effects.

Electrophysiologic effects of systemic and locally infused epibatidine on locus coeruleus neurons.

We evaluated the electrophysiologic response of locus coeruleus neurons to the systemic and local infusion of epibatidine. Rats were anesthetized with 2% halothane and single-unit locus coeruleus discharge was recorded after administration of systemic (2.5, 5 and 10 microg/kg subcutaneously) and intracoerulear (0.03-0.01-0.001 microg) epibatidine. The subcutaneous epibatidine activated locus coeruleus neurons only at the highest dose (10 microg/kg). The 2.5-5 microg/kg doses, previously shown to induce analgesia, did not activate locus coeruleus neurons. The intracoerulear infusion of epibatidine induced excitement of locus coeruleus neurons at every tested dose. Higher doses (0.03 and 0.01 microg) excited 100% of the recorded neurons. A significantly lower number of neurons (50% and 43% respectively) were excited when lower doses (0.005-0.001 microg) were used (P=0.035). The intracoerulear infusion of mecamylamine (1 microg) significantly reduced neuronal discharge rate (45%) and blocked the effects of epibatidine. The intra-dorsal raphe infusion of 0.03 microg epibatidine induced significant excitation of locus coeruleus neurons. These data show that the administration of epibatidine induces excitation of locus coeruleus neurons, which is mediated by nicotinic receptors. This activation occurs after systemic and selective local administration of epibatidine. The response of locus coeruleus neurons to systemic and locally administered epibatidine is dose-related.

Neuromodulation in Pediatrics: Case Series.

OBJECTIVES: Neuromodulation, particularly intrathecal drug delivery systems and spinal cord stimulators (SCSs), can be a valuable tool when treating chronic pain in adults. However, there is a paucity of literature with regard to its use in pediatrics. MATERIALS AND METHODS: We present a series of 14 children and adolescents with intractable pain who received a SCS or a pump for the intrathecal delivery of medications between 2010 and 2016 at our institution. RESULTS: During the study period, we placed 10 intrathecal pumps and 4 SCSs with an average age of 17 years old. Pain scores significantly improved after the implant (P<0.007) and function improved in 79% of patients. Opioid use was also significantly reduced. Three patients eventually had their device removed due to psychiatric comorbidities. Four patients had complications that were treated without further sequelae. CONCLUSIONS: Neuromodulation can offer important options in treating some pediatric chronic pain patients. In-depth knowledge of primary disease and strict patient selection in the context of the patient's social situation is vital to successful treatment.

The effects of clonidine on postoperative analgesia after peripheral nerve blockade in children.

BACKGROUND: The effect of clonidine on the duration of sensory blockade after peripheral nerve blockade is controversial. We evaluated the effects of clonidine on the duration of sensory and motor block and analgesia time in children who underwent a variety of peripheral nerve blocks. METHODS: We reviewed the regional anesthesia database that contains data on children who underwent an infraclavicular, lumbar plexus, femoral, fascia iliaca or sciatic nerve block for postoperative analgesia at The Children's Hospital of Philadelphia between October 2002 and December 2005. Patients were prospectively followed after the nerve block. RESULTS: Two hundred fifteen patients (47%) received either bupivacaine or ropivacaine local anesthetic (LA) and 220 (53%) a combination of local anesthetic and clonidine (LAC). The duration of sensory block was significantly longer in the LAC (17.2 +/- 5 h) compared with that in the LA group (13.2 +/- 5 h) (P = 0.0001). The increase in duration was independent from the type of peripheral nerve block, local anesthetic used and operation performed. The motor block duration was significantly longer in the LAC group (9.6 +/- 5 vs 4.3 +/- 4 h, P = 0.014). Two patients in the LAC and one in the LA group experience prolonged numbness (max 72 h). No paresthesia or dysesthesia was observed. CONCLUSION: The addition of clonidine to bupivacaine and ropivacaine can extend sensory block by a few hours, and increase the incidence of motor blocks.

The relationship between current intensity for nerve stimulation and success of peripheral nerve blocks performed in pediatric patients under general anesthesia.

