Page 43 Acute Pain Management
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Analgesic agents
1. Non‐selective NSAIDs do not increase the risk of reoperation for bleeding after
tonsillectomy in paediatric patients (R) (Level I [Cochrane Review]).
2. Dexamethasone reduces post‐tonsillectomy pain and postoperative nausea and vomiting
(N) (Level I) but high doses may increase the risk of bleeding (N) (Level II).
3. Paracetamol and non‐selective NSAIDs are effective for moderately severe pain and
decrease opioid requirements after major surgery (U) (Level II).
4. The efficacy of oral codeine in children is variable, individual differences in the ability to
generate active metabolites may reduce efficacy (U) (Level II) or increase side effects (N)
(Level IV).
Safe dosing of paracetamol requires consideration of the age and body weight of the SUMMARY
child, and the duration of therapy (U).
Aspirin should be avoided in children, but serious adverse events after non‐selective
NSAIDs are rare in children over 6 months of age (U).
Opioid infusions and PCA
1. Routine morphine infusion does not improve neurological outcome in ventilated preterm
neonates (N) (Level I [Cochrane Review]).
2. Postoperative intravenous opioid requirements vary with age in neonates, infants and
children (N) (Level II).
3. Effective PCA prescription in children incorporates a bolus that is adequate for control of
movement‐related pain, and may include a low dose background infusion (U) (Level II).
4. Intermittent intramuscular injections are distressing for children and are less effective for
pain control than intravenous infusions (U) (Level III‐1).
Intravenous opioids can be used safely and effectively in children of all ages (U).
Initial doses of opioid should be based on the age, weight and clinical status of the child
and then titrated against the individual’s response (U).
Regional analgesia
1. Topical local anaesthetic does not adequately control pain associated with circumcision
in awake neonates (U) (Level I [Cochrane Review]).
2. Caudal local anaesthetic and dorsal penile nerve block provide perioperative analgesia
for circumcision (U) (Level I [Cochrane Review]).
3. Clonidine prolongs analgesia when added to caudal local anaesthetic blocks (U) (Level I)
and improves analgesia when added to epidural local anaesthetic infusions (U) (Level II).
4. Wound infiltration, peripheral nerve blocks, and caudal local anaesthetic provide
effective analgesia after day‐case inguinal surgery (U) (Level II).
5. Epidural infusions of local anaesthetic and systemic opioids provide similar levels of
analgesia (U) (Level II).
6. Epidural opioids alone are less effective than local anaesthetic or combinations of local
anaesthetic and opioid (U) (Level II).
7. Intrathecal opioids provide prolonged analgesia after surgery (N) (Level II) and reduce
blood loss during spinal fusion (N) (Level II).
Acute pain management: scientific evidence xliii
