Good Practice in Postoperative and Procedural Pain Management ...

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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
a low-dose infusion but the child must be nursed in anappropriate area with adequate monitoring. Whenappropriate, alternative analgesics should be givenbefore stopping remifentanil, in sufficient time to providecontinuous and more prolonged pain relief.6.4.2 Opioid toxicity and side effectsOpioids have a wide range of effects on a number of differentorgan systems (See Table 6.4.2). These providenot only clinically desirable analgesic effects but also thewide range of adverse effects associated with opioid use.The profile of side effects is not uniform between theopioids or even between patients taking the same opioid.The incidence and severity of side effects in anindividual patient are influenced by a number ofgenetic and developmental factors and therefore appropriatemonitoring and adverse effect managementshould be performed with the use of opioids.Table 6.4.2 Physiological effects of opioidsCentral nervous systemAnalgesiaSedationDysphoria and euphoriaNausea and vomitingMiosisSeizuresPruritisPsychomimetic behaviors, excitationRespiratory systemAntitussiveRespiratory depressionfl respiratory ratefl tidal volumefl ventilatory response to carbon dioxideCardiovascular systemMinimal effects on cardiac outputHeart rateBradycardia seen on most occasionsVasodilation, venodilationMorphine other opioids ? histamine effectGastrointestinal systemfl intestinal motility and peristalsis› sphincter toneSphincter of oddiIleocolicUrinary system› ToneUterusBladderDetrusor muscles of the bladderMusculoskeletal system› chest wall rigidity6.5 Nonsteroidal anti-inflammatory drugs(NSAIDs)NSAIDs are effective for the treatment of mild ormoderate pain in children. In addition to analgesia,they have anti-inflammatory and antipyretic effects.They are opioid sparing. The combination of NSA-IDs and paracetamol produces better analgesia thaneither drug alone. Their mechanism of action is theinhibition of cyclooxygenase (COX) activity, therebyblocking the synthesis of prostaglandins and thromboxane.Aspirin, a related compound, is not used inchildren because of the potential to cause Reye’ssyndrome.6.5.1 NSAID preparations, dose, and routesA number of convenient NSAID formulations areavailable:l Ibuprofen tablet and syrup formulations for oraladministration and a dispersible tablet for sublingualadministrationl Diclofenac tablet (dispersible and enteric coated),suppository and parenteral formulationsllKetorolac for intravenous useNaproxen oral tabletsl Piroxicam oral tablets and a dispersible sublingualformulationl Ketoprofen oral tablets and syrup, parenteral formulationsSelective COX 2 inhibitors have been developed withthe expectation that the analgesic and anti-inflammatoryeffects of NSAIDs would be retained while reducingthe risk of gastric irritation and bleeding.However, in adult studies potential improvements insafety have been offset by an increase in the incidenceof adverse cerebral and cardiac thrombotic events.Reports of the use of selective COX-2 inhibitors inchildren are appearing in the literature, which demonstrateequal efficacy with nonselective NSAIDs. However,their role in pediatric practice is yet to beestablished. Pharmacokinetic data for the neonatal useof ibuprofen have been established from its use in patentductus arteriosus closure. Clearance is reduced andthe volume of distribution is increased. However, itsuse as an analgesic below age 3 months is not recommended,see section 6.5.3.ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79 75
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PediatricAnesthesiaVolume 22 Supple
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doi: 10.1111/j.1460-9592.2012.3838.
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1.6 Contact informationCorresponden
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RecommendationsChildren’s self-re
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Topical anesthetic preparations, fo
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2.7.6 Laparoscopic surgeryGood prac
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In order to assess pain, effective
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Postoperative painl NCCPC-PV (Non-C
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68 Broome ME, Richtsmeier A, Maikle
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however, reductions in the response
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increased success rate (i.e., less
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Newer preparations such as liposoma
Page 26 and 27: Good practice pointLubricant contai
Page 28 and 29: most effective. There are a number
Page 30 and 31: 12 Bellieni C, Bagnoli F, Perrone S
Page 32 and 33: venipuncture pain in a pediatric em
Page 34 and 35: 172 van Twillert B, Bremer M, Faber
Page 36 and 37: necessary to ensure that the patien
Page 38 and 39: when compared with LA alone and sal
Page 40 and 41: Peribulbar block improves early ana
Page 42 and 43: Analgesia Table 5.5.1 Sub-umbilical
Page 44 and 45: was more effective with less motor
Page 46 and 47: with using landmark techniques (205
Page 48 and 49: Good practice pointWound infiltrati
Page 50 and 51: Analgesia Table 5.6.4 Urological Su
Page 52 and 53: (298). Ketorolac did not influence
Page 54 and 55: well as the epidural technique for
Page 56 and 57: Good practice pointA multi-modal an
Page 58 and 59: 14 Grainger J, Saravanappa N. Local
Page 60 and 61: day-stay unit. Int J Paediatr Dent
Page 62 and 63: tinuous epidural infusion in childr
Page 64 and 65: 245 Morton NS, O’Brien K. Analges
Page 66 and 67: 321 Taenzer AH, Clark C, Taenzer AH
Page 68 and 69: Section 6.0AnalgesiaContents6.1 Ana
Page 70 and 71: enhance systemic absorption. Lidoca
Page 73 and 74: undergoes hepatic biotransformation
Page 75: tein binding are reduced and the ha
Page 79 and 80: Table 6.6.1 Paracetamol dosing guid
Page 81: steps that health care professional
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