Background/Objectives: Abdominal aortic aneurysms (AAAs) are exceedingly rare in pediatric patients but carry a significant risk of rupture, necessitating urgent surgical repair. Postoperative pain management following open AAA repair is particularly challenging and ultrasound-guided rectus sheath blocks (RSBs) offer a targeted and lower-risk alternative for midline abdominal incisions. Methods: We present an 8-yeaer old male who underwent open infrarenal AAA repair. Multilevel bilateral ultrasound-guided RSBs were performed at T7, the umbilicus and T12 using a mixture of liposomal bupivacaine, bupivacaine, and dexamethasone. Results: Postoperative pain scores remained consistently low through postoperative day (POD) 6, with minimal opioid requirements. Functional recovery was rapid, with sitting achieved by POD 1 and ambulation by POD 2. Plasma bupivacaine concentrations remained within safe limits throughout hospitalization. Conclusions: Multilevel bilateral RSBs with liposomal bupivacaine and dexamethasone provided prolonged opioid-sparing analgesia, facilitated early mobilization, and supported enhanced recovery in this complex pediatric surgical case.

Background/Objectives: Abdominal aortic aneurysms (AAAs) are exceedingly rare in pediatric patients but carry a significant risk of rupture, necessitating urgent surgical repair. Postoperative pain management following open AAA repair is particularly challenging and ultrasound-guided rectus sheath blocks (RSBs) offer a targeted and lower-risk alternative for midline abdominal incisions. Methods: We present an 8-year-old male who underwent open infrarenal AAA repair. Multilevel bilateral ultrasound-guided RSBs were performed at T7, the umbilicus and T12 using a mixture of liposomal bupivacaine, bupivacaine, and dexamethasone preservative free (PF). Results: Postoperative pain scores remained consistently low through postoperative day (POD) 6, with minimal opioid requirements. Functional recovery was rapid, with sitting achieved by POD 1 and ambulation by POD 2. Plasma bupivacaine concentrations remained within safe limits throughout hospitalization. Conclusions: Multilevel bilateral RSBs with liposomal bupivacaine, bupivacaine, and dexamethasone PF provided prolonged opioid-sparing analgesia, facilitated early mobilization, and supported enhanced recovery in this complex pediatric surgical case.

Background: Continuous epidural analgesia is widely used for postoperative pain management in neonates and small-weight infants. Epidural catheters may be inserted via a caudal-threaded approach or by direct lumbar/thoracic placement; however, comparative data on placement success, clinical use, postoperative analgesic outcomes, and complications remain limited. This study compared these two epidural techniques in neonates and small-weight infants undergoing surgery.Methods: This retrospective observational cohort study included all neonates and infants admitted to the Neonatal Intensive Care Unit at UPMC Children's Hospital of Pittsburgh who underwent attempted epidural catheter placement between January 2018 and December 2024. Demographic and perioperative data were extracted from the electronic medical record. Outcomes included patient, surgical, and epidural characteristics, epidural medications, postoperative pain and sedation scores, opioid consumption, technical success of catheter placement, and epidural catheter complications. Results: A total of 104 patients underwent attempted epidural catheter placement; five procedures were unsuccessful in four patients, resulting in 100 successful epidural catheter placements (70 caudal-threaded and 30 direct lumbar/thoracic). Epidural catheter placement was successful in 96.2% of patients. Patient and surgical characteristics, postoperative pain and sedation scores, and opioid consumption were similar between groups. Direct lumbar/thoracic epidural catheter placement required longer procedure times. Patients in the direct lumbar/thoracic epidural group were more likely than those in the caudal-threaded group to receive a ropivacaine/clonidine infusion (47% vs. 4%; p < 0.001) and a programmed intermittent bolus of epidural infusion (60% vs. 3%; p < 0.001). The direct lumbar/thoracic group experienced more postoperative catheter-related complications than the caudal-threaded group (20% vs. 4%; p = 0.02), primarily catheter leakage requiring premature catheter removal. Conclusions: Caudal-threaded and direct lumbar/thoracic epidural catheters provided comparable postoperative analgesic outcomes in neonates and small-weight infants when placed by a Pediatric Acute Pain Service. Direct lumbar/thoracic epidural catheters were associated with a higher incidence of postoperative catheter leakage and premature catheter removal. These findings may help clinicians select the most appropriate epidural technique for postoperative pain management in this population.

