Use of opioids in children during the perioperative period: SPA Guidelines

Opioids have long held a prominent role in the management of perioperative pain in adults and children.

The Society for Pediatric Anesthesia has released its recommendations for the use of opioids in children during the perioperative period. The goal of the recommendations was to address the most important issues concerning opioid administration to children after surgery, including appropriate assessment of pain, monitoring of patients on opioid therapy, opioid dosing considerations, side effects of opioid treatment, strategies for opioid delivery, and assessment of analgesic efficacy.

Following are the major recommendations:

Age-related pharmacokinetic and pharmacodynamic opioid effects

• A validated, age‐adjusted morphine dosing regimen should be used for all pediatric patients but particularly for neonates where the dose and dosing interval will need to be altered significantly.


• Dosage of most synthetic opioids should be decreased in neonates during the first two to four weeks of life (and for premature neonates until at least 44 weeks post conceptual age). For remifentanil, the effective half‐life in neonates is similar to that of older children and adults, and thus requires no adjustment. There is sparse information on methadone, but it appears to have similar pharmacokinetics across all age ranges.


• Dosage of most synthetic opioids should be decreased in neonates during the first two to four weeks of life (and for premature neonates until at least 44 weeks post conceptual age). For remifentanil, the effective half‐life in neonates is similar to that of older children and adults, and thus requires no adjustment. There is sparse information on methadone, but it appears to have similar pharmacokinetics across all age ranges.

The use of patient-controlled analgesia (PCA)

• The use of PCA opioid delivery is preferable to IM opioid delivery for perioperative pain control. IM administration of opioids is not recommended as a primary pain control modality.


• PCA opioid delivery is safe, efficacious, and correlated with higher patient satisfaction when compared to intermittent intravenous opioid analgesia.


• There is insufficient and conflicting evidence to recommend the use of a specific opioid over another for PCA post‐operative pain control. Due to the risk of accumulation of toxic metabolites (normeperidine) that may cause seizures, meperidine is not recommended by our expert panel.


• There is conflicting and insufficient evidence to indicate a difference in overall analgesia, sleep patterns, or adverse events with the addition of continuous opioid infusion to PCA in children. Use of a basal infusion should be individualized based on consideration of the clinical situation, pain severity, and risk factors.


• There is evidence that nurse controlled analgesia and parent-controlled analgesia is associated with safety and efficacy outcomes that are similar to that of standard PCA therapy. These methods must be applied in an institutionally‐sanctioned program with appropriate training and monitoring.


• The use of ketorolac should be strongly considered as an adjunct to PCA for pediatric perioperative pain control. Most evidence available for NSAID effect on PCA dosing involves ketorolac, however there is good reason to assume another NSAID would have a similar PCA dose sparing effect.


• The use of acetaminophen should be considered as an adjunct to PCA for pediatric perioperative pain control.

Recommendations for outpatient post‐operative opioid use in children

• Educational resources must be provided to inform parents of the appropriate indications for pain medications and strategies for the safe use of opioids, non‐opioids and other measures to manage their child’s post‐operative pain. Parents should receive both verbal and written detailed discharge instructions regarding home pain management with instructions regarding safe storage and disposal of leftover medications.


• Here is evidence to advise against the use of tramadol for specific populations of pediatric patients, particularly young patients (under 12) and those with OSA.


• There is insufficient evidence to recommend PRN vs. scheduled dosing strategies for opioids after surgery in children. Expert consensus is to use a PRN strategy until further evidence is available.


• Opioid pain medications should not be prescribed with benzodiazepines except in children for whom there is a specific indication and alternative treatment options are inadequate. Doses should be limited to the lowest effective level and parents should be warned about the potential for excessive sedation and respiratory depression.


• Opioid prescriptions should be limited to that required for the expected period of severe pain after surgery (local laws may set limits for quantity or time parameters for opioid prescriptions). Patients should be educated concerning the appropriate storage and disposal of opioids.

Opioid treatment of the patient with chronic pain scheduled for major surgery

• For pediatric patients with chronic pain who are maintained on opioids, continue established preoperative dosing during the perioperative period as a baseline. Acute post‐surgical analgesia should be provided over and above the baseline opioids. Use of non‐opioid analgesia is encouraged including regional analgesia techniques, alpha‐2 agonists, ketamine, acetaminophen, nonsteroidal anti‐inflammatory drugs, and neuropathic pain medications such as gabapentinoids or antidepressants.


