What are the guidelines for opioid use in pediatric surgeries?

Guidelines for Opioid Use in Pediatric Surgeries

Opioid use in pediatric surgeries should prioritize multimodal analgesia with non-opioid medications as first-line treatment, reserving opioids for breakthrough pain and using the lowest effective dose for the shortest duration possible. 1

Key Principles for Opioid Use in Pediatric Surgeries

Understanding Opioid Risks

• A significant proportion of adolescents with access to opioids misuse them, with many developing dependence or opioid use disorder 1
• Prescriptions from healthcare professionals are the most common source of opioids for adolescents who misuse them 1
• Adolescents who receive an opioid prescription after surgery may have a higher likelihood of future opioid prescriptions within the following year 1

Multimodal Pain Management Approach

Non-Opioid Medications (First-Line)

• NSAIDs should be used as a primary analgesic when not contraindicated 1

  • Ibuprofen: 10 mg/kg every 8 hours (oral/IV/rectal)
  • Diclofenac: 1 mg/kg every 8 hours (oral), 0.5-1 mg/kg every 8 hours (rectal)
  • Ketorolac: 0.5-1 mg/kg (max 30 mg) for intraoperative dose; 0.15-0.2 mg/kg (max 10 mg) every 6 hours for short-term therapy (maximum 48 hours) 1

• Paracetamol (Acetaminophen) should be used concurrently with NSAIDs 1

  • Oral: 10-15 mg/kg every 6 hours (max daily dose: 60 mg/kg)
  • IV: loading dose 15-20 mg/kg, then 10-15 mg/kg every 6-8 hours
  • Rectal: 20-40 mg/kg loading dose (15 mg/kg if <10 kg) 1

Regional Anesthesia

• Ultrasound-guided regional blocks should be utilized whenever possible to reduce opioid requirements 1, 2
• Specific blocks based on surgery type:
  • Penile block or bilateral pudendal nerve block for urological procedures 1
  • Caudal block with long-acting local anesthetics for lower abdominal or urological surgeries 1
  • Peripheral nerve blocks appropriate to the surgical site 1

Adjuvant Medications

• Consider adding:
  • Dexamethasone (0.15-0.25 mg/kg) to reduce postoperative swelling 1
  • Alpha-2 agonists like clonidine or dexmedetomidine as adjuncts to regional anesthesia 1
  • Ketamine (0.5 mg/kg) as co-analgesic during induction, with possible continuous infusion (0.1-0.2 mg/kg/h) 1

Appropriate Opioid Use When Necessary

Intraoperative Opioids

• Fentanyl: 1-2 mcg/kg 1
• Morphine: 25-100 mcg/kg depending on age, titrated to effect 1
• Remifentanil: 0.05-0.3 mcg/kg/min 1

Postoperative Opioid Management

• For PACU breakthrough pain:

  • Fentanyl: 0.5-1 mcg/kg, titrated to effect 1
  • Morphine: 25-100 mcg/kg depending on age, titrated to effect 1

• For ward breakthrough pain (when non-opioids insufficient):

  • Use tramadol (1-1.5 mg/kg every 4-6 hours) as a preferred option over stronger opioids 1
  • For infants: nalbuphine 0.05 mg/kg 1
  • For children >3 months: nalbuphine 0.1-0.2 mg/kg 1

• Important: Avoid codeine and tramadol in children <12 years due to FDA black box warnings 1

Procedure-Specific Considerations

Minor Procedures

• Opioid-free recovery is recommended for many minor pediatric procedures 1
• Use combination of NSAIDs and acetaminophen as primary analgesics 1
• Consider regional anesthesia techniques when appropriate 1

Moderate Procedures

• Prioritize non-opioid medications and regional anesthesia 1
• Use opioids only for breakthrough pain in PACU 1
• Transition to oral non-opioid medications as soon as possible 1

Major Procedures

• Use multimodal approach with regional anesthesia when possible 1
• For major reconstructive surgery, consider IV patient-controlled analgesia (PCA) with appropriate monitoring 1
• In case of epidural catheter, use patient-controlled regional anesthesia with adequate monitoring 1

Special Considerations

Age-Specific Considerations

• Neonates and infants (<3 months): Use reduced opioid doses (25-50 mcg/kg morphine) and increased monitoring due to higher sensitivity to respiratory depression 2
• Elderly or debilitated patients: Use caution due to altered pharmacokinetics and increased sensitivity 2

Safety Precautions

• Monitor for respiratory depression, especially in patients with risk factors (obesity, sleep apnea) 2
• Fentanyl transdermal systems should ONLY be used in opioid-tolerant pediatric patients 2 years of age or older 2
• Provide education to families about safe opioid use, storage, and disposal 1

Implementation Strategy

• Develop procedure-specific ERAS (Enhanced Recovery After Surgery) protocols 1
• Aim for oral administration of medications as soon as possible 1
• Provide clear discharge instructions regarding pain management and when to contact healthcare providers 1, 3

By following these guidelines and emphasizing multimodal analgesia with appropriate use of regional anesthesia techniques, opioid use can be minimized while still providing effective pain control for pediatric surgical patients.