Analgesia

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim

To guide PCH Emergency Department (ED) staff in the appropriate use of analgesia in the ED.

Background 

  • Painful medical conditions and injuries in children are a common presentation to the ED.
  • Pain is often undertreated in children.

Assessment

  • Older children can use visual analogue scales to self-report pain.
  • Physiological and behavioural parameters can be used in patients of all ages to assess pain.
  • Reassessment of pain is important after providing analgesia.

Management

  • Non pharmacological strategies are an important adjunct to medications.
  • Consider KKIND principles e.g. distraction techniques such as blowing bubbles, singing and storytelling are a useful adjunct to analgesic medications especially during painful procedures.
  • Analgesics should be prescribed according to pain intensity.
  • Local anaesthetic and nerve blocks provide effective analgesia in suitable patients. Femoral nerve block should be used early and before transport of any child with a fractured femur.
  • Painful lacerations may be managed with topical local anaesthetic preparations such as ‘Laceraine®’ or local anaesthetic infiltration.

Options for commonly used analgesics for children in the ED

  • Refer to PCH monographs or AMH Children’s Dosing Companion for more comprehensive drug information such as dose adjustments in obesity, renal impairment and hepatic impairment, administration and monitoring
  • Doses should be calculated on ideal body weight (IBW) and titrated to analgesic effect. 

Mild to moderate pain

Sucrose

  • Sucrose may be used in infants for procedural pain.
  • For babies aged up to 18 months.
  • Dose:
    • Birth (term) to 1 month: 0.5-1mL per procedure (maximum 5mL in 24 hours)
    • 1 month to 18 months: 1-2mL per procedure (maximum 5mL in 24 hours if <3 months of age or 10mL in 24 hours if >3 months age)
  • Onset: 10 seconds3.
  • Peak effect: 2 minutes3.

Paracetamol

  • Refer to the PCH Paracetamol – Paediatric Monograph (WA Health only) for age appropriate dosing information 
    • NB: Birth (at term) to 1 month differ for oral/rectal and IV dosing.
  • Dose (1 month to 18 years):
    • Oral: 15mg/kg (to a maximum of 1g) every 4 to 6 hours (max dose 60mg/kg daily). Maximum of 4 doses in 24 hours.
    • Rectal: 15-20mg/kg (to a maximum of 1g) every 6 hours (round doses to appropriate suppository strength available – 125mg, 250mg and 500 mg). 
    • Rectal absorption can be delayed and /or erratic.
  • Severe pain:
    • Dose may be increased to 90mg/kg/day (not to exceed 4g daily) for a maximum of 48 hours.
  • Adult dose: 1g/dose to a maximum of 4g/day.
  • Onset: 20-40 minutes3.
  • Peak effect: 2 hours3.
  • Generally well tolerated.
  • Intravenous preparation is available for patients who are unable to have paracetamol via the oral or rectal route.

Ibuprofen

  • Age: 3 months and older.
  • Dose: 10mg/kg/dose (maximum 400 mg) 6-8 hourly orally.
  • Maximum daily dose: 30mg/kg to maximum of 2.4g.
  • Onset: 30 minutes3.
  • Peak effect: 60-90 minutes3.
  • May cause GI upset - give with or soon after food if possible.
  • Avoid in the presence of dehydration or potential renal impairment and in any child with suspected bleeding diathesis or oncological condition.

Moderate to severe pain

Note: Opioids should rarely be given without a simple analgesic such as paracetamol which provides adjunctive pain relief.

Oxycodone (immediate release preparation)

  • Refer to the PCH Oxycodone – Paediatric Monograph (WA Health only)
  • Age: Over 12 months age 
  • Weighs over 10 kg
  • Dose: 0.05-0.1mg/kg/dose every 4 hours (Adult dose 5-15mg) orally.
  • Onset: 15-30 minutes3.
  • Peak effect: 1 hour3
  • Test dose must be administered and observed for 1-2 hours before considering discharge from ED.
  • Record baseline vital signs pre-administration and hourly for a minimum of two hours post first dose: Respiratory rate and effort, SpO2, HR, sedation score (UMSS) and pain intensity scores. 
  • Monitor for respiratory depression, over-sedation and analgesic effects. 

Intranasal Fentanyl

  • Refer to the PCH Fentanyl - Paediatric Monograph (WA Health only) for more information regarding dosing, administration
  • Age: Children >1 year
  • Dose: 1.5micrograms/kg intranasal via 1mL syringe with an atomiser attached1.
  • Dose may be repeated once after 5 to 10 minutes if required. Usual maximum dose is 100 micrograms due to volume limitations. 
  • Use 100 microgram/2mL IV ampoules. 
  • Divide the dose between both nostrils to prevent swallowing.
  • If an atomiser is used, draw up an extra 0.1mL to prime the atomiser prior to administration.
  • Onset: 2 minutes3
  • Peak effect: 5-10 minutes3
  • Preferred potent analgesic in patients without IV access.

Morphine

  • Refer to PCH Morphine Paediatric Monograph (WA Health only)
    • Dose1: Birth (at term) to 1 month: IV 0.025–0.05mg/kg; repeat every 10 minutes if required, to a cumulative maximum of 0.1mg/kg every 4–6 hours. 
    • 1 month to 12 months: IV 0.05mg/kg; repeat in 10 minutes if required, to a cumulative maximum of 0.1 mg/kg every 2–4 hours. 
    • 1 year to 18 years: IV 0.05–0.1mg/kg; repeat every 10 minutes if required, to a cumulative maximum of 0.2 mg/kg every 2–4 hours (usual adult dose 5–10 mg). 
  • Adjust dose according to response
  • Onset: 3-5 minutes3
  • Peak effect: 15-30 minutes3.
  • Monitor for respiratory depression, hypotension.

Nursing

 

  • Pre-administration and ongoing post analgesia pain scores.

  • Analgesia administered to a patient for moderate to severe pain will require baseline and post dose observations of heart rate, level of sedation, respiratory rate, oxygen saturations and blood pressure.

  • Record heart rate, respiratory rate, oxygen saturations and blood pressure and level of sedation 5 minutely for 15 minutes post administration.

  • Refer to specific ED drug administration guidelines for Intranasal Fentanyl and Morphine nursing considerations.

References

  1. AMH Children’s Dosing Companion (2015) Australian Medicines Handbook Pty Ltd
  2. Pediatric & Neonatal Dosage Handbook 24th Edition Carol K. Taketomo, PharmD
  3. Clinical Pharmacology (online). http://elsevierresources.com/clinical-pharmacology-ck/

Reviewer/Team: ED Consultants, ED CNS, ED CNM, Senior Pharmacists
Last reviewed: March 2019


Review date: Mar 2022
Endorsed by:

Drugs and Therapeutics Committee Date:  Mar 2019


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