Acute pain relief services protocol (APRS)

Objectives

To provide evidence based information and protocol based guidance for the provision of analgesia for paediatric patients.

Scope

As this is an analgesic guideline for acute pain but important to note that recommendations may not be appropriate for use in all circumstances.

Audience

This protocol is intended to be used by both nursing and medical professionals involved in the acute care of children during pre/post –op surgical management. It can also be used for range of acute pain management scenarios within other specialties, in the RHC, Glasgow.

Programming of major analgesic devices should only be undertaken by pain nurses, anaesthetists or appropriately trained staff. In addition, local anaesthetic top-ups should only be administered by anaesthetists.

Minimum monitoring standard for patients - MAJOR analgesic techniques

Patients should be centrally monitored when on wards
Use of DECT phones is required.
One nurse per 4 patients.
Continuous pulse-oximetry.
Hourly pain assessment and nurse recordings using appropriate monitoring charts which are available in clinical areas.
Regular visits by pain relief nurse specialist and/or duty anaesthetists

Minimum monitoring standard for patients ALL OTHER analgesic techniques

Four hourly pain assessments should be carried out on the PEWS charts.

General points

Doses are a guide only and should be titrated with monitoring. The medical condition, surgical condition, age and maturity of the child should be taken into account.
Any member of nursing or medical staff who have had appropriate training can perform refilling of opioid syringe.
All children with epidural infusions, nerve infusions, NCA and PCA should have accompanying IV fluids for the duration of time the technique is running. However if the patient has PCA Accufuser, hourly 0.9% N .Saline flushes should be prescribed to ensure patency of IV cannula.
If patient has wound infusion 6 houry 0.9% N .Saline should be prescribed to ensure patency of IV cannula.
Programming or reprogramming of PCA/NCA devices or epidural pumps should only be performed by the APRS and appropriately trained staff.
APRS staff only should change local anaesthetic bags and administer epidural top-ups.
Ensure all syringes, bags and lines for opioid or local anaesthetic infusions are correctly labelled.
Ensure prescription is correctly and legibly written, signed, dated and timed on the additive label, in the drug Kardex and on the monitoring/prescription chart.
Ensure the appropriate monitoring/prescription chart has all the requested information accurately completed, and accompanies the patient to the ward or unit.
If in PICU, duplication of signs/recordings on the APRS chart is not required but fields not recorded on the PICU electronic record should be completed on the paper chart.

Beware!

All opioid and local anaesthetic infusions should be checked and signed by 2 practitioners.

Double check

Drug dosages.
Drug dilutions.
Pump settings.
Concurrent prescription of different opioids,
All PCA/NCA must have an antisyphon line to prevent siphoning and reflux of opioid.
Ensure opioid and epidural pumps not >20cm above patients head to prevent gravity free flow of infusion.
Ensure obvious labelling of local anaesthetic infusions to avoid misconnections.

Injection or infusion of the wrong substances into epidurals or iv cannulae can be fatal.

MORPHINE TITRATION:

Morphine titration or loading dose pre infusion if required
Pre-term neonate	Give increments of 0.005mg/kg ie. 5micrograms/kg at 5 minute intervals up to 0.025mg/kg ie. 25micrograms/kg
From term neonate onwards	Give increments of 0.02mg/kg ie. 20micrograms/kg at 5 minute intervals up to 0.1mg/kg ie. 100micrograms/kg

Opioid infusions

Morphine sulphate is the first line opioid used in RHC, Glasgow. However there may be occasions to use a different opioid. For example: when there is an increase in morphine side effects or when switching opiates are appropriate.

Oxycodone is the second line of opioid choice in RHC, Glasgow.

Intravenous morphine/oxycodone infusion

Dedicated anti-syphon/reflux infusion lines with maintenance fluids to ensure patency of cannula.

