Plan

A. Opioid Use for Moderate to Severe Pain. Consider opioids (IV versus oral), if severe pain. Tailor analgesic regimen to meet patient's needs (Table I—18).

1. For moderate to severe pain, start treatment with IV morphine. Patient may require repeated doses every 15-30 minutes, titrated to achieve pain relief. Patients on home oral opioids may be opioid tolerant and require higher doses of morphine (1.5-2 times or more standard starting dose); titrate dose by assessing between each dose.

2. If patient is unable to tolerate morphine due to adverse effects, hydromorphone is an alternative. When switching from one

TABLE I—18. OPIOID DOSING FOR PAIN IN INFANTS, CHILDREN, AND ADOLESCENTS

Opioid Drug

Parenteral Dosing Range

Oral Doslng Range

Morphine

0.05-0.1 mg/kg q3-4h

0.15-0.3 mg/kg q3-4h

Hydromorphone

0.01 mg/kg q3-4h

0.05 mg/kg q3-4h

Fentanyl

0.5-1.5 mcg/kg q30min

NA

Oxycodone

NA

0.1-0.2 mg/kg q3-4h

Codeine

NA

0.5-1 mg/kg q3-4h

NA = not applicable.

NA = not applicable.

opioid to another, decrease dose of new opioid because tolerance to the new opioid may be less.

3. Avoid meperidine in patients with sickle cell disease, renal failure, or renal disease. Accumulation of normeperidine metabolite may precipitate seizures.

4. If patient experiences adequate pain relief with 1-2 doses of IV opioids, consider giving acetaminophen-codeine or acetamin-ophen-oxycodone every 4 hours. Oxycodone alone may be used if there is concern over total acetaminophen dose.

5. Oral route is preferred whenever possible, unless patient is unable to take oral medication or pain is severe enough to require rapid management.

6. If multiple doses of IV opioids are needed to achieve pain relief, initiate IV morphine or hydromorphone around-the-clock or start patient-controlled analgesia (PCA), if patient is cognitive-ly, developmentally, and physically able to manage.

B. PCA. Consider intermittent PCA versus intermittent PCA plus basal infusion (Table I-19).

1. PCA allows patients to self-titrate to an acceptable level of comfort, giving them some control in their care. Children with sickle cell disease who are known to be opioid tolerant will need a larger PCA intermittent dose to obtain analgesia.

2. A low-dose basal infusion given with PCA helps maintain analgesia during sleep, minimizing patient waking due to severe pain. Opioid-tolerant patients handle basal infusions well, but use caution in opioid-naive patients because the basal infusion bypasses the inherent safety mechanism that occurs when an awake patient titrates his or her analgesia. See Table I-19 for PCA dosing guidelines.

C. Conversion to Oral Opioids (Table I-20). Remember when converting oral to parenteral opioid administration, or vice versa, that lower parental narcotic doses are required compared with oral doses. It is important that patients receive adequate oral opioid doses to maintain analgesia after discharge. Codeine is a relatively weak opioid, and between 4% and 12% of patients lack the enzyme that converts codeine to morphine, which is the source of

TABLE I—19. PCA DOSING FOR OPIOID-NAIVE PATIENTS WITH PAIN (INFANTS, CHILDREN, AND ADOLESCENTS)

Opioid

PCA Dose

Lockout Time

Basal Ratea

1-Hour Maximum

Morphine

0.02 mg/kg

6-12 min

0-0.02 mg/kg/h

0.1 mg/kg

Hydromorphone

0.003-0.004 mg/kg

6-12 min

0.003-0.004 mg/kg/h

0.02 mg/kg

Fentanyl

0.5 mcg/kg

6-12 min

0-0.5 mcg/kg/h

2.5 mcg/kg

PCA = patient-controlled analgesia. a As continuous infusion.

PCA = patient-controlled analgesia. a As continuous infusion.

TABLE I-20. COMPARISON OF NARCOTIC ANALGESICS USED FOR PAIN IN INFANTS, CHILDREN, AND ADOLESCENTS

IV Equianalgesic

PO Equianalgesic

Analgesic

Comparison (mg)

Comparison (mg)

Parenteral Oral Ratio

Morphine

10

30

1:3

Hydromorphone

1.5

7.5

1:5

Fentanyl

0.1-0.2

NA

NA

Codeine

NA

200

NA

Oxycodone

NA

30

NA

NA = not applicable.

NA = not applicable.

the analgesic effect. Oxycodone or hydrocodone may be better alternatives. Around-the-clock dosing of oral opioids is preferred over prn.

D. Management of Opioid Side Effects. Respiratory depression is a serious and important side effect of opioid administration. Ensure appropriate clinical monitoring and assessment. Have naloxone available. Be prepared to manage opioid-induced side effects promptly with antiemetics, antipruritics, and laxatives or stool softeners.

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