GENERAL PRINCIPLES

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GENERAL PRINCIPLES
N.B. This document is intended for use primarily in the peri-operative setting.
1. Prevention is better than cure: it is important to maintain analgesia with regular
dosing, rather than waiting for severe pain and trying to treat this.
2. The dosages in this guide assume that children are healthy (ASA 1 or 2). It
excludes:
 Neonates
 Children aged < 6 months
 Children with hepatic or renal impairment
 Children with significant CNS disease
 Children with significant respiratory depression
3. It is best to provide a balanced approach to analgesia e.g. intra-operative local
anaesthetic +/- simple analgesic +/- opioid.
Simple Analgesics– PLEASE ALWAYS PRESCRIBE THIS FOR EVERY
CHILD BEFORE THEY LEAVE THEATRE
e.g. paracetamol, NSAIDs
 Non-narcotic, non-addictive, non-sedative
 Suitable for mild to moderate pain
 Generally oral or rectal administration
 Reduce post-operative opioid requirements
Opioid Analgesics
e.g. morphine
 May be administered orally, subcutaneously or I.V. (intermittent bolus or PCA)
N.B. IM administration should be avoided where possible as this is distressing for
the child
Main side-effects include:
 Respiratory depression
 Drowsiness
 Nausea and vomiting
 Delayed gastric emptying
N.B. Addiction does not occur in short-term analgesic setting
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SIMPLE ANALGESICS
PARACETAMOL
Paracetamol may be used alone after minor procedures, or given concurrently with
an opioid after more major procedures. It also has an antipyretic action. It can be
given rectally, but absorption is slow and bioavailability is poor by this route.
It is a very safe drug (caution in liver disease) and may be used in neonates.
Acute overdose is often due to error in dose calculation.
Over-dose may cause liver damage, sometimes undetectable for several days.
TOXICITY is usually due to chronic use => limit use to 5days;
limit to 3 days if liver disease, viral illness, or age < 3 months.
Formulations:
Tablets - 500mg (also soluble)
Suspension – 120mg /5mls, 250mg /5mls
Suppositories - 60mg, 120mg, 240mg, 500mg (refrigerated)
*Intravenous (Perfalgan) – 500mg or 1g vials (10mg/ml)
DOSE
Loading Dose : oral 20 mg/kg
: pr 40 mg/kg
: loading dose not recommended for i.v. administration
Maintenance : (any route) 15 mg / kg 4-6 hourly
Maximum 90 mg/kg in 24h (maximum 60mg/kg/day i.v.)
Review dosage after 72h.
Neonates :
Restrict loading dose to 20mg / kg
Increase dosing interval 8-12h
Maximum dose 60 mg/kg in 24h.
Review dosage after 48h.
*Notes on intravenous paracetamol:
Not recommended in children and infants <10 kg
i.v. paracetamol dose to be infused over a period of 15 minutes
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NSAIDS:
 Analgesic
 Anti-inflammatory
Side-effects include gastric irritation, renal failure, exacerbation of asthma and
occasionally post-operative bleeding.
AVOID in
 Severe asthma (i.e. child who has required hospitalisation for asthma, or who is
taking oral steroids)
 Renal failure
 Infants <1 year (renal immaturity)
 Coagulopathy or bleeding disorder
 (GI ulcer)
 Aspirin is contra-indicated in children <12y due to rare but serious complication
of Reye’s Syndrome
DICLOFENAC
Formulations:
Suppositories – 12.5mg, 25mg, 50mg, 100mg
Dispersible tablets – 50mg
EC tablets – 25mg, 50mg
DOSE
1 – 3 mg per kg per dose (Oral: 1mg/kg 8hourly)
Maximum 3mg / kg in 24 hours (maximum 150mg / day)
KETOROLAC (IV)
0.5 – 1.0 mg/kg (max 15mg), followed by bolus injections of 0.5 mg/kg 6 hourly
The maximum daily dosage is 90mg, and the maximum duration of treatment is 48
hours.
IBUPROFEN
This may be preferable to diclofenac for oral administration as it is available as a
suspension
Formulations: (oral only):
Suspension – 100mg / 5ml
Tablets - 200mg, 400mg
DOSE
10 mg / kg 8hourly
or 5 mg / kg 6 hourly
PIROXICAM - FELDENE MELT (20mg tablets)
 licenced for 16year olds
 but licenced for juvenile arthritis at 6years
 once daily administration
 0.4 mg / kg
3
OPOID ANALGESICS
 effective in moderate to severe pain.