Morphine/Oxycodone syringe should be prepared as 1mg/kg in 50mls 0.9%saline
(≡0.02mg/kg/ml ie.20micrograms/kg/ml); maximum 50mg in 50mls

Initial IV Morphine / Oxycodone settings for paediatrics
Self-ventilating
Age :	Pre-term: up to 0.005mg/kg/h ie. 5micrograms/kg/h ≡ 0.25ml/hr Term neonate: up to 0.08mg/kg/h ie. 8micrograms/kg/h ≡ 0.4ml/hr 1-3m: up to 0.010mg/kg/h ie. 10micrograms/kg/h ≡ 0.5ml/hr >3m: up to 0.020mg/kg/h ie. 20micrograms/kg/h ≡ 1ml/hr
Ventilated in intensive care
Up to 0.04mg/kg/h ie. 40micrograms/kg/h ≡ 2ml/hr

Patient controlled analgesia with morphine / oxycodone (PCA):

Dedicated anti-syphon/reflux infusion lines with maintenance fluids to ensure patency of cannula. However if the patient has PCA Accufuser, 6 hourly 0.9% N.Saline flushes should be prescribed to ensure patency on IV cannula.

Morphine / Oxycodone syringe should be prepared as 1mg/kg in 50mls 0.9%saline
(≡0.02mg/kg/ml ie.20micrograms/kg/ml); maximum 50mg in 50mls (1mg/ml)

Initial IV PCA settings
Bolus dose 0.020mg/kg ie. 20micrograms/kg ≡ 1.0ml. Maximum bolus dose 1mg (for 50kg+) Lockout interval 5 minutes Background infusion 0.004mg/kg/hr ie.4micrograms/kg/h ≡ 0.2ml/hr [useful in first 24h to improve sleep pattern] Omit if 50kg+ or if has had single shot epidural or regional block

Nurse-controlled analgesia with morphine /oxycodone (NCA):

Dedicated anti-syphon/reflux infusion lines with maintenance fluids to ensure patency of cannula.

Morphine /Oxycodone syringe should be prepared as 1mg/kg in 50mls 0.9%saline
(≡0.02mg/kg/ml ie.20micrograms/kg/ml); maximum 50mg in 50mls (1mg/ml)

Initial NCA settings

Age <1m self-ventilating

Bolus dose 0.005mg/kg ie. 5 micrograms/kg ≡ 0.25ml

Lockout interval 30 minutes

No background infusion

Age 1-3m self-ventilatingG

Bolus dose 0.010mg/kg ie. 10micrograms/kg ≡ 0.5ml

Lockout interval 30 minutes

No background infusion

Age > 3m self-ventilating,or child of any age ventilated in intensive care

Bolus dose 0.020mg/kg ie. 20micrograms/kg ≡ 1.0ml

maximum bolus dose 1mg (for 50kg+)

Lockout interval 20 minutes

Background infusion 0.020mg/kg/h ie.20micrograms/kg/h ≡ 1ml/h

Co-analgesia for acute pain

Gold standard co-analgesia should be given regularly.

Paracetamol

Please refer to Paracetamol dosing guidance as per current BNF for Children.

Caution with: Liver dysfunction and neonatal unconjugated hyperbilirubinaemia - reduce loading dose and increase dosing interval

The pain management medical and nursing staff may optimise pain management for children using weight derived doses of paracetamol. (15mg/kg). Specific information will be highlighted on individual drug kardex.

Each child should be reviewed individually and caution should be exercised when prescribing at the extremes of expected body weight.

NSAIDS

Diclofenac & Ibuprofen
Please refer to diclofenac and ibuprofen dosing guidance as per current BNF for Children.

The pain management medical and nursing staff may optimise pain management for children using slightly increased doses of NSAID’s. Specific information will be highlighted on individual drug kardex.

