PAEDIATRIC ANALGESIA GUIDELINES

Transcription

1 PAEDIATRIC ANALGESIA GUIDELINES V5.2 Sept 2017 Paediatric Analgesia Guidelines

2 Table of Contents 1. Introduction Purpose of this Policy/Procedure Scope Definitions / Glossary Ownership and Responsibilities Standards and Practice Guidelines for Paediatric Analgesia Guidance for the use or oral sucrose solution prior to minor painful procedures in babies under 4 months Intranasal Diamorphine (Ayendi) IV Morphine Infusion Morphine Patient Controlled Analgesia (PCA) Morphine Nurse Controlled Analgesia (NCA) Fentanyl Infusion and PCA Paediatric Recovery Epidurals Management of Leg Weakness with Epidurals Mean Values for weight, height and gender by age Dissemination and Implementation Monitoring compliance and effectiveness Updating and Review Equality and Diversity Equality Impact Assessment Appendix 1. Governance Information Appendix 2. Initial Equality Impact Assessment Form Appendix 3 GUIDANCE FOR ANTICIPATORY PRESCRIBING AND SYMPTOM CONTROL IN PAEDIATRIC PATIENTS

3 1. Introduction 1.1. This policy has been drawn up to ensure that Paediatric patients within the Trust receive appropriate pain relief This version supersedes any previous versions of this document. 2. Purpose of this Policy/Procedure 2.1. The purpose of this policy is to inform all staff of the appropriate analgesia regimes for paediatric patients. 3. Scope 3.1. This policy applies to anyone who looks after children within RCHT. 4. Definitions / Glossary 4.1. PCA- Patient Controlled Analgesia NCA- Nurse Controlled Analgesia TTO- Tablets to Take Out NSAID- Non Steroidal Anti-Inflammatories IV- Intravenous 5. Ownership and Responsibilities 5.1. The Acute Paediatric Pain Service is responsible for the development, management and implementation of this policy/procedure Dr Julian Berry Medicines Practice Committee Acute Paediatric Pain Service Anaesthetists (Paediatric) Clinical staff members 3

4 6. Standards and Practice 6.1. Hints and Tips Hints and Tips (Not for use with children under 3 months of age) PROTOCOLS ON EPMA Whenever possible use a pre-prescribed weight-based EPMA protocol: PAED PERI- For children going to theatre. PAED PAIN- For inpatient analgesia FEMUR CHILD- For children admitted with a fractured femur. Paracetamol Orally is rapidly absorbed from the small bowel, almost 100% bioavailability, and has a similar onset time to IV preparation. IV dose will result in higher plasma and effect site concentrations 1 Rectally uptake is slower and more variable; doses of 20mg/kg are often not therapeutic and take 2-4 hrs to reach therapeutic concentrations 2. Therefore PR 40mg/kg followed by 20mg/kg doses are recommended Always go for oral dosing first, as the cost of rectal and IV preparations are comparable and are 10 times greater than oral. NSAIDs: Ibuprofen and Diclofenac NSAIDs opioid-sparing effect of 30 40% 3 Only 2% with asthma have a deterioration in lung function when given aspirin, only 5% of those patients have a cross sensitivity to other NSAIDS therefore risk is low. In orthopaedic procedures benefits outweigh the risks of reduced bone healing in most cases. Avoid if non-union or scoliosis surgery 4. Cochrane review has demonstrated that there is no increase in bleeding post tonsillectomy Diclofenac: No longer routinely used in Paediatrics. Codeine Phosphate and Oramorph Codeine should only be used to relieve acute moderate pain in children older than 12 years and only if it cannot be relieved by other painkillers such as Paracetamol or Ibuprofen alone. A significant risk of serious and life-threatening adverse reactions has been identified in children with obstructive sleep apnoea who received codeine after tonsillectomy or adenoidectomy (or both). Codeine is now contraindicated in all children younger than 18 years who undergo these procedures for obstructive sleep apnoea 5 Oramorph should be used at doses of micrograms/kg max 4 hourly for in-patient analgesia. If TTOs are required they should be prescribed as micrograms/kg max 6 hourly. Ensure that simple analgesia doses are appropriate and given regularly before adding Oramorph. Opiates In Paediatrics morphine PCA provides superior analgesia to the intramuscular route or to continuous infusion of morphine, with comparable outcome to epidural morphine. 6 See intravenous opiate guidelines 1 Morton, N S.(2007) Arch Dis Child Educ Pract Ed 92: ep14-ep19 2 Anderson, B J. (1998) What we don t know about Paracetamol in children. Paediatric Anaesthesia ;8: Kokki, H. (2003) Non steroidal anti-inflammatory drugs for postoperative pain: a focus on children. Paediatric Drugs; 5: Ippokratis Pountos, Theodora Georgouli, Giorgio M. Calori, and Peter V. Giannoudis (2012). Do Nonsteroidal Anti-Inflammatory Drugs Affect Bone Healing? A Critical Analysis. The Scientific World Journal, Volume 2012, Article ID MHRA (2013) Drug safety update. MHRA; Volume 6, Issue Morton, N. (1997) Paediatric Patient Controlled Analgesia. Paediatric Perinat Drug Ther; 1:

