Pain management options to provide children comfort after surgery

A pediatric anesthesia team is tasked with the job of bringing children into and out of anesthesia for surgery and other procedures. When your child is in the operating room, it’s the pediatric anesthesiologist and the rest of the pediatric anesthesia team who ensure that your child is given the right combination of medications in order for them to drift off to sleep for the procedure and have a smooth recovery once the procedure is complete.

There’s more to it than that, though. When we see these things in the movies, we see the patient drift off to sleep and then wake up in the recovery room. One of the things missed in those characterizations, however, is the expertise of the anesthesia team in preventing and managing a patient’s pain, not only while a procedure is taking place, but after the procedure and even once a patient is sent home.

Our pediatric anesthesia team here at Arnold Palmer Hospital offers several options for postoperative pain management in addition to traditional intravenous narcotic pain medicines. These additions to pain management, called regional anesthesia, can offer children better pain relief while allowing lower doses of general anesthesia and narcotic pain medication. This, in turn, minimizes the negative side effects children often feel from narcotic pain medication: nausea, vomiting, sleepiness, itching and constipation. In other words, our kids feel better faster after surgery. It’s a win for everyone.

We’ve asked our anesthesia team to answer a few questions about these services:

What are some of the post-operative pain management options you offer?

For post-operative pain management, our pediatric anesthesia team offers single shot nerve blocks, nerve catheters, and epidural catheters.

Single shot nerve blocks are a one-time injection of local anesthesia medicine at the site of the nerve that provides sensation to the limb undergoing surgery. The medicine has a numbing effect that lasts for several hours which helps the patient have less sensation and therefore less pain during and after surgery.

Nerve catheters are a type of nerve block, but instead of a single injection, a small flexible plastic catheter is threaded under the skin near the nerve and is attached to a pump of numbing medicine that infuses over a longer period of time. This allows patients to be discharged home after surgery with a pump of local anesthesia to provide pain relief for up to two days, or longer if necessary. Single shot nerve blocks and catheters are commonly provided for orthopedic and sports medicine-related procedures as well as general surgeries involving the abdominal and chest areas.

Pediatric epidural catheters are provided for abdominal, thoracic and hip surgeries. Catheters are placed in the epidural space in the mid or lower back, depending on the surgical site, while the patient is in the operating room and can remain intact for days after surgery. The catheter is hooked up to a pump that infuses local anesthesia medicine and/or narcotic pain medicine to provide pain relief at the surgical site.

All of these options are a part of a multifaceted approach to pain management. No single option is going to relieve 100% of the patient’s pain, but the expected outcome is that regional anesthesia allows for less intravenous narcotic to be used during and after surgery, and therefore the patient will likely have fewer side effects from narcotics such as nausea, vomiting and constipation.

Can you explain how and why nerve blocks and nerve catheters are placed?

While general anesthesia is the medication used to put your child into a deep sleep and affects all of the body, a nerve block uses a local anesthetic that works only in the part of the body where it is needed. It is indicated when a patient undergoes a surgery that is known to have significant post-operative pain and when a nerve can be safely accessed by a needle to inject numbing medicine. This block can be accomplished under sedation before general anesthesia in older, cooperative patients or while completely asleep in the case of our smallest patients. During the procedure, the nerve is either visualized with an ultrasound machine and/or a nerve stimulator is used depending on the location so the anesthesiologist knows exactly where to deposit the medicine for maximum effectiveness.

A nerve catheter is placed with the same insertion technique as above and a needle is used to thread a small, flexible catheter under the skin near the nerve and is connected to tubing and a pump. The pump infuses local anesthesia medicine over the course of approximately 48 hours.

What are the benefits of nerve catheters?

One benefit of a nerve catheter is that it provides much longer pain relief than a single shot nerve block. When nerve catheters are placed at the beginning of the surgery, we can begin infusing medicine right away and throughout the surgery. This allows for less narcotic medicine to be given during and after surgery and results in less side effects from narcotics such a nausea, vomiting and constipation.

Patients receive superior pain relief, are often able to resume normal functioning and movement sooner, and can often be released from the hospital sooner than they would have otherwise.

What are the risks?

The risks for these procedures are very low as our pediatric anesthesiologists are trained in multiple techniques to minimize any issues. One technique is to visualize the nerve and blood vessels under ultrasound guidance and view exactly where the medicine is being deposited. Another technique ensures correct placement with motor nerves by using a stimulator that illustrates to the doctor how close in proximity the needle is to the nerve. A third safety technique we employ is the use of a pressure manometer, which is a gauge placed on the injecting syringe that notifies the provider if there is injection inside the nerve.

As with any procedure, there are risks of possible complication when a physician places a nerve block. The risks associated with these regional anesthesia techniques could include injecting medicine into a nearby blood vessel, which can cause seizure, or in severe cases, cardiac arrest. Also, injecting into a nerve can cause chronic pain or nerve damage. However, these risks are exceedingly rare.

How have kids fared with nerve catheters versus other means of pain relief?

We follow up by phone daily on all patients who go home with nerve catheters and nerve blocks and we personally visit all patients who stay in house after these procedures. Patients consistently tell us that even after the block has worn off they have minimal or well-controlled pain, especially when nerve blocks and catheters are used as a multi-modal approach to pain management.

Can you explain what an epidural is and why it is used?

An epidural catheter is placed in the mid or lower back and sometimes in the tail bone area. Of course, placement of the epidural catheter depends on the surgical site that needs to be blocked. The catheter is introduced into the epidural space near the nerves that provide sensation and movement to the lower extremities. Local anesthesia medicine and/or narcotic pain medicine is then infused to provide numbness and relief of post-surgical pain. Children will be sedated or asleep at the time the epidural is placed to aid in comfort during placement. Epidural catheters can be used in multiple types of surgeries including painful orthopedic, chest and some abdominal procedures.

Is it common for kids to get an epidural for pain relief? Is it available in other hospitals?

Many pediatric anesthesiologists consider regional anesthesia a best practice and is common in pediatric hospitals that have anesthesiologists that specialize in pain management. Epidural use in children has lagged behind its use in adults because of the specialized training and experience needed to perform epidural catheters safely in children, which is not available at all facilities.

Why do you choose an epidural over other types of pain relief?

Since epidural catheters provide superior pain relief by giving medication to the epidural space, which is close to the spinal cord, this makes both sides of the body numb for as long as the epidural is connected to an infusion pump. This allows for a lighter level of general anesthesia during surgery, with less narcotic use needed to control pain both during and after surgery.

Are epidurals safe for kids? What are the risks?

The use of epidurals in children has been well studied and is a common procedure in pediatric hospitals with specialists who provide services in pain management. As with any procedure there are risks, which are very rare, but can include infection, bleeding, local anesthesia toxicity, nerve damage, and spinal headache.

The purpose of single shot nerve blocks, nerve catheters and epidural catheters is to minimize post-operative pain and maximize recovery time. Sending our child into surgery is probably one of the most difficult things a parent could experience. We are entrusting our child into someone else’s hands, and it takes great courage. Not only are we trusting the surgeon to perform the surgery successfully, we are also trusting the anesthesiologist to bring our child into and out of anesthesia as comfortably as possible. Our pediatric anesthesiologists all have this same goal and are excited to offer these pain management options to our patients.