Caution:

Bleeding risk.
Severe Asthma.
Renal dysfunction.
GI ulceration/bleeding.
On anticoagulants

Gastro- intestinal protection

Omeprazole – Body weight 10-20kg : 10mg once daily PO
Body weight >20kg : 20mg once daily PO

COX 2 antagonists

Not routinely in use in RHC at present. Actively avoid in cardiac patients.
Seek consultant advice prior to prescribing

ORAL OPIATES

Immediate release:

Oral Morphine Solution (Oramorph):	Guideline starting dose 0.1 – 0.3 mg/kg 4-6hourly. If under 1year consider starting 0.05mg (50micrograms)/kg 4-6 hourly
Morphine Sulphate tablet (Sevredol 10mg tablet):	Doses as above.
Oxycodone immediate release liquid or tablet:	This maybe helpful if patient is experiencing side effects of morphine. Doses as above.
Dihydrocodeine :	Not commonly used in RHC, doses recommended by experienced Practitioners 0.5mg-1mg/kg 4-6hourly – Use under guidance of consultant anaesthetist

Modified release:

This may be helpful in patients requiring opiates for prolonged periods. For example, following NUSS/Ravitch procedures.

MST Continus: Use under guidance of pain team and consultant anaesthetist.

Oxycodone modified release: Use under guidance of pain team and consultant anaesthetist.

Ensure any parenteral morphine has been stopped (avoid concurrent prescription of opioids).

Oral Clonidine – can be considered
1-3micrograms/kg three times daily - Use under guidance of consultant anaesthetist.

Antagonists

Use Basic Life Support measures (ABC); give oxygen

For morphine antagonism

	Naloxone dose
Excess sedation but SaO2>94% air Responds to pain stimulus	2micrograms/kg iv stat; can be repeated every 60 seconds
Excess sedation & SaO2<94% in air Responds to pain stimulus	10micrograms/kg iv stat
Unresponsive	20micrograms/kg iv stat

Start an infusion, if required, at 10micrograms/kg/hr; use lowest effective dose;

For benzodiazapam antagonism:
Flumazenil 5 micrograms/kg iv stat;
Can be repeated every 60 seconds or start infusion at 10 micrograms/kg/hr
Beware seizures precipitated by antagonists

Ketamine infusion

This should only be undertaken by anaesthetists or trained pain management nurse specialist - if a trainee, discuss with your consultant and the pain team.

Sickle cell crisis

For pain management in sickle cell crisis please refer to hyperlinks below.
NHSGGC Sickle Cell Protocol

ENT surgery

Antacid and Oxetacaine Oral Suspension - SUGGESTED DOSING
10-15mls orally, 15-30minutes before meals and at night.
Hold in mouth prior to swallowing - avoid drinking immediately afterwards.

Colic pain

Peppermint Water BP [not licenced for use in children less than 12 years however may be considered for use within RHC] - Do not give under 3 months

AGE	DOSE
3-6 months	2.5mls – 20mins before feed/food (max 4 doses per day)
6 months - 2 years	5mls– 20mins before feed/food (max 4 doses per day)
2 - 12 years	10-40mls– 20mins before feed/food (max 4 doses per day)

Antiemetics

Ondansetron	0.15mg/kg (150micrograms) iv or oral 8hrly
Dexamethasone	0.1-0.15mg/kg (100 – 150 micrograms) once (caution tumour lysis syndrome) Further doses should be approved by senior medical staff. Avoid in neurosurgical patients until discussed with surgeon

In children unable to have dexamethasone consider IV droperidol (contraindicated in Long QT syndrome)

Droperidol 10-20micrograms/kg IV 8 hourly

Cyclizine 1mg/kg 8 hourly (slow injection if IV). May be used if a 3^rd line is required but there is limited evidence of efficacy in children

For other antiemetics please refer to APA Post op nausea and vomiting guideline

Muscle spasms in orthopaedics / bladder spasms in urology

Diazapam 0.1mg/kg (100micrograms/kg) 6hourly oral

Lorazepam - suggested dose range: 10-25mcg/kg 12 hourly.
^{(Not used in children under 1 year old. Avoid co-administration of benzodiazapines.)}

