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Background: A randomized prospective trial of marrow-versus-steroids treatment of solitary bone cyst was ongoing. Protocol required contrast injection of the cyst. A subpopulation was noted to have large, rapid venous outflow of contrast material (omnipaque). Central embolization and resultant acute respiratory distress syndrome has been reported with bone marrow transplant. Particulate injection can result in bradycardia, low exhaled CO2, decreased SaO2 and voltage changes on electrocardiogram. Methods: Precordial Doppler can measure flow and turbulence centrally after a peripheral cyst injection. Our cases were monitored with precordial Doppler as well as heart rate, ETCO2, blood pressure, electrocardiogram, and pulse oximetry. Results: Five patients/7 injections were noted to have large and rapid outflow veins from solitary bone cyst. The Doppler showed increased signal in all 7 particulate injections (2 steroid injections, 5 bone marrow aspirates and cyst injections.) One marrow injection resulted in transient bradycardia and decreased blood pressure with no sequelae. One developed transient decrease in exhaled CO2. Conclusions: Rapid outflow has been reported in the past but precordial Doppler monitoring of injection into peripheral cysts is not reported. The potential for embolization with serious physiologic effects is a concern. Others have advocated injection of more particulate substances, such as calcium, sulfate, and demineralized bone matrix. This Doppler technique may be valuable for monitoring the potential harmful effects of these injections and lead to a better understanding of failure of cyst healing due to rapid outflow of material. Level of Evidence: Level IV case series with poor reference standard.

The treatment of pain in children, the elderly, and intensive care unit patients presents some unique problems. Here a unifying theme is emphasized: the difficulty in adequately assessing pain in patients who are often unable to communicate. Also addressed are the differences in pharmacokinetics and pharmacodynamics from neonates to the elderly. Finally, common pain syndromes in each group, the associated treatments, and recent controversies are discussed. Because of changing demographics, pain treatment for these groups will become increasingly important. Only in the past 10 years has pediatric pain been treated with the same energy as adult pain; application of the newest techniques still lags far behind these patients' adult counterparts. Pain treatment in the elderly will inevitably become a larger problem as our population ages. Finally, recent advances in technology enable us to sustain patients with increasingly severe illnesses. Thus, pain management in these special populations will take on progressively greater importance.

The management of pain in terminally ill pediatric patients has incalculable benefits to patients, their families, and physicians and nurses. A therapeutic management plan is dependent on a thorough understanding of the causes of pain in these patients, on pain assessment, and on the myriad drugs and drug strategies that are essential in pain treatment. Aggressive symptom control of treatment-related side effects can ensure successful implementation of such a plan.

The past decade has brought about an explosion of knowledge about the physiology of nociception and many new techniques for pain relief, new analgesic drugs, and new applications of old analgesic drugs. These techniques include methods of opioid administration by transdermal and transmucosal absorption and the use of neuraxial analgesia for the management of pain in children. Interest in the use of regional anesthesia in children has been rekindled, and analgesic properties and pre-emptive analgesic properties of many agents not typically considered analgesics, such as clonidine and ketamine, have been recognized. Perhaps the greatest advance has been the paradigm shift in the recognition that pain not only exists in infants and children but also is a significant cause of morbidity and even mortality. Given the unprecedented interest in pain management in adults and children, physicians can now look forward to the development of new methods of drug delivery and of receptor-specific drugs that divorce analgesia from the untoward side effects of existing analgesics. Improvement in the quality of life of hospitalized children also will occur.