Good Practice in Postoperative and Procedural Pain Management ...

Codeine dosing schedulesOral, intramuscular or rectal:Neonate or child: 0.5–1 mgÆkg )1 4–6 hourly (carewith repeated doses in neonates)DihydrocodeineDihydrocodeine is an opioid analgesic related tocodeine. It is used for the relief of moderate-to-severepain, often in combination with paracetamol. Theanalgesic effect of dihydrocodeine appears to be primarilydue to the parent compound (unlike codeine); itis metabolized in the liver via the cytochrome P450 isoenzymeCYP2D6 to dihydromorphine, which haspotent analgesic activity, and some is also convertedvia CYP3A4 to nordihydrocodeine.Dihydrocodeine dosing schedulesOral or intramuscular:>1 year: 0.5–1 mgÆkg )1 4–6 hourlyOxycodoneOxycodone can be given by mouth or by subcutaneousor intravenous injection for the relief of moderate-toseverepain (12). It can be given by continuous infusionor PCA. The oral potency is about twice that ofmorphine, whereas intravenously it is about 1.5 timesas potent. Although not widely used at present in theUnited Kingdom, it may be a useful and safe alternativeto morphine and codeine as an oral opioid.Oxycodone dosing schedulesOral: 100–200 mgÆkg )1 4–6 hourlyTramadolTramadol hydrochloride is an opioid analgesic withnoradrenergic and serotonergic properties that maycontribute to its analgesic activity (13,14). Tramadolcan be given by mouth, intravenously, or as a rectalsuppository. It has also been given by infusion or aspart of a PCA system.Tramadol is increasingly used in children of all agesand has been shown to be effective against mild-tomoderatepain. It may produce fewer typical opioidadverse effects such as respiratory depression, sedation,and constipation; though, it demonstrates a relativelyhigh rate of nausea and vomiting.Tramadol dosing schedules:Oral, rectal, or intravenous: 1–2 mgÆkg )1 4–6 hourlyFentanylFentanyl is a potent opioid analgesic related to pethidineand is primarily a l-opioid agonist. It is morelipid soluble than morphine and it has a rapid onsetand short duration of action. Because of its high lipophilicity,fentanyl can also be delivered via the transdermal(±iontophoresis) or transmucosal routes.Small intravenous bolus doses can be injected immediatelyafter surgery for postoperative analgesia andPCA systems have been used.After transmucosal delivery, about 25% of the dose israpidly absorbed from the buccal mucosa; the remaining75% is swallowed and slowly absorbed from the gastrointestinaltract. Some first-pass metabolism occurs viathis route. The absolute bioavailability of transmucosaldelivery is 50% of that for intravenous fentanyl.Absorption is slow after transdermal application.The clearance is decreased and the half-life of fentanylis prolonged in neonates. As with morphine, neonatesare more susceptible to the adverse effects offentanyl, and appropriate monitoring and safety protocolsshould be implemented when fentanyl is used inthis age group. There are differences in pharmacokineticsbetween bolus doses and prolonged infusionwith highly lipophilic drugs such as fentanyl; the context-sensitivehalf-time progressively increases with theduration of infusion.Fentanyl dosing schedulesAn appropriate monitoring protocol should be useddependent on the route of administration and age ofthe child. For neuraxial dosing, see section 6.3.Intravenous dose: titrated according to response0.5–1.0 mcgÆkg )1 (decrease in neonates)Intravenous infusion: 0.5–2.5 mcgÆkg )1 Æh )1Transdermal: 12.5–100 mcgÆh )1RemifentanilRemifentanil is a potent short-acting l-receptor opioidagonist used for analgesia during induction and/ormaintenance of general anesthesia. It has also been usedto provide analgesia into the immediate postoperativeperiod. Remifentanil is given intravenously, usually byinfusion. Its onset of action is within 1 min and theduration of action is 5–10 min. Remifentanil is metabolizedby esterases and so its half-life is independent ofthe dose, duration of infusion, and age of child.Remifantanil is a strong respiratory depressant. Itcan be used in the spontaneously breathing patient as74 ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79