5 6.2. Guidelines for Paediatric Analgesia Guidelines for Paediatric Analgesia (NOT FOR USE IF UNDER 3 MONTHS) Whenever possible use a pre-prescribed weight-based EPMA protocol: Paed Pain (ward), Paed Peri (theatre) or Femur Child (# femur in ED). Adequate and regular dosing is essential. Use the oral route if pain is not severe. Use parenteral administration if the drug can only be used this way or if enteral administration has failed or ineffective. Prescribe ONE drug from each colour only. If more than two IV opiate doses are required, consider IV infusion/pca/nca with guidelines. Contact Paediatric Pain Team on bleep 2283 (office hours) or Senior Anaesthetic Trainee (bleep3513) for advice or help. DRUG ROUTE DOSE ESCALATING ANALGESIA Paracetamol Suspension- 120mg/5ml 250mg/5ml Tablets- 500mg Soluble tablets- 500mg Suppositories- 60, 120, 250, 500mg 20mg/kg 6 hourly PO/PR for 48 hours Then reduce to 15/mg/kg 6 hourly Intravenous Paracetamol Ibuprofen Morphine Diamorphine ONLY TO BE PRESCRIBED IF ORAL ROUTE NOT AVAILABLE 50mls- 500mg 100mls- 1g Suspension- 100mg/5ml Tablets- 200, 400mg Oramorph- 10mg/5ml Tablets- 10, 20mg Injection- 10mg/ml Intranasal spray- 720micrograms/spray 1600micrograms/spray Maximum daily dose 75mg/kg, not exceeding 4g / day <10kg- 7.5mg/kg 6 hourly >10kg- 15mg/kg 6 hourly >50kg- 1g max 6 hourly 3-6months- 5mg/kg 8 hourly PO >6 months- 10mg/kg 8 hourly PO Maximum daily dose 30mg/kg or 1.2g Orally <12 months- 50 micrograms/kg 4 hourly >12 months micrograms/kg 4 hourly Intravenous- <6 months 100 micrograms/kg 6 hourly >6 months 100 micrograms/kg 4 hourly TTO s of Oramorph- >12 months- 100 micrograms/kg 6 hourly If OSA/altered respiratory drive- 50micrograms/kg 6 hourly INTRANASAL- ONCE ONLY See separate guideline on intranet intranet anaesthetic guidelines paediatric pain RESPIRATORY DEPRESSION Give oxygen, contact paediatric or ITU consultant. Consider PERT call. < 12 years- Naloxone 10micrograms/kg IV bolus and repeat if necessary. If no response, give subsequent doses of 100 micrograms/kg (max 2mg) > 12 years- Naloxone 100micrograms IV bolus and repeat if necessary. If no response, give subsequent doses in increments of 100micrograms every 2 minutes if required (max dose 10mg). Ondansetron See BNFC for alternatives FIRST-LINE ANTI-EMETIC Intravenous 0.1mg/kg 8 hourly Can cause severe constipation. Orally <4 years- 2mg 8 hourly May be ineffective in opioid induced nausea >4 years- 4mg 8 hourly and vomiting. CONSIDER ENTONOX FOR PROCEDURAL PAIN RELIEF 5