Midazolam infusion 0.025mg/kg/h (25micrograms/kg/h iv i.e. ¼ of the sedative dose)

If an epidural is in situ - consider adding clonidine (see section on "Additives to epidural solutions" below for dosing guidance)

Dressings and drain removals

Consider Entonox (see below) opioid bolus or epidural top up

RHC Entonox Guideline [Staffnet link]

Skin graft donor sites

Put epidural catheter on dressing surface and infuse levobupivacaine

Wound infusion: 1.25mg/ml at 0.1-0.2ml/kg/hr = 0.125 – 0.25mg/kg/hr;

Pajunk Infusor pump: Available to use under guidance of consultant anaesthetist. Clinical guideline for use of Pajunk wound infusion catheters [Staffnet link]

Bone graft donor sites

Wound perfusion with levobupivacaine

1.25mg/ml plain at 0.1ml/kg/hr=0.125mg/kg/hr=125micrograms/kg/hr;

Epidural levobupivacaine (plain solutions)

Guideline for maximum dose of levobupivacaine as a continuous infusion doses:

< 6 months old: 1 mg/kg per 4 hour period
>6 months old: 2mg/kg per 4 hour period

This is principally to avoid the risk of accumulation during infusions. However, the loading doses given in theatre in order to establish the block will frequently mean the dose exceeds the guideline.

Guideline for motor block observations and epidurals

Guideline for epidural set disconnection

Postoperative Infusion regimen

Age < 6months
Levobupivacaine infusion – 1.25mg/ml plain @ 0.1-0.2ml/kg/hr ≡ 0.125-0.25mg/kg/hr.
May need top ups levobupivacaine, 2.5mg/ml 0.1-0.3ml/kg ≡ 0.25-0.75mg/kg in fractionated doses [maximum total dose (including top ups) per 4h period 1.0mg/kg]

Age >6 months
Levobupivacaine infusion - 1.25mg/ml plain @ 0.2-0.4ml/kg/h ≡ 0.25-0.5mg/kg/hr
May need top ups levobupivacaine, 2.5mg/ml 0.1-0.3ml/kg ≡ 0.25-0.75mg/kg in fractionated doses [maximum total dose (including top ups) per 4h period 2.0mg/kg]

Check block; give top up in fractionated doses; check BP, HR, RR, SpO2 every 5 minutes for 15 minutes; recheck block and pain score. Aim for differential block with preservation of motor power and good analgesia. If block is very dense with profound motor blockade, consult senior for review.

Additives to epidural solutions

In specific cases, an additive may be mixed with levobupivacaine to prolong the analgesia from a single dose or to increase the dermatomal coverage of the block. These should only be undertaken by anaesthetists and if a trainee, discuss with your consultant and the pain team.

Diamorphine Loading dose - 50 micrograms/kg
Infusion solution :
Levobupivacaine 1.25mg/ml 200ml bag – add 50micrograms/ml – rate 0.1ml/kg/hr max

Levobupivacaine 1.25mg/ml 200ml bag – add 25micrograms/ml – rate 0.2ml/kg/hr max
Maximum diamorphine infusion dose = 5mcg/kg/hr

[avoid if age <1y; do not increase infusion rate; top up with plain levobupivacaine; for pruritis use low dose naloxone 0.5micrograms/kg, repeated every 1-2 minutes until symptoms resolve then give this total dose hourly as a continuous infusion]

Clonidine
1-2 microgram/kg added to single injection blocks;

Infusion solution:
Levobupivacaine 1.25mg/ml 200ml bag – add 150mcg clonidine = 0.75mcg/ml
Maximum clonidine dose 2.4micrograms/kg/8hrs

Drugs used in the management of excessively high block

Use Basic Life Support measures (ABC); give oxygen; give IV fluids; call duty anaesthetist