 Opioid requirements are decreased by the concomitant use of simple analgesics
(though opioid side-effects may still be evident)
Main side-effects include:
 Respiratory depression
 Nausea and vomiting
 Delayed gastric emptying, constipation
 Drowsiness
 Avoid use in head injury or raised intracranial pressure (may cause respiratory
depression, pupillary constriction)
1. Oral Formulations
DIHYDROCODEINE (DF118)
Not to be used for children under one year or those with (potential) respiratory
depression.
Formulations:
Elixir – 10mg / 5ml
Tablets – 30mg
DOSE
1 - 4 years = 0.5 mg / kg 6 hourly
4+ years = 0.5 - 1 mg / kg 6 hourly
(max dose = 30mg)
ORAMORPH
Oral solution of morphine sulphate. May be used in severe pain in children
provided oral intake is adequate (e.g. not suitable immediately post-op
appendicectomy / trauma etc until oral intake re-established).
DOSE
0.3 mg / kg 4hourly
 monitor Spo2 if 2nd dose required
CODEINE PHOSPHATE
Recently there has been concern that Codeine could cause respiratory
depression in children who are rapid metabolisers. We now avoid using
codeine in children who will not be observed in hospital.
Oramorph at a dose of 0.1 – 0.2mg/kg is a suitable alternative to oral codeine
in the post-operative period.
4
PARENTERAL ANALGESICS
MORPHINE
Morphine is an opioid analgesic used to control severe pain in children.
It should be avoided in neonates if possible and used with caution in children under
6 months (consider apnoea monitor, esp. in ex-prem)
Morphine can be given by IV bolus or PCA.
Subcutaneous administration is no longer recommended.
All children receiving systemic opioids should be monitored closely.
IV bolus:
0.1 – 0.2 mg / kg 2 hourly
( 0.05 mg / kg as bolus if IV morphine infusion running)
PCA:
N.B. Dedicated cannula or anti-reflux valve required
Suitable for cooperative children 6y+
Child, parents and nursing staff should all understand principles!
Dilution : child’s body weight (kg) in mg diluted in 50ml normal saline (20
micrograms / kg / ml)
PCA bolus = 0.5 –1ml (10 – 20 mcg / kg); lockout 5 minutes
Consider background 0.2 ml/h (4 mcg/kg/h); background infusion should only be
used in a high-dependency area.
IV Infusion: this should only be used in a high-dependency area and should be
avoided if at all possible.
N.B. Dedicated cannula or anti-reflux valve required
Infusion rate : 0.5 – 2 ml/h (= 10 – 40 micrograms / kg / h)
IM injections may be distressing to children and should be avoided where possible.
IM dosage:
Up to 1 year : 0.2 mg / kg 4hourly
Over 1 year : 0.2 – 0.4 mg / kg 4hourly
5
TRAMADOL HYDROCHLORIDE
Tramadol is not licensed for children under the age of 12 years.
DOSAGE
12 – 18 years = 50 – 100 mg q 4h oral or i.v.
OPIOID ANTAGONIST = NALOXONE
Dose = 2-10 mcg/kg bolus. Repeat every 60sec as required.
Infusion = 10mcg/kg/h.
If no i.v. access, IM dose = 100mcg/kg
6
Nausea and Vomiting
 Minimise opioid use (e.g. LA use, NSAID, paracetamol)
 Anti-emetics are not prescribed routinely in children due to an increased risk of
extrapyramidal side-effects (e.g. oculogyric crisis)
 Newer anti-emetics e.g. ondansetron and dexamethasone may have an improved
safety profile
 Children > 12y can use adult anti-emetic regimens
 Anti-emetics should be administered systemically rather than orally whenever
possible
 Combination therapy intra-operatively is more effective than single agent use
 Post-operative anti-emetics should be given for treatment of persistent postoperative nausea and vomiting which is severe enough to prevent the ingestion
of oral analgesics or fluids.
Anti-emetics
1. ONDANSETRON
0.1 mg / kg by slow IV injection (maximum 4mg) 8 hourly prn
2. DEXAMETHASONE
0.15 – 0.25 mg/kg by slow IV injection (maximum 8mg) intra-op.