6 6.3. Guidance for the use or oral sucrose solution prior to minor painful procedures in babies under 4 months Indication for use In conjunction with non-nutritive sucking, oral sucrose solution can relieve pain in neonates during minor procedures such as venepuncture, heel prick, cannulation, intramuscular injections, subcutaneous injection, lumbar puncture etc. Sucrose is only effective when given orally, directly onto the infant's tongue. There is no analgesic effect if sucrose is given directly into the stomach via a nasogastric tube. Breast feeding is more efficacious than sucrose. The efficacy and safety of repeated doses/maximum doses is not known. Necrotising enterocolitis. Contraindications Suspected hyperglycaemia. Do not use in ventilated or paralysed babies. Dose Must be prescribed on their drug chart. Ideally, obtain consent from the parent to use. The dose is administered onto the baby s tongue approximately 2 minutes prior to the procedure. After administration the baby should be given a dummy or comforter to suck on as this can potentiate the analgesic effect of sucrose. The effect may last for approximately 10 minutes. Preterm neonates <3kgs Term neonates > 3kgs 0.5-1ml of 24% sucrose solution 1-2ml of 24% sucrose solution 4 times a day 6-8 times a day There is no data regarding repeated doses or long term effects of using sucrose. Holsti, L. and Grunau, R.E. (2010) Considerations for using sucrose to reduce procedural pain in preterm infants, Pediatrics, 125(5) pp Stevens, B., Yamada, J., Lee, G. and Ohlsson, A. (2013) Sucrose for analgesia in newborn infants undergoing painful procedures, Cochrane Database of Systematic Reviews; Cochrane Neonatal Group, DOI: / CD pub4 6

7 6.4. Intranasal Diamorphine (Ayendi) Indications First line treatment of severe pain in a child without IV access e.g. Clinically suspected limb fractures Painful dressings/burns Procedural pain Intranasal Diamorphine is usually effective within 5-10 minutes but allow 20 minutes for maximum pain control. Analgesic effect lasts for up to 4 hours. Oxygen saturation monitoring will be required once Diamorphine has been administered and for 1 hour post administration. Ensure that intravenous access is obtained as soon as possible. Ensure that supplementary analgesia is prescribed (see coloured paediatric analgesia dosing guideline) e.g. Paracetamol and NSAIDs. Naloxone must be prescribed (see coloured paediatric analgesia dosing guideline). *Child less than 12kg weight (unlicensed) only to be administered by a senior doctor. Contraindications Nasal trauma or epistaxis. Decreased conscious level or head injury Allergy to opiates. Dose schedule Dosing is based on weight Preparation and administration- Reconstitute, if required and date the bottle. Attach pump and nasal tip, remove green collar and prime with 8 sprays. Subsequent doses- Remove the green safety collar. Attached new nasal tip and before use prime using 2 sprays. Administer the required number of sprays (alternate nostrils). Discard the used nasal tip and replace the green safety collar. CD register- Record both the wastage from priming and the number of sprays in the register. NB AFTER RECONSTITUTION THE BOTTLE MUST BE DISPOSED OF AFTER 14 DAYS. WEIGHT OF CHILD APPROX AGE TOTAL NUMBER OF SPRAYS TOTAL DOSE DELIVERED 720micrograms/spray 10-30kg * kg 1- <2 years 1 720micrograms 12- < 18kg 2-5 years mg 18- < 24kg 5-8 years mg 24- <30kg 8-10 years mg 1600micrograms/spray 30kg- 50kg 30- <40kg years 2 3.2mg 40-50kg years 3 4.8mg 7