Ephedrine
0.1-1 mg/kg IV

Phenylephrine
1 microgram/kg

These drugs are not kept on every ward with epidurals or in PICU resus bags but are in the PICU pharmacy and in theatre. If not available, use Adrenaline 1:10,000; 0.1 mls/kg/IM = 0.01mg/kg (10 micrograms/kg) i.e. same dose and route of admin as for anaphylaxis

Atropine 10-20 micrograms/kg IV

Management of Local Anaesthetic Toxicity
‘Red Boxes’ kept in theatre recovery
AAGBI Management of Severe Local Anaesthetic Toxicity

Intralipid stored in:

Theatre recovery (‘Red Emergency Boxes’ - 1^st stage recovery)
PICU pharmacy (one in fridge)

Epidural catheters in children receiving LMWH (low molecular weight heparin)

In children with an epidural indwelling catheter, on LMWH thromboprophylaxis, concomitant treatment with antiplatelet medication (e.g. NSAID’s) should be avoided if possible.

REMOVAL:
In children on ONCE DAILY dose LMWH thromboprophylaxis the removal of the epidural should be at least 10 hours after the last dose of LMWH.

NEXT LMWH DOSE:
In children on ONCE DAILY dose LMWH thromboprophylaxis, the next dose of LMWH should be given at least 4 hours after the removal of the epidural catheter.

REMOVAL:
In children receiving TWICE DAILY LMWH thromboprophylaxis the removal of the epidural should be at least 8 hours (2 half lives) after the last dose.

NEXT LMWH DOSE:
In children receiving TWICE DAILY LMWH thromboprophylaxis, the next dose of LMWH can be given 4 hours after the removal of the catheter, so the BD prescription times do not need to be changed.

If a blood tap occurs during the placement or removal of the epidural catheter. The event should be recorded in the notes, the consultant must be informed, greater degree of vigilance exercised, (please refer to policy for motor block density) and the next dose of anticoagulant delayed for 24 hours.

In patients receiving LMWH, monitoring and observation of neurological status should be continued for at least 24 hours after the catheter removal and recorded in the notes

AAGBI Regional Anaesthesia and Patients with Abnormalities of Coagulations

NEONATES: Before removing epidural or caudal catheters in neonates, use caution as some surgical neonates may be at risk of post-operative coagulopathy. Seek senior advice prior to removal if concerned.

SOP for Removal of Epidural Catheter [Staffnet link]

Contacts

Pain Relief Nurse Specialist Dect phone : 84319/84320

Duty Anaesthetist Dect phone: 84342 / 84842

Pain Consultant or on call consultant check rota via switchboard or via extension 84316

References

Good Practice in Postoperative Procedural Pain Management. Pediatric Anaesthesia 1.Supp1 May 2008
Acute pain Management: Scientific Evidence 4th ed 2015. Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine
Entonox Protocol RHC, 2018
Ketamine Protocol, RHC [Staffnet link], 2017
Chronic Pain Guideline, RHC, 2017
Motor block observations & epidurals. RHC Glasgow APS Guideline.V.2.
Based on guideline from Birmingham CH. [Staffnet link]
AAGBI Safety Guideline. Management of Severe Local Toxicity, 2010
AAGBI Epidural Catheters and LMWH 2013
APA. Guidelines on the Prevention of Post-operative Vomiting in Children, Autumn 2016
Sickle cell policy, RHC 2018

Editorial Information

Last reviewed: 01 February 2020

Next review: 31 May 2022

Author(s): Dr Ewan Wallace

Version: 20

Co-Author(s): CNS Margaret Canning, CNS Kay Reilly, CNS Kareen Love, Dr Graham Bell, Dr Tony Moores.

Approved By: Paediatric Clinical Effectiveness & Risk Committee

NHSGGC Guidelines

Acute pain relief services protocol (APRS)

Related Guidelines

Objectives

Scope

Audience

Related Resources