BACKGROUND: We evaluated the relationship between the lowest current amperage used to obtain a motor response, the success rate and the incidence of neurological complications with peripheral nerve blocks (PNB) in pediatric patients under general anesthesia. METHODS: We reviewed the regional anesthesia database at The Children's Hospital of Philadelphia and included all pediatric patients who received a single-injection PNB under general anesthesia with the aid of a peripheral nerve stimulator between October 2002 and July 2006. Data analyzed included age, sex, type of block, stimulation threshold, presence of sensory and motor blockade, and neurological complications. RESULTS: Six-hundred sixty patients received a PNB during the study period. The average age of the patients was 13.8 yr (range = 2-18 yr). All the blocks were performed using a current ranging between 0.2 and 1 (median = 0.5 mA, interquartile range: 0.45-0.55 mA). The overall success rate was 96%. There was no difference in success rate between blocks performed using a stimulation threshold of < or =0.5 or >0.5 mA (96.3% vs 95.9%; P = 0.793). There was no correlation between the success rate and sex, type of block performed or intensity of current used. Two patients reported prolonged nerve blockade of the great toe and dorsum of the foot after a sciatic nerve block, which lasted for 72 h. No long-term sequelae were noted in our patients. CONCLUSION: In this study, a similar PNB success rate was observed with both a low (*0.5 mA) and a high stimulation threshold (>0.5 mA). Therefore, it may not be necessary to perform needle manipulations to achieve a low stimulation threshold (< or =0.5 mA), as this may increase the risk of intraneural injection.

Low-dose intrathecal morphine for postoperative analgesia in children.

BACKGROUND: We evaluated the efficacy and safety profile of low-dose (4-5 mcg/kg) intrathecal morphine for postoperative pain management after various surgical procedures in children. METHODS: We reviewed the pain management service database and the medical records of patients who received low-dose intrathecal morphine for postoperative analgesia at The Children's Hospital of Philadelphia between October 2003 and March 2006. Patients had been prospectively followed for 24-48 h after the intrathecal morphine administration. RESULTS: The medical records of 187 patients were examined. The mean age was 5.6 +/- 5.1 yr (median 4.0, interquartile range [IQR] 1.0-10.0). The median maximum pain score during the first 24 h in patients evaluated by the FLACC score and in those evaluated by the numeric verbal rating scale, was 0 (IQR 0-3) and 0 (IQR 0-4), respectively. The mean time to first rescue opioid was 22.4 +/- 16.9 h (range: 0-48 h, 95% CI: 19.9-24.8 h). During the first 24 h after surgery, 70 patients (37%) did not receive any opioids (oral or IV). Of the 117 patients who received opioids, 59 (50%) were managed with oxycodone only. Pain was managed with ketorolac in 33% of patients, either alone (11%) or in combination with IV or oral opioids (22%). The incidence of nausea or vomiting, pruritus, and urinary retention was 32%, 37%, and 6% respectively. One patient had transient postdural puncture headache, while two patients received supplemental oxygen beyond the first 60 postoperative minutes to manage occasional episodes of hypoxemia. No severe respiratory depression requiring assisted ventilation or naloxone administration was observed. CONCLUSION: We conclude that low-dose intrathecal morphine in the pediatric population can be a useful and safe adjunct for postoperative analgesia.

Continuous peripheral nerve blockade for inpatient and outpatient postoperative analgesia in children.