8 6.5. IV Morphine Infusion IV Morphine infusion Any patient requiring a morphine infusion with complex medical or surgical needs requires paediatric HDU. Early discussion with Paediatric Consultant on call required before commencing case. Young infants require reduced doses. Prematurely-born neonates and infants must be discussed with a consultant anaesthetist. The current pump to use is a PCAM pump with the handset removed. It should be programmed with the background as ml/hr with no bolus. Ensure adequate loading dose of 100 micrograms/kg. A continuous infusion will provide a relatively steady state. Rate can be adjusted to pain score. Must have naloxone prescribed (see coloured paediatric analgesia dosing guideline). Please complete yellow paediatric pain audit form to ensure follow-up. TO MAKE INFUSION Dose: 1mg/kg morphine made up to 50ml with normal saline. Maximum dose is 50mg of morphine in 50mls of saline Example For a 20kg child, use 20mg morphine and dilute to 50ml with normal saline. 20mg divided by 50ml = 0.4 mg/ml (or 400 micrograms/ml). Results in 1ml/hr = 400 micrograms/hr or 20 micrograms/kg/hr. Infusion regimes 0-1 months: maximum of 5 micrograms/kg//hour = max 0.25mL/hour 1-3 months: maximum of 10 micrograms/kg/hour = max 0.5mL/hour Over 3 months: maximum of 40 micrograms/kg/hour = max 2mL/hour Maximum infusion rate should be 2ml/hr, which is equal to 40 micrograms/kg/hr. ALARIS PCAM pump setup Pumps are kept in recovery, need drug keys to unlock. Keys for PCA machines are kept together with the controlled drug keys by the nurse in charge. Select protocol C; Paediatric Morphine protocol. The default is set to 200 micrograms/ml, this needs adjusting depending on weight: o The micrograms/ml concentration is the child s weight divided by 50. o Go to modify protocol, scroll to Drug Concentration and alter o To set rate, scroll down to continuous and alter the rate in mls. 8

9 6.6. Morphine Patient Controlled Analgesia (PCA) Indications for use For use in 4 years and above, usually have the ability to understand and push the button. Need adequate loading dose to gain child s confidence in PCA Loading dose: 100 micrograms/kg. This can be repeated if required. May need a background infusion for the first 24hrs. Must prescribe naloxone (see coloured paediatric analgesia dosing guideline). Bolus: press bolus button, then code, then enter amount. Please complete yellow paediatric pain audit form to ensure follow-up. Drawing up a Morphine PCA Dose: 1mg/kg morphine made up to 50ml with normal saline. Gives a final concentration of 20 micrograms/kg/ml. Maximum dose is 50mg of morphine in 50mls of saline Example BACKGROUND (IF USED) BOLUS LOCKOUT 20kg child = 20mg of morphine in 50ml. Gives 0.4mg per ml,= which is 400 micrograms/ml 6 micrograms/kg/hour (0.3ml/hr). 1ml over 1minute, 20 micrograms/kg. 5 minutes. ALARIS PCAM pump setup Pumps are kept in recovery, keys for PCA machines are kept together with the controlled drug keys by the nurse in charge. Select protocol C; Paediatric Morphine protocol. The default is set to 200 micrograms/ml, this needs adjusting depending on weight: o The micrograms/ml concentration is the child s weight divided by 50. o o Go to modify protocol, scroll to Drug Concentration and alter. To set rate, scroll down to continuous and alter the rate in mls 9

