Peri-operative analgesia

Please see pain pathways within Central Nervous System chapter for further treatment choices.

Refer to BNF/product information.

Prescribing Notes:

Rectal diclofenac and oral paracetamol are also included in the East Region Formulary, see Pain pathways.

History Notes

27/10/2022

East Region Formulary content agreed.

Prescribing Notes:

Acute postoperative pain is managed similarly to other pain and usually follows a step down approach. The treatment of acute and chronic pain follows the general principles developed by the World Health Organisation (WHO):

Step 1: mild pain: use paracetamol and/or NSAID

Pain persisting or increasing >

Step 2: mild to moderate pain: use codeine plus paracetamol and/or NSAID

Pain persisting or increasing >

Step 3: moderate to severe pain: use morphine and paracetamol and/or NSAID

History Notes

16/11/2020

Content migrated from LJF website.

Paracetamol with or without NSAID (see prescribing notes)

For inpatient prescribing:
Under 3 months, 10mg/kg every 4-6 hours. Max. total daily dose 60mg/kg.
Over 3 months, 15mg/kg every 4-6 hours. Max. total daily dose 90mg/kg, or 4g in 24 hours.

For outpatient or discharge prescribing:
Under 1 month, 10-15mg/kg every 6-8 hrs; max 30mg/kg/day.
1-3 months, 30mg every 4-6 hrs; max. 4 doses in 24 hrs.
3-6 months, 60mg every 4-6 hrs; max. 4 doses in 24 hrs.
6-24 months, 120mg every 4-6 hrs; max 4 doses in 24 hrs.
2-4 years, 180mg every 4-6 hrs; max 4 doses in 24 hrs.
4-6 years, 240mg every 4-6 hrs; max 4 doses in 24 hrs.
6-8 years, 250mg every 4-6 hrs; max 4 doses in 24 hrs.
8-10 years, 375mg every 4-6 hrs; max 4 doses in 24 hrs.
10-12 years, 500mg every 4-6 hrs; max 4 doses in 24 hrs.
13-14 years, 750mg every 4-6 hrs; max 4 doses in 24 hrs.
15 years and over, 1 gram every 4-6 hrs; max 4 doses in 24 hrs.

For inpatient prescribing:
3-6 months, on specialist advice, 5mg/kg every 6-8 hours.
Over 6 months, 5-10mg/kg every 6-8 hours (max. 600mg per dose).

For outpatient or discharge prescribing:
6-11 months (7-10kg), 50mg every 6-8 hours.
1-3 years (10-16kg), 100mg every 6-8 hours.
4-6 years (17-22kg), 150mg every 6-8 hours.
7-9 years (23-29kg), 200mg every 6-8 hours.
10-11 years (30-39kg), 200-300mg every 6-8 hours.
13-14 years (40-50kg), 200-400mg every 6-8 hours.
Over 15 years (above 50kg), 200-600mg every 6-8 hours.

Above 6 months, 0.3-1mg/kg 2-3 times a day (max. 50mg per dose).

Prescribing Notes:

Relative contra-indications to NSAIDs include renal impairment, history of gastro-intestinal bleeding, heart failure, hypertension, coagulation defects; absolute contra-indications include proven hypersensitivity to aspirin or any NSAID.
Assess the hydration status of the patient before prescribing NSAIDs. There is a risk of precipitating renal failure if NSAIDs are administered to patients who are dehydrated.
NSAIDs may enhance the effects of warfarin.
NSAIDs may worsen asthma; they are contra-indicated if aspirin or any other NSAID has precipitated attacks of asthma, although this occurs rarely in children.
Paracetamol doses may need to be increased, and given at longer time intervals, when given rectally to achieve the same plasma levels as the oral route.
The higher paracetamol doses used for inpatients should not be continued for more than 5 days.
Aspirin should not be given to children under 12 years for analgesia or children under 15 years as an antipyretic because of the risk of Reye’s syndrome.

History Notes

09/07/2024

Paracetamol 60mg suppositories discontinued

16/11/2020

Content migrated from LJF website.

Paracetamol AND codeine, with or without NSAID (ibuprofen or diclofenac sodium)

For inpatient prescribing:
Under 3 months, 10mg/kg every 4-6 hours. Max. total daily dose 60mg/kg
Over 3 months, 15mg/kg every 4-6 hours. Max. total daily dose 90mg/kg, or 4g in 24 hours.

For outpatient or discharge prescribing:
Under 1 month, 10-15mg/kg every 6-8 hrs; max 30mg/kg/day.
1-3 months, 30mg every 4-6 hrs; max. 4 doses in 24 hrs.
3-6 months, 60mg every 4-6 hrs; max. 4 doses in 24 hrs.
6-24 months, 120mg every 4-6 hrs; max 4 doses in 24 hrs.
2-4 years, 180mg every 4-6 hrs; max 4 doses in 24 hrs.
4-6 years, 240mg every 4-6 hrs; max 4 doses in 24 hrs.
6-8 years, 250mg every 4-6 hrs; max 4 doses in 24 hrs.
8-10 years, 375mg every 4-6 hrs; max 4 doses in 24 hrs.
10-12 years, 500mg every 4-6 hrs; max 4 doses in 24 hrs.
13-14 years, 750mg every 4-6 hrs; max 4 doses in 24 hrs.
15 years and over, 1 gram every 4-6 hrs; max 4 doses in 24 hrs.

Codeine is not licensed for use under 12 years of age.

