Analgesia & Sedation

Analgesia

Paracetamol

20 mg/kg (max 90 mg/kg/day) orally or PR

Non Steroidal Anti-Inflammatory Drugs

naproxen 5 - 10 mg/kg (max 500 mg) 12-hrly orally or PR
ibuprofen 2.5 - 10 mg/kg (max 600 mg) 6-8hrly orall

Opioids

codeine 0.5 - 1 mg/kg orally (as adjunct - Liquigesic-fever or Painstop- sedation)
pethidine 1mg/kg i.m. or 0.25 - 0.5 mg/kg i.v.
morphine 0.1 mg/kg i.m. or 0.05 - 0.1 mg/kg i.v.

Note:

Use i.v. if older child/adolescent with easy intravenous access .
Titrate boluses (ie. give 1/2 of dose first to see effect, then repeat at 5 - 10 minute intervals as required up to maximum total dose).
Respiratory depression risk - reduce doses if combined with sedatives. May get delayed respiratory depression after treating cause of pain.
Multi-trauma - do not withhold but give with caution, particularly if hypovolaemic.

Sucrose

Oral sucrose has been shown to reduce pain in infants less than three months of age during minor procedures.
Oral sucrose may be given to infants during procedures such as blood collection, IV insertion, eye examination and lumbar puncture.
Sucrose may be more effective if given with a dummy as the dummy promotes non-nutritive sucking which contributes to calming.
Other strategies which assist in calming infants and can be used as an adjunct to sucrose include feeding (if allowed), cuddling, and wrapping.
Other appropriate local or systemic analgesic agents should be administered as required.

Dose:

Maximum 2mL (0.5mL for infants below 1500 grams) administered orally for each procedure.
Two minutes prior to a painful procedure, administer a small amount (around 0.25ml) of sucrose onto the infant's tongue. Offer a dummy if this is part of the infants care.
Continue giving remainder of sucrose slowly during the procedure for a total dose of 2ml, until the procedure is completed.
Stock bottles of 33% sucrose are available from Royal Children's Hospital Pharmacy Department.

Note:

Sucrose is only effective if given orally. There is no effect if given via an oral or nasogastric tube.
The addition of non-nutritive sucking enhances the analgesic effect of sucrose.

Specific uses of Analgesia

IV insertion
Topical anaesthetic cream for 30 - 45 mins; distraction eg.calico dolls.
Oral sucrose combined with non-nutritive sucking for infants under three months
Lumbar puncture
Topical anaesthetic cream for 30 - 45 mins, 1% lignocaine with 25G needle.
Oral sucrose combined with non-nutritive sucking for infants under three months
Removal of nasal/pharyngeal foreign body
Topical phenylephrine (0.5%) & lignocaine spray (Cophenylcaine) or nebulised lignocaine (1.0%) 1ml in 3ml 0.9% NaCl.
Earache
Topical auralgin otic (lie ear up for 10 mins) or 1% Lignocaine 2 drops.
Eye
Topical amethocaine 0.5% to examine; patch +/- atropine (to relieve iris spasm)
Oral sucrose combined with non-nutritive sucking for infants under three months.
Regional anaesthesia (eg. Bier’s block) - see Intravenous Regional Anaesthesia guideline.
Systemic analgesia – see nitrous oxide section below

Sedation - Midazolam

Properties

anxiolytic and anterograde amnestic.
onset is usually within minutes

Indications

procedures such as suturing, removal of foreign body from nose etc.

Dose

oral / buccal 0.5 - 1.0 mg/kg.(max 15mg)
intranasal 0.6mg/kg (max 10mg) - may have more rapid onset.
Draw up solution (5 mg/ml) in a 1 or 2 ml syringe. May be mixed with small volume of cordial to disguise acid taste.

Cautions

Observe the child in Emergency until fully alert (usually recover by 60 minutes)
Midazolam will potentiate the effects of other sedative drugs eg. opiates.
Midazolam should not be given to children with pre-existing respiratory insufficiency, or neuromuscular problems such as myasthenia gravis.

Nitrous Oxide / Oxygen Mix (Entonox, Zeropain)

See Nitrous Oxide Guideline

Ketamine

See Ketamine Guideline