10 6.7. Morphine Nurse Controlled Analgesia (NCA) Indications for use For children under 6 years or those incapable of using a PCA. Use with constant background, and allows bolus for breakthrough and procedures. Use on paediatric HDU only. Early discussion with Paediatric Consultant on call required before commencing case. Avoids delay with increasing background alone. Must prescribe naloxone (see coloured paediatric analgesia dosing guideline). Please complete yellow paediatric pain audit form to ensure follow-up. Drawing up a Morphine NCA Dose: 1mg/kg Morphine made up to 50ml with normal saline, example as above for morphine. Maximum dose is 50mg of morphine in 50mls of saline BACKGROUND BOLUS LOCKOUT 10-20micrograms/kg/hr = 0.5-1ml/hr micrograms/kg = 0.5-1ml per bolus minutes. ALARIS PCAM pump setup Pumps are kept in recovery, need drug keys to unlock. Keys for NCA/PCA machines are kept together with the controlled drug keys by the nurse in charge. Select protocol C; Paediatric Morphine protocol. The default is set to 200 micrograms/ml; this will need adjusting, depending on weight: o The micrograms/ml concentration is the child s weight divided by 50. o o Go to modify protocol, scroll to Drug Concentration and alter. To set rate, scroll down to continuous and alter the rate in mls 10

11 6.8. Fentanyl Infusion and PCA FENTANYL PCA TO BE PRESCRIBED BY SENIOR CLINICIAN ONLY Indicated for morphine intolerance; nausea and vomiting; poor renal function Paediatric protocol up to 40 kg. Above 40kg use adult protocol included below If patient BMI>30 calculate an ideal body weight using patient height-50 th centile weight chart (see page 17 or BNFc back page). FENTANYL INFUSION <40kgs (renal impairment or those with significant side effects to morphine) Dose: 50 micrograms/kg Fentanyl made up to 50ml with normal saline (max 40kg). Gives a final concentration of 1 microgram/kg/ml. Must prescribe naloxone (see coloured paediatric analgesia dosing guideline). Please complete yellow paediatric pain audit form to ensure follow-up. Example For a 20kg child use 50 micrograms/ml Fentanyl and draw up 20mls (ie 2 large 500 micrograms amps), dilute with normal saline to 50ml: 1000 micrograms divided by 50ml = 20 micrograms/ml. Maximum dose 50mls (i.e. 5 large 500microgram ampoules). Results in 1ml/hr = 1 microgram/kg/hr. Range is 0.5-2ml/hr = 0.5-2micrograms/kg/hr. FENTANYL PCA <40kgs (renal impairment or those with significant side effects to morphine) Dose: 50micrograms/kg Fentanyl made up to 50mls with Normal Saline (max 40kg). Gives a final concentration of 1 microgram/kg/ml. Must prescribe naloxone (see coloured paediatric analgesia dosing guideline). Please complete yellow paediatric pain audit form to ensure follow-up. Example BACKGROUND (IF USED) BOLUS LOCKOUT 4 HOURLY MAXIMUM DOSE 20kg patient draw up 20ml of 50micrograms/ml for a (= 2 large 500microgram/10ml vials) and dilute with normal saline to 50mls. 0.5ml/hr on 1 st -2 nd post op day. 0.5ml over 1 minute, 0.5 microgram/kg. 10 minutes. 12mls in 4 hours. 11

12 ALARIS PCAM pump setup Pumps are kept in recovery, need drug keys to unlock. Keys for NCA/PCA machines are kept together with the controlled drug keys by the nurse in charge. Select protocol E; Paediatric Fentanyl protocol. The default is set to 10 micrograms/ml; this will need adjusting, depending on weight: o o o The micrograms/ml concentration is1 microgram/kg/ml. Go to modify protocol, scroll to Drug Concentration and alter. To set rate, scroll down to continuous and alter the rate in mls FENTANYL PCA >40KGS (renal impairment or those with significant side effects to morphine) 500micrograms Fentanyl (=10mls neat fentanyl) made up to 50mls with Normal saline There is no per kilogram calculation Dose: 10micrograms/ml BOLUS LOCKOUT 4 HOURLY MAXIMUM DOSE 1ml 5 minutes 50mls (500micrograms) in 4 hours ALARIS PCAM pump setup Pumps are kept in recovery, need drug keys to unlock. Keys for NCA/PCA machines are kept together with the controlled drug keys by the nurse in charge. Select protocol B; Fentanyl protocol. 12