BACKGROUND: This is an audit of the continuous peripheral nerve blockade (CPNB) program that was implemented at our institution to provide postoperative analgesia after orthopedic procedures in children. METHODS: We reviewed the departmental regional anesthesia registry and the medical records of consecutive children who received CPNB for postoperative analgesia at The Children's Hospital of Philadelphia between February 2003 and July 2006. Patients were prospectively followed until cessation of the effects of CPNB and/or resolution of any related complications. Data collected contemporaneously included presence of sensory and motor blockade, pain scores in inpatients, opioid administration, and complications related to CPNB. RESULTS: A total of 226 peripheral nerve catheters were placed in 217 patients. One hundred eight patients (112 catheters) were discharged home with CPNB. The ages ranged from 4 to 18 yr (13.7 +/- 3.4). Local anesthetic solution (0.125% bupivacaine [n = 164], 0.1% ropivacaine [n = 12], or 0.15% ropivacaine [n = 27]) was infused at an initial rate of 2-12 mL/h based on patients' weights and locations of catheters. The mean duration of local anesthetic infusion was 48.4 +/- 29.3 h (range 0-160 h). The percentage of patients who did not require any opioids in the first 8, 24, and 48 h after surgery was 56%, 26%, and 21%, respectively. The incidence of nausea and vomiting was 14% (13% in outpatients, 15% in inpatients). Complications were noted in 2.8% of patients. Three patients had prolonged numbness (>24 h) that resolved spontaneously; one developed superficial cellulitis that resolved with a course of antibiotics; one had difficulty removing the catheter at home and one developed tinnitus 24 h after starting CPNB that resolved quickly after clamping of the catheter followed by removal. CONCLUSION: It is feasible to implement a CPNB program to provide an alternative method of inpatient and outpatient postoperative analgesia after orthopedic surgery in children when appropriate expertise is available. Patient and family education along with frequent follow-up are crucial to detect and address adverse events promptly.

Unique Considerations in Spinal Cord Stimulator Placement in Pediatrics: A Case Report.

Spinal cord stimulation can be a valuable treatment option in the management of neuropathic pain in select pediatric patients. We present a unique case of a 16-year-old girl with Klippel-Trenaunay-Weber syndrome and scoliosis who required the placement of a spinal cord stimulator (SCS) for severe sciatic nerve neuropathic pain after a right above-knee amputation. Several attempts at lead placement were required before successful pain coverage was achieved because of late recognition of significant vertebral body rotation. This case highlights important considerations in pediatric SCS placement including a careful review of the spinal cord anatomy before the placement of an SCS.

Chronic Pain in Children: A Look at the Referral Process to a Pediatric Pain Clinic.

We reviewed the referral pattern of children with chronic pain to a specialized pediatric pain clinic. Data were obtained from referring physicians and medical records and during an interview with patients and their parents by physicians and a psychologist. We analyzed the following: referral diagnosis, demographics, duration of symptoms, number of physicians previously consulted, school attendance, sports activities, presence of psychological disorders, final team diagnosis, and outcomes. Children had been experiencing pain for 34 ± 55 months. Patients had consulted on average 3 physicians in addition to their pediatrician. 32% of the patients had missed at least 10 days of school in a calendar year, and 47% had stopped playing sports. 15% had an operation because of pain that had been unsuccessful. The most common missed diagnosis was anxiety (25%) and depression (13%). 69% of the patients were back to school and/or playing sports within 4 months from our initial consultation. 32% of the patients did not make any progress during the follow-up period. The most common reasons for failure to improve were no compliance with the recommended treatments and poorly controlled major mood disorder. The time to refer children with chronic pain for specialized care could be extremely long causing significant social and psychological consequence.

Short- and long-term results of an inpatient programme to manage Complex Regional Pain Syndrome in children and adolescents.

The aim of this retrospective study was to determine whether an inpatient approach and the use of regional anaesthesia techniques can accelerate the recovery to normal functions in children with Complex Regional Pain Syndrome (CRPS). This study looked at the data of patients admitted to the rehabilitation unit with a diagnosis of CRPS from January 2010 to April 2015. Variables such as hospital stay, medications administered, regional anaesthesia procedures, changes in functional status prior to treatment and at the time of discharge, psychological evaluation and diagnosis were evaluated. A total of 31 patients (21 females and 10 males) were admitted with a diagnosis of CRPS 1 and 2. In all, 97% of the patients received a peripheral or central nerve catheter for an average of 4 days with pain scores of Verbal Numeric Scale (VNS) score = 1.0 ± 0.7 and an average length of hospital stay of 8.2 ± 2.6 days. The modified Functional Independence Measure for Children (WeeFIM) scores and Canadian Association of Occupational Therapists tests significantly improved at the time of hospital discharge, as well as their pain scores, which decreased from 8.2 ± 2 to 1.6 ± 3. In conclusion, these data suggest that the use of regional anaesthesia techniques and an intensive inpatient rehabilitation programme could accelerate the recovery of children with CRPS.