Vasopressor and Post-Operative Pain Management for 14-Year-Old Trauma Patient
Vasopressor Selection
Norepinephrine is the best vasopressor choice for this 14-year-old patient with hypotensive episodes, as it is the first-line agent recommended for maintaining mean arterial pressure ≥65 mmHg in trauma and perioperative settings, with both vasoconstrictor and beta-agonist properties to support cardiac contractility. 1, 2
Rationale for Norepinephrine
Norepinephrine infusions are now viewed as the first vasopressor of choice to maintain MAP ≥65 mmHg in trauma and emergency surgery settings, providing both alpha-adrenergic vasoconstriction and beta-1 adrenergic support for cardiac contractility. 1
The European Trauma Guideline recommends norepinephrine administration in addition to fluids when restricted volume replacement fails to achieve target blood pressure, particularly after the patient has received 2 units PRBC and ongoing resuscitation. 1
Optimize intravascular volume first before initiating vasopressors - this patient has received 2 units PRBC but may still require volume assessment given the hypotensive episodes and trauma context. 1
Recent high-quality evidence from 2025 demonstrates that prophylactic norepinephrine infusion is more effective than ephedrine boluses in preventing post-induction hypotension and reducing postoperative complications in major surgery. 3
Practical Administration
Start norepinephrine at 0.48 mg/hour (0.016 mg/mL solution) via continuous infusion from induction, as demonstrated effective in the 2025 Anesthesiology trial for major surgery. 3
Dilute 4 mg norepinephrine in 1,000 mL of 5% dextrose solution (4 mcg/mL concentration) and titrate to maintain MAP ≥65 mmHg or systolic BP 80-100 mmHg. 2
Norepinephrine can be safely started via large peripheral vein until central access is established, which is particularly relevant given the patient refused ICU admission. 1
Target MAP of 65 mmHg is appropriate for this adolescent patient, as this threshold has been shown effective in reducing end-organ injury including acute kidney injury and myocardial injury. 1
Why Not Other Vasopressors
Avoid ephedrine as first-line - it is subject to tachyphylaxis and was associated with 74% cumulative hypotensive episodes versus 15% with norepinephrine in the 2025 trial. 3
Phenylephrine is not preferred as it can induce reflex bradycardia and decrease cardiac output, which may worsen perfusion in this trauma patient with ongoing resuscitation needs. 1
The 2023 feasibility trial comparing norepinephrine versus phenylephrine showed no significant differences in outcomes, but norepinephrine's combined alpha and beta effects make it more physiologically appropriate for trauma. 4
Post-Operative Pain Management
Use a multimodal opioid-sparing approach with scheduled acetaminophen, NSAIDs (if not contraindicated by bleeding risk), and patient-controlled analgesia (PCA) with morphine or hydromorphone as the foundation, since peripheral nerve blocks and neuraxial techniques are avoided.
Multimodal Analgesic Strategy
Scheduled acetaminophen 15 mg/kg IV/PO every 6 hours (maximum 1 gram per dose given 42 kg weight) as the baseline non-opioid analgesic. [@general medicine knowledge@]
Consider ketorolac 0.5 mg/kg IV every 6 hours (maximum 15-30 mg per dose) for 48-72 hours if platelet count remains stable (currently 158) and no active bleeding, as NSAIDs provide excellent orthopedic pain control. [@general medicine knowledge@]
PCA with morphine or hydromorphone is the primary opioid delivery method:
- Morphine: 0.01-0.02 mg/kg demand dose with 6-8 minute lockout, no basal rate initially
- Hydromorphone: 0.002-0.004 mg/kg demand dose with 6-8 minute lockout [@general medicine knowledge@]
Additional Adjuncts
Gabapentin 5-10 mg/kg PO (maximum 300-600 mg) preoperatively and continued postoperatively can reduce opioid requirements in orthopedic surgery. [@general medicine knowledge@]
Ketamine infusion 0.1-0.2 mg/kg/hour can be considered as an adjunct for severe pain, particularly beneficial in trauma patients with significant tissue injury. [@general medicine knowledge@]
Local infiltration analgesia by the surgeon at the surgical site with long-acting local anesthetic (bupivacaine or ropivacaine) provides additional pain control without the risks of regional techniques. [@general medicine knowledge@]
Critical Monitoring Considerations
Monitor for opioid-related respiratory depression given the patient is on the ward (not ICU) - consider continuous pulse oximetry and capnography if high-dose opioids are required. [@general medicine knowledge@]
Reassess pain scores every 2-4 hours and adjust the multimodal regimen accordingly, as inadequate pain control can contribute to tachycardia and increased oxygen consumption. [@general medicine knowledge@]
The elevated WBC (18.14) and neutrophilia (80%) suggest ongoing inflammatory response from trauma; adequate pain control helps reduce the stress response and may improve outcomes. [@general medicine knowledge@]
Important Caveats
Avoid NSAIDs if platelet count drops below 100 or if there are signs of ongoing bleeding, given the recent trauma and need for 2 units PRBC transfusion. [@general medicine knowledge@]
The mild anemia (Hgb 106, Hct 0.32) should be monitored but does not contraindicate the pain management approach; ensure adequate oxygenation to optimize pain medication safety. [@general medicine knowledge@]
Given the patient refused ICU, ensure ward nursing staff are trained in PCA management and have clear escalation protocols for inadequate pain control or adverse effects. [@general medicine knowledge@]