13 6.9. Paediatric Recovery Use of IV Fentanyl post operatively in children < 50kgs Acute post operative pain score >5. Indication for use Rapid relief of moderate to severe pain relief. Provides immediate pain relief, lasts approx. 20 minutes. Ensure oxygen available. Monitor for respiratory depression, sedation and itch If patient BMI>30 calculate an ideal body weight using patient height-50 th centile weight chart (see page 17 or BNFc back page). Dose 0.25micrograms/kg per dose Dose can be repeated every 15minutes up to a maximum 4 doses (1microgram/kg in 1 hour) Practice points Ensure supplementary analgesics (Paracetamol, NSAIDs) are prescribed regularly on prescription chart. If prolonged post-op pain likely, in addition consider morphine administration in recovery and ensure IV and oral preparations prescribed on ward chart. Must have naloxone prescribed (see coloured paediatric analgesia dosing guideline). Must have anti-emetics prescribed (see coloured paediatric analgesia dosing guideline). 13

14 6.10. Epidurals Indications for use Children require larger volume with lower concentrations of opiate to block dermatomes. Bolus loading dose in theatre should be ml/kg of 0.25% Levobupivicaine. Continuous infusion rates of around 0.4mg/kg/hr are effective for children > 3 months. Maximal dose of Levobupivicaine in children is 2.5mg/kg. Must have naloxone prescribed (see coloured analgesia dosing guideline). All patients should have a urethral catheter. Must have working cannula in-situ at all times. Please complete a yellow paediatric acute pain audit form to ensure follow-up. Infusion Strength Rate 0.125% Levobupivicaine + 2mcg/ml Fentanyl ml/kg/hr Example For a 10kg child the rate would be 2-4ml/hr 2-4ml/hr = 2.5mg 5mg of Levobupivicaine/hr = 4-8 micrograms of Fentanyl/hr Always check the dosing is appropriate for the child in front of you. McKinley Pump Setup Keys for epidural machines are kept together with the controlled drug keys by the nurse in charge. After switching on enter code First prime the line through the pump. Then select protocol depending on strength of epidural mix. 14

15 Trouble Shooting for Epidurals PROBLEM ACTION Infusion rate too low On-call should give a bolus dose of epidural mixture and increase rate. Bolus dose is 0.25ml/kg of 0.25% Levobupivicaine, e.g x 20kg = 5mls of 0.25%. A bolus of epidural mix can also be given, 0.25mls/kg. Press and hold bolus, enter code, then amount, MAX 10ml. Catheter not in epidural space, or kinked Check catheter site for leakage. Consider removing and replacing with PCA. Regular review of site. Child may have full bladder Consider catheterisation. Patchy Block Consider top-up in correcting position. Remove and replace with PCA. Witnessed catheter Clean the end of the catheter with 2% Chlorhexidine, allow disconnection from filter. drying and holding the catheter with a sterile swab, cut the catheter with a sterile scissors approximately 2 3 cm and Un-witnessed catheter disconnection from filter. insert into the filter. Epidural will require removal. If in doubt contact the Acute Pain Team or 1st Call Anaesthetist Side effects SIDE EFFECTS Ventilatory Depression Pruritus/ Urinary retention Local anaesthetic toxicity. Signs and symptoms: Dizziness, blurred vision, decreased hearing, tingling in mouth and lips, restlessness, tremor, hypotension, bradycardia, arrhythmias, seizures, sudden loss of consciousness. Leg weakness/ motor block DENSE MOTOR BLOCK IS ABNORMAL! TREATMENT Oxygen. Naloxone Should be prescribed for all patients receiving IV or neuraxial opioids (opioid delivered into the brain and spinal cord). <12 years 10 micrograms/kg and repeat if no response 12-18years 3 micrograms/kg and repeat If no response repeat 100 microgram every 2mins Consider infusion 5-20micrograms/kg/hr and contact Consultant Naloxone 1 micrograms/kg (NB small dose, care in drawing up) STOP infusion, contact Senior Anaesthetic Trainee bleep 3513 as an emergency. Local anaesthetic rescue boxes are located in: General and trauma recovery. Eden Ward ITU Stop infusion, monitor sensory and motor block every 15 minutes, contact on call anaesthetist or pain team, the concern is epidural haematoma. See flow chart on next page. 15

