BNF for Children 2011-2012

640 15.1.4 Sedative and analgesic peri-operative drugs BNFC 2011–2012Diclofenac, ibuprofen (section 10.1.1), paracetamol(section 4.7.1), and ketorolac are used to relieve postoperativepain in children; diclofenac and paracetamolcan be given parenterally and rectally as well as bymouth. Ketorolac is given by mouth or by intravenousinjection.Toradol c (Roche) ATablets, ivory, f/c, ketorolac trometamol 10 mg, netprice 20-tab pack = £5.45. Label: 17, 21Injection, ketorolac trometamol 10 mg/mL, net price1-mL amp = 89p; 30 mg/mL, 1-mL amp = £1.0815 AnaesthesiaKETOROLAC TROMETAMOLCautions section 10.1.1; avoid in acute porphyria(section 9.8.2); interactions: Appendix 1 (NSAIDs)Contra-indications section 10.1.1; also complete orpartial syndrome of nasal polyps; haemorrhagic diatheses(including coagulation disorders) and followingoperations with high risk of haemorrhage or incompletehaemostasis; confirmed or suspected cerebrovascularbleeding; hypovolaemia or dehydrationHepatic impairment section 10.1.1Renal impairment max. 60 mg daily by intravenousinjection; avoid if serum creatinine greater than160 micromol/litre; see also section 10.1.1Pregnancy section 10.1.1Breast-feeding amount too small to be harmfulSide-effects section 10.1.1; also gastro-intestinal disturbances,taste disturbances, dry mouth; flushing,bradycardia, palpitation, chest pain, hypertension,pallor; dyspnoea, asthma; malaise, euphoria, psychosis,paraesthesia, convulsions, abnormal dreams,hyperkinesia, confusion, hallucinations, urinary frequency,thirst, sweating; hyponatraemia, hyperkalaemia,myalgia; visual disturbances (including opticneuritis); purpura, pain at injection siteLicensed use not licensed for use in children under16 yearsIndication and doseShort-term management of moderate to severeacute postoperative pain only. By mouthChild 16–18 years 10 mg every 4–6 hours asrequired; max. 40 mg daily; max. duration oftreatment 7 days. By intravenous injection over at least 15 secondsChild 6 months–16 years initially 0.5–1 mg/kg(max. 15 mg), then 500 micrograms/kg (max.15 mg) every 6 hours as required; max. 60 mgdaily; max. duration of treatment 2 days. By intravenous injection over at least 15 secondsChild 16–18 years initially 10 mg, then 10–30 mgevery 4–6 hours as required (up to every 2 hoursduring initial postoperative period); max. 90 mgdaily (children weighing less than 50 kg max.60 mg daily); max. duration of treatment 2 daysNote When converting from parenteral to oral administration,total combined dose on the day of convertingshould not exceed 90 mg (60 mg in children weighing lessthan 50 kg) of which the oral component should notexceed 40 mgKetorolac (Non-proprietary) AInjection, ketorolac trometamol 30 mg/mL, net price1-mL amp = £1.1015.1.4.3 Opioid analgesicsOpioid analgesics are now rarely used as premedicants;they are more likely to be administered at induction.Pre-operative use of opioid analgesics is generally limitedto children who require control of existing pain. Themain side-effects of opioid analgesics are respiratorydepression, cardiovascular depression, nausea, andvomiting; for general notes on opioid analgesics andtheir use in postoperative pain, see section 4.7.2.For the management of opioid-induced respiratorydepression, see section 15.1.7.Intra-operative analgesia Opioid analgesics given insmall doses before or with induction reduce the doserequirement of some drugs used during anaesthesia.Alfentanil, fentanyl, and remifentanil are particularlyuseful because they act within 1–2 minutes and haveshort durations of action. The initial doses of alfentanilor fentanyl are followed either by successive intravenousinjections or by an intravenous infusion; prolongedinfusions increase the duration of effect.Repeated intra-operative doses of alfentanil or fentanylshould be given with care since the resulting respiratorydepression can persist postoperatively and occasionallyit may become apparent for the first time postoperativelywhen monitoring of the child might be less intensive.Alfentanil, fentanyl, and remifentanil can causemuscle rigidity, particularly of the chest wall muscle orjaw muscle, which can be managed by the use of neuromuscularblocking drugs.In contrast to other opioids which are metabolised in theliver, remifentanil undergoes rapid metabolism by nonspecificblood and tissue esterases; its short duration ofaction allows prolonged administration at high dosage,without accumulation, and with little risk of residualpostoperative respiratory depression. Remifentanilshould not be given by intravenous injection intraoperatively,but it is well suited to continuous infusion;a supplementary analgesic is given before stopping theinfusion of remifentanil.Neonates The half-life of fentanyl and alfentanil isprolonged in neonates and accumulation is likely withprolonged use.ALFENTANILCautions section 4.7.2 and notes aboveContra-indications section 4.7.2Hepatic impairment section 4.7.2Renal impairment section 4.7.2Pregnancy section 4.7.2Breast-feeding present in milk—withhold breastfeedingfor 24 hours