Below 3 months, under specialist supervision only.
3 months-11 years, 0.5-1mg/kg/dose repeated 4-6 times a day.
12-18 years, 30-60mg 4-6 times a day. Max 240mg/day.

NSAID (ibuprofen or diclofenac sodium)

Above 6 months, 0.3-1mg/kg 2-3 times a day (max. 150mg daily).

Paracetamol AND dihydrocodeine, with or without NSAID (ibuprofen or diclofenac sodium)

1-3 years; 500micrograms/kg every 4-6 hours.
4-11 years; 0.5-1mg/kg every 4-6 hours (max per dose 30mg).
12-17 years; 30mg every 4-6 hours.

NSAID (ibuprofen or diclofenac sodium)

Above 6 months, 0.3-1mg/kg 2-3 times a day (max. 150mg daily).

Prescribing Notes:

Relative contra-indications to NSAIDs include renal impairment, history of gastro-intestinal bleeding, heart failure, hypertension, coagulation defects; absolute contra-indications include proven hypersensitivity to aspirin or any NSAID.
Assess the hydration status of the patient before prescribing NSAIDs. There is a risk of precipitating renal failure if NSAIDs are administered to patients who are dehydrated.
NSAIDs may enhance the effects of warfarin.
NSAIDs may worsen asthma; they are contra-indicated if aspirin or any other NSAID has precipitated attacks of asthma, although this occurs rarely in children.
Management of postoperative pain should follow hospital acute pain guidelines where they exist.
Dihydrocodeine may be prescribed short-term for postoperative pain. However, local experience is that it may be abused in the community and it should be prescribed with caution. Patients are given 3 doses only following day case surgery.
Codeine is an inefficient analgesic in approximately 10% of patients who are unable to convert it to morphine.
Naloxone may be used to reverse the effects of opioids. The recommended dose in children of all ages is 4 microgram/kg repeated every 2-3 minutes as necessary until respiratory improvement is achieved. Note that since the half-life of an opioid may be longer than that of naloxone, a second dose may be required to prevent respiratory depression recurring.

History Notes

09/07/2024

Paracetamol 60mg suppositories discontinued

16/11/2020

Content migrated from LJF website.

Paracetamol AND morphine, with or without NSAID (ibuprofen or diclofenac sodium)

Child 1-2 months; Initially 50-100 micrograms/kg every 4 hours, adjusted according to response.
Child 3-5 months; 100-150 micrograms/kg every 4 hours, adjusted according to response.
Child 6-11 months; 200 micrograms/kg every 4 hours, adjusted according to response.
Child 1 year; Initially 200-300 micrograms/kg every 4 hours, adjusted according to response.
Child 2-11 years; Initially 200-300 micrograms/kg every 4 hours (max. per dose 10 mg), adjusted according to response.
Child 12-17 years; Initially 5-10 mg every 4 hours, adjusted according to response.

Using modified-release medicines - every 12 or 24 hours, dose adjusted according to daily morphine requirements, dosage requirements should be reviewed if the brand is altered.

Child 1-2 months; Initially 50-100 micrograms/kg every 4 hours, adjusted according to response.
Child 3-5 months; 100-150 micrograms/kg every 4 hours, adjusted according to response.
Child 6-11 months; 200 micrograms/kg every 4 hours, adjusted according to response.
Child 1 year; Initially 200-300 micrograms/kg every 4 hours, adjusted according to response.
Child 2-11 years; Initially 200-300 micrograms/kg every 4 hours (max. per dose 10 mg), adjusted according to response.
Child 12-17 years; Initially 5-10 mg every 4 hours, adjusted according to response.

See BNF for dosages for subcutaneous injection or by intravenous injection.

NSAID (ibuprofen or diclofenac sodium)

Above 6 months, 0.3-1mg/kg 2-3 times a day (max. 150mg daily).

Prescribing Notes:

Morphine should be given parenterally when possible for acute severe pain. The first dose of intravenous morphine should be given slowly over 5-10 minutes, titrated to effect, and respiratory rate monitored. The initial dose is determined by the age of the child and previous exposure to opiates, and should be reduced, as described under ‘Dose’ above, in those under 6 months of age.
For small doses of morphine, draw up 1mL of 10mg/mL solution, dilute to 10mL with 0.9% NaCl (to provide 1mg/mL solution), mix well. For children ≤10kg transfer this solution to a 1mL syringe to enable an accurate dose to be measured.
Above doses are starting doses intended for general ward use. If higher doses are required the patient should be transferred to a high dependency area.
A balance has to be found between the lowest dose of morphine required to improve function versus higher doses required to abolish symptoms. Treatment dose should be discussed with the patient/carer.
Relative contra-indications to NSAIDs include renal impairment, history of gastro-intestinal bleeding, heart failure, hypertension, coagulation defects; absolute contra-indications include proven hypersensitivity to aspirin or any NSAID. Caution should also be exercised in prescribing NSAIDs for patients who are dehydrated.
NSAIDs may enhance the effects of warfarin.
NSAIDs may worsen asthma; they are contra-indicated if aspirin or any other NSAID has precipitated attacks of asthma, although this occurs rarely in children.
For postoperative pain refer to relevant hospital acute pain protocols.
Naloxone may be used to reverse the effects of opioids. The recommended dose in children of all ages is 4 microgram/kg repeated every 2-3 minutes as necessary until respiratory improvement is achieved. Note that since the half-life of an opioid may be longer than that of naloxone, a second dose may be required to prevent respiratory depression recurring.

History Notes

09/07/2024

Paracetamol 60mg suppositories discontinued

16/11/2020

Content migrated from LJF website.