Pediatric Post-Op Pain Management, MMC

Updated May 6, 2014
Author: DeCourcey / McKinley

Description: Continuous Epidural Placement & Analgesic Management in Pediatrics for post-op & post-traumatic Pain

for ADULT Post-Op Pain Management at MMC click here

  1. Indications & Techniques for Epidurals in Children
  2. Placement & Epiduralgrams
  3. Post-Op Pain Management by Pediatric Pain Service
    1. Epidural Local Anesthetic Infusions
    2. Clonidine
    3. Narcotic Analgesics
    4. IV Acetominophen & Ketorolac
  4. Transfer of Care after Epidural Removed
  5. Consultations for Chronic or Malignant Pain

Indications & Techniques for Epidurals in Children

Indications:
1. Post-op pain management with reduced opioid requirements
2. Augmentation of general anesthesia

An excellent summary of Epidural Placement in Children is found in this NYSORA article from 2009(pdf)


Catheter Placement & Epiduralgrams

Epidurals placed in anesthetized children and children who are developmentally unable to communicate epidural catheter function should be imaged radiographically.

Epidural catheters placed in children less than 2 yrs old should be injected with 0.1cc/kg of Omnipaque 140. 
Catheters placed in children 2 yrs old and older should be injected with 0.1cc/kg to a max of 3cc of Omnipaque 300.

All catheters should have an AP or lateral X-ray demonstrating contrast in the epidural space at the desired level of analgesia.  If confirmed with fluoroscopy, a single image should be saved to Impax.  Epiduralgram results should be documented on the epidural insertion note.

Summary:

  1. Epiduralgrams for all children unable to convey analgesic dermatomal level.
  2. At least one view documented in Impax demonstrating epidural spread.
  3. Dose of Contrast (Omnipague):
  4. Document Results of epiduralgram in Insertion Procedure Note

 


Post-Op Pain Management by Pediatric Pain Service

As of 2012 there have been some new changes to the management of APMS and the Pediatric Pain Service, a subset of the APMS devoted exclusively to the care of Infants and children under age 18. 

We will now be responsible for the management of epidural analgesia and all analgesics, antiemetics and sedatives administered while the epidural catheter is in place. 

The exception is for NICU patients: analgesia and sedation will continue to be directed by neonatologists. 

Acetaminophen may be ordered by APMS or by surgery. 

We will not be ordering ketorolac, as this will most likely be ordered by surgery when the epidural is removed. 

We now have new epidural infusion choices that include opioids and clonidine in addition to local anesthetics.  

 APMS orders for pain management will supersede all other pain orders.  No other analgesics or sedatives other than acetaminophen may be given unless approved by APMS.  (Exception NICU patients) 


Epidural Local Anesthetic Infusions

New epidural infusion choices that include opioids and clonidine in addition to local anesthetics.  

Age < 6 Months:

  1. CHLOROPROCAINE 1.5%

  2. Available Formulations from Pharmacy / Epic

    • Chloroprocaine 1.5%
    • Chloroprocaine 1.5% with Fentanyl 1 mcg/ml
    • Chloroprocaine 1.5% with Clonidine 0.04mcg/ml
    • Chloroprocaine 1.5% with Fentanyl 1 mcg/ml and Clonidine 0.04mcg/ml

     

    Dosing is based on the Chloroprocaine 1.5% formulation
    Suggested Starting Dose = 0.3ml/kg/hr (4.5mg/kg/hr)
    Suggested Maximum Infusion Dose = 0.5ml/kg/hr (7.5mg/kg/hr)

     

  3. BUPIVACAINE 0.1%

  4. Available Formulations from Pharmacy / Epic

    • Bupivacaine 0.1%
    • Bupivacaine 0.1% with Fentanyl 1 mcg/ml
    • Bupivacaine 0.1% with Clonidine 0.04mcg/ml
    • Bupivacaine 0.1% with Fentanyl 1 mcg/ml & Clonidine 0.04mcg/ml

     

    Dosing is based on the Bupivacaine 0.1% formulation
    Suggested Maximum Infusion Dose = 0.4 ml/kg/hour (0.4mg/kg/hr)

     

Age > 6 months

  1. BUPIVACAINE 0.125%

    Available Formulations from Pharmacy / Epic

    • Bupivacaine 0.125%
    • Bupivacaine 0.125% with Clonidine 0.4mcg/ml
    • Bupivacaine 0.125%  with Fentanyl 2mcg/ml
    • Bupivacaine 0.125%  with Fentanyl 2mcg/ml and Clonidine 0.4mcg/ml
    • Bupivacaine 0.125% with Hydromorphone 10mcg/ml
    • Bupivacaine 0.125% with Hydromorphone 10mcg/ml and Clonidine 0.4mcg/ml