• If a patient with chronic pain on opioid therapy undergoes surgery and the patient’s underlying pain source was independent of the surgery, the patient’s baseline pain should continue to be managed by the physician who had been doing so preoperatively. Opioid analgesics for the perioperative pain, if needed, should be prescribed in limited quantities consistent with the degree of physiologic trespass.


• For pain management of patients with central sensitization – strategies should be similar to those for pediatric pain patients on chronic opioids (use non‐opioid analgesic techniques to the greatest extent possible). Opioids should be prescribed as needed. These patients benefit from the involvement of a pain physician for the purposes of assuring appropriate use and discontinuation of medications in a reasonable time frame.

Assessment of pain and analgesic efficacy

• Regular pain assessments should be part of the perioperative care/treatment of pediatric patients who are receiving opioid medications. These assessments should be made using validated measures. The pain assessment should consider the unique circumstances of the child’s psychological state and the extent of surgery.


• Pain intensity scores can be used to assess a child’s perceived degree of discomfort. However, decisions to administer analgesics should take into consideration patient functional behaviors, situational factors such as pain source, self‐reported pain scores, parental observation, and other potential sources of distress, rather than arbitrarily selected pain score cutoffs.


• Behavioral observation can be used to assess pain‐related distress in children. Directions to administer analgesics in children who cannot self‐report should take into consideration situational factors such as pain source, observational pain scores, and other potential sources of distress, rather than arbitrarily selected pain score cut‐offs.


• Changes in pain scores should be used in conjunction with other verbal/behavioral measures as indicators of pain relief and analgesic response (e.g. side effects) when making analgesic decisions.


• Physiologic parameters should be used to assess the child’s nociceptive response when it is not possible to assess pain with self‐report of behavioral measures (e.g., when the child is sedated or is receiving neuromuscular blockers). It is recommended that other potential sources of physiologic distress (e.g., emotional distress, hypovolemia, fever, hypercarbia) be considered and/or ruled out when making treatment decisions.


• A child’s functional recovery should be assessed to inform treatment plans.


• Assessing pain location is recommended to differentiate incisional pain from other potential sources of postoperative pain. The nature of pain should be assessed to assist in the differentiation of pain type.

Monitoring of patients on perioperative opioid therapy

• Physiologic monitoring of children receiving initial intravenous opioid treatment should include pulse oximetry for the first 24 hours. Continuous monitoring of respiratory rate and ECG should be considered in pediatric patients who are on oxygen, or who have risk factors for respiratory depression. Physiological monitoring may be suspended when the patient is alert, awake, and/or ambulating.


• Although not specifically addressed in the literature, the expert panel recommends frequent assessment of the quality, as well as the rate of respiration, should be performed by direct observation and recorded in the medical record. Increased frequency and intensity of these observations is recommended for children in high‐risk groups in addition to standard electronic monitoring.


• Patients with obstructive sleep apnea, obesity (>95 percentile BMI), and recurrent nighttime oxygen desaturations are at higher risk for opioid-induced respiratory depression. Opioid dosing should be based on ideal or lean body weight and the dose of opioid should be reduced by 50% to 67%. Additionally, extended respiratory monitoring is required when opioids are being administered to this population in the perioperative period.


• Patients receiving opioid analgesia perioperatively should have regular assessment of their level of sedation using a validated sedation score that evaluates level of alertness or mentation, rather than utilizing a procedural sedation scale. This rating should be part of the medical record along with measures of pain and physiological status.


• Review of code team calls or emergency response calls and delivery of emergent naloxone doses should be part of institutional efforts to critically evaluate and reduce preventable opioid‐related adverse events.

Opioid side effects in children

• Naloxone infusion is helpful in treating and possibly preventing opioid‐induced pruritus.


• Expert consensus supports the use of nalbuphine although there is conflicting evidence concerning its effectiveness at this time.


• Opioid use should be minimized where possible to decrease the incidence of nausea and vomiting.


• Naloxone infusion should be considered for intravenous opioid therapy for the prevention or treatment of nausea and vomiting.


• It is reasonable to consider common anti‐emetic medications for the treatment or prevention of nausea and vomiting while on intravenous opioid therapy. Preference should be for non‐sedating medications.


• Postoperative opioid‐induced ileus may be improved with methylnaltrexone in infants and children.

For more details click on the link: https://doi.org/10.1111/pan.13639