Page 113 WHO - Guidelines on the pharmacological treatment of persisting pain in children with medical illness

GRADE Table 5 (table excluded during evidence appraisal as not addressing
the clinical questions on comparison of strong opioids and route of
administration within the scope of these guidelines)

Author: Wiffen PJ
Date: 17-04-2009
Question: Should epidural morphine vs. epidural fentanyl or epidural hydromorphone be used for
post-operative pain control for orthopaedic surgery in children aged 3–19 years?
Settings: Children’s hospital, Los Angeles, CA, USA.
Bibliography: Goodarzi M. Comparison of epidural morphine, hydromorphone and fentanyl for
post-operative pain control in children undergoing orthopaedic surgery. Paediatric Anesthesia, 1999,
9:419–422.

Summary of findings
Quality assessment No. of
patients Effect

Epidural
No. of studies Design Limitations Inconsistency Indirectness Imprecision Other considerations Epidural morphine Epidural Relative (95% CI) Absolute Quality
fentanyl

hydro-
mor-
phone
Post-operative pain scores (follow-up: mean 30 hours; 5-point VAS scale)
1 Rand- No No Serious a No Epidural 30 30 Descrip- – VERY
omized serious serious serious route 30 tive data LOW
trial limita- inconsist- impreci- only. Good
tions ency sion pain relief
achieved,
similar
in all
groups b,c

Adverse events (follow-up: mean 30 hours)
1 Rand- No No Serious a No Epidural – – Descriptive – VERY
omized serious serious serious route data only d LOW
trial limita- inconsist- impreci-
tions ency sion
CI, confidence interval; VAS, visual analogue scale.
a Acute post-operative pain: morphine 10 mcg/kg/h; hydromorphone 1 mcg/kg/h; fentanyl 1 mcg/kg/h.
b Ninety participants: 30 per group.
c All groups reported good to excellent pain relief. No statistically significant difference.
d Respiratory depression, somnolence, nausea, vomiting, pruritis and urinary retention, all at greater incidence in
morphine group.

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