     

    Dosing is based on the Bupivacaine 0.125% formulation
    Suggested Maximum Infusion Dose = 0.32 ml/kg/hour (0.4 mg/kg/hour)

  2. BUPIVACAINE 0.0625%

  3. Available Formulations from Pharmacy / Epic

    • Bupivacaine 0.0625%
    • Bupivacaine 0.0625% with Clonidine 0.2mcg/ml
    • Bupivacaine 0.0625%  with Fentanyl 1mcg/ml
    • Bupivacaine 0.0625%  with Fentanyl 1mcg/ml and Clonidine 0.2mcg/ml
    • Bupivacaine 0.0625% with Hydromorphone 5mcg/ml
    • Bupivacaine 0.0625% with Hydromorphone 5mcg/ml and Clonidine 0.2mcg/ml           

     

    Dosing is based on the Bupivacaine 0.0625% formulation
    Suggested Maximum Infusion Dose = 0.64 ml/kg/hour (0.4 mg/kg/hour)

  4. BUPIVACAINE 0.25%

  5. Available Formulations from Pharmacy / Epic

    • Bupivacaine 0.25%

     

    Dosing is based on the Bupivacaine 0.25% formulation
    Suggested Maximum Infusion Dose = 0.16 ml/kg/hour (0.4 mg/kg/hour)

    MAXIMUM Cumulative Bupivacaine Dose = 2.5mg/kg/four hours


Clonidine (Catapres®)

(NOTE: Rebound hypertension when stopping Clonidine is unlikely to occur with clonidine dose < 15mcg/kg/day)

 


Narcotic Analgesics

IV Narcotics

Guidelines for nurse administrated PRN analgesics:

 

PCA for Children Age > 6 years

MORPHINE:  (Avoid in Renal Dysfunction)
Loading Dose 0.025-0.050 mg/kg  MAX 2 mg
PCA Dose 0.010-0.040 mg/kg MAX 1.8 mg
Lock-out Interval 7-12 mins  
4-Hour Limit 0.4-0.6 mg/kg  
Continuous 0.010-0.020 mg/kg/hr  

 

HYDROMORPHONE:
Loading Dose 0.005-0.01 mg/kg MAX 0.4 mg
PCA Dose 0.002-0.006 mg/kg MAX 0.3 mg
Lock-out Interval 7-12 mins  
4-Hour Limit 0.06-0.10 mg/kg  
Continuous 0.003-0.004 mg/kg/hr   

 

FENTANYL: 
Loading Dose 0.3-0.5 mcg/kg  MAX 20 mcg
PCA Dose 0.2-0.4 mcg/kg MAX 18 mcg
Lock-out Interval 7-12 mins  
4-Hour Limit 4-6 mcg/kg  
Continuous 0.1-0.25 mcg/kg/hr  

 


Side Effects, Treatment of


IV Acetominophen and Ketorolac

Acetaminophen may be ordered by APMS / PPS or by surgery. 

APMS / PPS will not order ketorolac, as this will most likely be ordered by surgery when the epidural is removed. 

Guidelines for patient selection of Ofirmev® (IV acetaminophen):
Currently Ofirmev® is not approved with restrictions for use, but may be in the future due to significant cost difference for IV vs PO.

Patient selection:

Ofirmev® (IV Acetominophen): 
Age Weight Dose/Frequency
Adolescent (>12 yr) <50kg 1000mg IV q 6Hr (Max 4000 Mg/day)
Adolescent (>12 yr) <50 kg 15 mg/kg q 6Hr (Max 75 mg/kg/day)
Child 2-12 years   15 mg/kg q 6Hr (Max 75 mg/kg/day)
Child <2 yr (provider decision, off-label) 15 mg/kg q 6Hr (Max 75 mg/kg/day)

Transfer of Care after Epidural Removed

The Pediatric Pain Service will transfer analgesic care to the primary service at the time the epidural catheter is removed.  Exception to the above and continued APMS involvement can be requested on an individual basis.


Consultations for Chronic or Malignant Pain

Consultations for the consideration of interventional techniques for the management of malignant pain (e.g. intrathecal catheters, nerve blocks) will be provided by anesthesiologists specializing in the care of pediatric patients.