3. PROCHLORPERAZINE
Formulations: Suppositories – 5mg, 25mg
(Syrup – 5mg / 5ml)
DOSAGE
0.25 mg/kg pr (to the nearest 5mg)
( oral dose 0.25 mg/kg)
4. METOCLOPRAMIDE
To be administered by slow IV injection:
<1y (10kg)
1mg 12h
1 – 3y (10 – 14kg)
1mg 8h
3 – 5y (15 – 19 kg)
2mg 8h
5 – 9y (20 – 29kg)
2.5mg 8h
9 – 14y (30kg+)
5mg 8h
14y+ (60kg+)
10mg 8h
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REFERENCES
1. Postoperative Analgesia Protocols: Royal Hospital for Sick Chidren, Edinburgh
(Dr. E. Doyle)
2. Paediatric Acute Pain Protocols: Royal Hospital for Sick Children, Yorkhill,
Glasgow (Dr. N. Morton, S/N S. Aitkenhead)
3. Howell, TK. Paracetamol use in Children. Care of the Critically Ill 1999; 15:
208-213
4. Howell, TK. What we should know about paracetamol. Paediatric Anaesthesia
1999; 9: 367
5. Korpela R, Olkkola KT. Paracetamol – misused good old drug? Acta
Anaesthesiologica Scandinavica 1999; 43: 245-247
6. Birmingham PK et al. Twenty-four-Hour Pharmacokinetics of Rectal
Acetaminophen in Children. Anesthesiology 1997; 87: 244-252
7. Howell, TK. Post-operative Pain Relief: Doing Simple Things Better. (lecture
and report) Seventh Annual Paediatric Anaesthesia Update, Manchester, Jan
2000
8. Ward B, Alexander-Williams JM. Paracetamol revisited. Acute Pain 1999; 2:
139-149
9. Morton NS. Prevention and control of pain in children. British Journal of
Anaesthesia 1999; 83: 118-129
10.Pain in children. Acute Pain Management: scientific evidence. P93-108 (source:
http://www.health.gov.au/nhmrc/publicat/pdf/cp57.pdf)
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APPENDIX
Suggested Analgesic Regimens for some Common Procedures
These suggestions are for guidance only. It is up to the individual clinician to
decide upon the most appropriate regimen for each patient.
A balanced analgesic regimen is ideal e.g. intra-operative opioid plus
supplementation with pr NSAID plus local anaesthetic technique if appropriate.
If NSAIDs are contra-indicated, consider the use of i.v. paracetamol intraoperatively.
Caudal analgesia:
 the usual dose is 0.8 – 1ml/kg of 0.25% bupivacaine (maximum dose 20ml).
 The use of additives; It is up to the individual to decide whether or not to add an
adjunct to the caudal in order to increase duration of action
e.g. Clonidine 2 microgrammes/kg
We DO NOT recommend Ketamine due to concerns about neurotoxicity
Step-Down Analgesia
This may be required after procedures where the child has been prescribed
parenteral opioids post-operatively e.g. PCA morphine.
 Always prescribe a simple analgesic in addition to the opioid e.g. paracetamol or
NSAID
 Never prescribed oral opioid (e.g. dihydrocodeine) at the same time as parenteral
opioid
 Oral opioid (e.g. dihydrocodeine) may require to be prescribed when PCA is
removed.
9
Intra-op:
Post-op:
To Take Away
(TTA):
Intra-op:
Post-op:
Intra-op:
Post-op:
Intra-op:
Post-op:
Tonsillectomy
Fentanyl (~2/3 - 1 mcg/kg) +
morphine (~0.05 mg/kg) +
IV paracetamol +
NSAID (oral ibuprofen premed or pr voltarol)
Paracetamol +
ibuprofen +
oramorph 0.1 - 0.2 mg/kg prn +
ondansetron prn
Paracetamol +
ibuprofen +
difflam spray +
dihydrocodeine
We are planning on also giving them a few doses of
oramorph TTA (o.1 - 0.15 mg/kg). Pharmacy arrangements
need to be finalised
Circumcision
Caudal or penile block
Lignocaine gel or EMLA cream TTA
Paracetamol plus ibuprofen TTA
Inguinal hernia
Caudal or ilio-inguinal block or LA infiltration
Paracetamol plus ibuprofen TTA
Appendicectomy, Laparotomy
IV morphine
Plus LA infiltration, TAP Block or wound catheter
Plus pr diclofenac or IV Ketorolac
PCA morphine (>6y with good understanding)
Plus paracetamol (oral or i.v.)
Intra-op:
Post-op:
Orthopedics e.g. MUA, ORIF
Diclofenac
+/- Fentanyl where appropriate
Plus LA infiltration where appropriate
Paracetamol plus ibuprofen +/- dihydrocodeine / oramorph if
appropriate
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