Good Practice in Postoperative and Procedural Pain Management ...

Table 6.5.1NSAIDDosemgÆkg )1IntervalhoursMaximum daily dosemgÆkg )1 Æday )1Licensedfrom ageIbuprofen 5–10 6–8 30 3 monthsDiclofenac 1 8 3 6 monthsKetorolac a 0.5 6 2Naproxen 7.5 12 15Piroxicam a 0.5 24 0.5 N/RKetoprofen a 1 6 4a High incidence of GI complications. Not licensed for acutepain.6.5.2 NSAID toxicity and side effectsBecause of their mechanism of action, NSAIDs havethe potential to cause adverse effects at therapeuticplasma levels.l Hypersensitivity reactionsl NSAIDs reduce platelet aggregation and prolongbleeding time. Therefore, they are usually contraindicatedin children with coagulation disorders or inthose who are receiving anticoagulant therapy.l NSAIDs can inhibit prostaglandin-mediated renalfunction, and this effect is greater in the presence ofrenal disease and dehydration. Ibuprofen has beenshown to reduce the glomerular filtration rate inneonates by 20%. NSAIDs should not be administeredconcurrently with nephrotoxic agents. Renaltoxicity is low in healthy children.l NSAIDs can cause gastric irritation and bleeding.They are therefore relatively contraindicated in childrenwith a history of peptic ulcer disease. Ibuprofenhas the lowest potential for gastric irritation. The riskof adverse GI effects is low when NSAID use is limitedto 1–3 days in the postoperative period; it may be furtherreduced by co-prescription of proton pump inhibitors,for example, omeprazole and H2 antagonists inpatients at higher risk. Piroxicam, ketorolac, and ketoprofenare known to be especially likely to cause GI sideeffects particularly in the elderly. In the UK, piroxicamis no longer licensed for acute indications and is subjectto special prescribing and monitoring restrictions.l Owing to excess leukotriene production, NSAIDshave the potential to exacerbate asthma in a predisposedsubset of asthmatics. It is estimated that 2% ofasthmatic children are susceptible to aspirin-inducedbronchospasm and 5% of this subgroup are likely tobe cross-sensitive to other NSAIDs, that is, 1:1000.The incidence of asthma in children is increasing, andit is important that children who are not sensitive arenot denied the benefits of NSAIDs. History of previousuneventful NSAID exposure should be establishedin asthmatic children whenever possible.Studies have provided some reassuring data regardingthe safety of short-term use of ibuprofen and diclofenacin asthmatic children. NSAIDs should be avoidedin children with severe acute asthma.l NSAIDs should be used with caution in childrenwith severe eczema, multiple allergies, and in thosewith nasal polyps. NSAIDs should be avoided in liverfailurel Animal studies using high doses of Ketorolac demonstrateddelayed bone fusion. This has led to concernthat the use of NSAIDs in children may delay bonehealing following fracture or surgery. This has notbeen supported by human studies, and the analgesicbenefits of short-term NSAID use outweigh the hypotheticalrisk of delayed bone healing: see section 5.8.l NSAIDs are not currently recommended for analgesiain neonates due to concerns that they mayadversely affect cerebral and pulmonary blood flowregulation.Of the NSAIDs currently available, ibuprofen has thefewest side effects and the greatest evidence to supportits safe use in children. In a large community-basedstudy in children with fever, the risk of hospitalizationfor GI bleeding, renal failure, and anaphylaxis was nogreater for children given ibuprofen than those givenparacetamol (15).6.6 ParacetamolParacetamol is a weak analgesic (16,17). On its own, itcan be used to treat mild pain; in combination withNSAIDs or a weak opioid such as codeine, it can beused to treat moderate pain. Studies have demonstratedan opioid sparing effect when it is administeredpostoperatively.6.6.1 Paracetamol preparations, doses, androutesParacetamol is available for oral administration insyrup, tablet, and dispersible forms. Following oraladministration, maximum serum concentrations arereached in 30–60 min. As the mechanism of action iscentral, there is a further delay before maximum analgesiais achieved. Suppositories are available; however,there is wide variation in the bioavailability of paracetamolfollowing rectal administration. Studies have demonstratedthe need for higher loading doses (of the76 ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79