Epidural/Caudal Infusion rates:

• Bupivacaine
• Infant < 2 months of age: maximum rate = 0.25 mg/kg/hr (maximum duration at this rate: 48 hrs)
• Infant > 2 months of age: maximum rate = 0.5 mg/kg/hr
• Morphine
• Bolus: 0.03 to 0.05 mg/kg
• Infusion: usual range: 3 to 8 ug/kg/hour
• Fentanyl
• Bolus: 0.5 to 1.0 ug/kg
• Infusion: usual range 0.5 to 1 ug/kg/hr
• Note: The most important limiting factor for infant epidural infusions is the potential for cumulative local anesthetic toxicity.

Monitoring

• ICU level of care: all patients less than 6 months of age with epidural/caudal infusion.
• Apnea monitor: all pts less than two years of age while unsupervised. Note: a pulse oximeter is fine instead of a "CR" monitor. Monitoring should continue for 8 hrs after the last morphine bolus, 2 hrs after any infusion is stopped.

Nursing Orders

• Vital sign monitoring: 8 hrs after last epidural morphine bolus & for 2 hrs after any infusion is stopped.
• Maintain venous access for 8 hrs after last epidural morphine bolus & for 2 hrs after stopping any infusion.
• Call acute pain service for respiratory rate less than:

• Pressure Point Protection: Consider ordering egg crate mattress and regular repositioning for any child with a continuous sensory/motor block secondary to local anesthetic infusion.

• Pruritis

1. Nalbuphine: 0.1 mg/kg q 6h IV
2. Benadryl: 0.5 to 1.0 mg/kg IV, 1 mg/kg PO/PR
3. Naloxone: bolus of 1 to 4 mcg/kg ± infusion of 1 to 4 mcg/kg/hr (a lower infusion rate of 0.5 to 1 mcg/kg/hr may be sufficient in older children)
4. Vistaril: (hydroxyzine) 0.5 to 1.0 mg/kg PR

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• Vomiting

1. Phenergan: 0.25 to 0.5 mg/kg PR (phenergan may be contraindicated if the patient has a seizure disorder).
2. Naloxone bolus and infusion (as for pruritis)
3. Remove or reduce narcotic portion of epidural infusion

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• Urinary Retention

1. Treatment: Catheterization (intermittent or indwelling) and/or
2. Naloxone bolus/infusion as above

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• Over-sedation

1. Naloxone bolus of 5 to 10 mcg/kg followed by infusion of naloxone and/or
2. Reduction or change in type of epidural analgesia

PF Morphine (single or "loading" dose)

Indications

Post surgical-Thoracic, Abd

Special Considerations

Catheter does not need to be site specific. Good for single shot

Dosing

0.03 to 0.05 mg/kg in NS Total Vol: Caudal injection: 3cc < 5kg, 5cc for 5 to 15 kg, 10cc if > 15 kg

For lumbar/thoracic catheters use smaller volumes or undiluted

Problems

Resp depression < 1 yr (esp <3 months), higher doses or IV narcotics.

Urinary retention is a problem

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PF Morphine Infusion (40 mcg/ml)

Indications

Post surgical-Thoracic, Abd,

Special Considerations

Catheter does not need to be site specific

Dosing

Bolus as above, followed by 3 to 8 mcg/kg/hr. of Epidural MS Infusion solution (40 mcg/ml).

Problems

Side effects probably less than w/ bolus methods.

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PF Morphine plus Butorphanol

Indications

Post surgical-Thoracic, Abd,

Special Considerations

Catheter does not need to be site specific. Good for single shot. May have better side effect profile. Increased duration of analgesia ass. w/ significant sedation but w/o resp. depression.

Dosing

0.05 mg/kg PF morphine + 0.025 mg/kg butorphanol
Total volumes are the same as for PF Morphine alone.

Problems

Final story on side effect profile is not in. Urinary retention and puritis do occur but are probably less frequent than with PF Morphine alone.

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Local Infusions (Bupivacaine)

Indications

G/U, Ortho Thoracic & Abd.

Special Considerations

Motor block must be acceptable.

Dosing

0.1 to 0.125%: rate depends on # of dermatomes to be blocked.
Max Infusion Rate: 0.5 mg/kg/hr infants < 1 month: 0.2 mg/kg/hr

Problems

Higher potential for systemic toxicity. Urinary retention probably common when sacral block is present.

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Fentanyl - Bupivacaine Infusions: (Fentanyl: 2 mcg/ml, Bupiv: 0.1%)

Indications

Thoracic, Abd. G/U & Ortho

Special Considerations

Site specific catheter. Some motor block may occur with prolonged use. Theoretically the best side effect profile. May work well for some ortho cases when postop muscle spasms are a problem. Good for thoracic catheters when narrow band of analgesia required.

Dosing

For Pediatrics: Rate depends on # of dermatomes to be blocked. Start at about 0.1 to 0.2 ml/kg/hr, max rate 0.5 ml/kg/hr. (0.2 ml/kg/hr for neonates) May need more for procedures crossing many dermatomes, less for thoracotomy & site specific catheter. In infants consider 0.05% bupivacaine to allow more volume.

Problems

Fewer narcotic side effects. Probably the least likely to be associated with urinary retention w/ high lumbar or thoracic catheter. Max dosing same as for plain bupivacaine. May increase the fentanyl conc. for cases using low infusion vol. (< 0.2 cc/kg/hr).

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PF Morphine-Bupivacaine Infusions: (PF Morphine: 15 to 40 mcg/cc, Bupiv.:0.1%)

Indications

As for F-B

Special Considerations

Site specificity still desired but range of "coverage" may be broader than w/ F-B.

Dosing

More dilute morphine (down to 15 mcg/ml) will allow more volume, hence local anesthetic, to be delivered. Max rate as for MS and/or bupivacaine as noted above. In infants consider 0.05% bupivacaine to allow more volume.

Problems

Side effect profile similar to plain morphine infusion.

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Clonidine

Indications

A supplement for SS caudals

Dosing

1 to 2 mcg/kg

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