Background/Objectives: Continuous epidural analgesia is desirable for improving infant outcomes after surgeries. However, its contribution to facilitating extubation is not well known. Methods: A retrospective chart review was conducted at the UPMC Children’s Hospital of Pittsburgh to identify all infants who received an epidural catheter between 2018 and 2024 and required postsurgical admission to the Neonatal Intensive Care Unit (NICU). The study examined the timing of extubation and reintubation, along with associated factors, in 100 infants who underwent major surgeries. Results: In total, 100 infants, 43 females and 57 males, 40 (38.39–42.07) weeks corrected gestational age, 3 (2.52–3.42) kg received epidural catheters. Sixty-two patients had a pulmonary condition. Of 45 infants extubated in the operating room, 32 received fentanyl intraoperatively, and 16 required a morphine infusion in the NICU. Among 55 infants that remained intubated, 24% underwent a thoracic procedure, 46 received intraoperatively fentanyl, and 21 needed an opioid infusion postoperatively. The extubation day was median (IQR) 2 (1–4), and 24% remained intubated beyond day 5. Twelve infants were intubated preoperatively, and six required prolonged ventilation beyond day 5. Of 15 infants that required reintubation, 8 received a morphine infusion. The medians (IQR) of the average of three pain and sedation scores before reintubation were 1.67 (1–3) and 0 (−1.67–0), respectively. Conclusions: Epidural analgesia may facilitate early extubation in some infants undergoing surgeries. Morphine infusion was administered at a similar rate between infants extubated and those who remained intubated, and its role in delaying extubation timing remains unclear.

Background: Continuous epidural analgesia is widely used for postoperative pain management in small infants. Epidural catheters may be inserted via a caudal-threaded approach or by direct lumbar/thoracic placement; however, comparative data on placement success, clinical use, postoperative analgesic outcomes, and complications remain limited. This study compared these two epidural techniques in small-weight infants undergoing surgery. Methods: This retrospective observational cohort study included all infants admitted to the Neonatal Intensive Care Unit at UPMC Children’s Hospital of Pittsburgh with documented epidural catheter placement in the chart between January 2018 and December 2024. Demographic and perioperative data were extracted from the electronic medical record. Outcomes included technical success of catheter placement; patient, surgical, and epidural characteristics; epidural medications; postoperative pain and sedation scores; opioid consumption; and epidural catheter complications. Results: A total of 104 patients had documentation of 105 epidural catheter placements in the chart; five procedures were unsuccessful in four patients, resulting in 100 successful epidural catheter placements (70 caudal-threaded and 30 direct lumbar/thoracic). Patient and surgical characteristics, postoperative pain and sedation scores, and opioid consumption did not differ significantly between groups. Direct lumbar/thoracic epidural catheter placement required longer procedure times. Patients in the direct lumbar/thoracic epidural group were more likely than those in the caudal-threaded group to receive a ropivacaine/clonidine infusion (47% vs. 4%; p < 0.001) and a programmed intermittent bolus of epidural infusion (60% vs. 3%; p < 0.001). The direct lumbar/thoracic group experienced more postoperative catheter-related complications than the caudal-threaded group (20% vs. 4%; p = 0.02), primarily catheter leakage requiring premature catheter removal. Conclusions: Epidural catheter placement was successful in 96.2% of patients. No statistically significant between-group differences were detected in postoperative pain scores, sedation scores, or opioid consumption between caudal-threaded and direct lumbar/thoracic epidural catheters in small-weight infants (median 3 kg) when placed by a Pediatric Acute Pain Service. Direct lumbar/thoracic epidural catheters were associated with a higher incidence of postoperative catheter leakage and premature catheter removal; however, these complications cannot be attributed solely to the location of epidural catheter insertion. These findings may help clinicians select the most appropriate epidural technique for postoperative pain management in this population.