16 6.11. Management of Leg Weakness with Epidurals Routine observations Increasing leg weakness? Motor block score 3 or 4 Yes Contact the Paediatric Pain Team or Senior Anaesthetic Trainee bleep 3513 to inform them of the situation Yes Switch epidural infusion off Recommence epidural infusion Yes Reassess leg strength every 30 minutes Patient comfortable? Yes Leg strength improving? No No Contact Paediatric Pain Team or on call anaesthetist to assess patients analgesia More than 4 hours since stopping epidural infusion? Yes Suspect an epidural haematoma? Contact Paediatric Pain Team 2283 or Senior Anaesthetic Trainee bleep 3513 An epidural haematoma has to be evacuated within 8 hours of the onset of symptoms for your patient to have the best chance of recovery of neurological function. DO NOT DELAY. 16

17 6.12. Mean Values for weight, height and gender by age The table below shows the mean values for weight, height and gender by age; these values have been derived from the UK-WHO growth charts 2009 and UK1990 standard centile charts, by extrapolating the 50th centile, and may be used to calculate doses in the absence of actual measurements. However, the child s actual weight and height might vary considerably from the values in the table and it is important to see the child to ensure that the value chosen is appropriate. In most cases the child s actual measurement should be obtained as soon as possible and the dose re-calculated. Age Weight Height kg cm Full term neonate month months months months months year years years years years years year-old boy year-old girl Adult male Adult female BNF for Children

18 7. Dissemination and Implementation 7.1. This policy will be disseminated to all staff via and publication on the Document Library. Any new version of this policy will be re circulated and all relevant staff made aware of the updates. 8. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Adherence to the published RCHT guidelines Dr. Julian Berry Acute Paediatric Pain Service Regular audit of the acute paediatric pain service is undertaken by the lead clinician along with weekly review of complicated cases. see above The committee reviewing the audit will be the anaesthesia directorate. Cases will be discussed at audit meetings and the details will be recorded in the minutes. As above The audits/recommendations will also be shared with Child Health through the children s business and audit group. Required changes to practice will be identified and actioned within a month. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders 9. Updating and Review 9.1. This document will be reviewed and updated in June Any revision activity is to be recorded in the Version Control Table as part of the document control process. 10. Equality and Diversity 10.1.This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website Royal Cornwall Hospitals NHS Trust is committed to a Policy of Equal Opportunities in employment. The aim of this policy is to ensure that no job applicant or employee receives less favourable treatment because of their race, colour, nationality, ethnic or national origin, or on the grounds of their age, gender, gender reassignment, marital status, domestic circumstances, disability, HIV status, sexual orientation, religion, belief, political affiliation or trade union membership, social or employment status or is disadvantaged by conditions or requirements which are not justified by the job to be done. This policy concerns all aspects of employment for existing staff and potential employees Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. 18

19 Appendix 1. Governance Information Document Title Paediatric Analgesia Guidelines Date Issued/Approved: June 2017 Date Valid From: June 2017 Date Valid To: June 2020 Directorate / Department responsible (author/owner): Dr Julian Berry Consultant Paediatric Anaesthetist Contact details: Brief summary of contents This guidance is to inform all staff of the appropriate analgesia regimes for paediatric patients. Suggested Keywords: Target Audience Executive Director responsible for Policy: Paediatric analgesia, Children s analgesia PCA, NCA, Epidural RCHT PCH CFT KCCG Medical Director Date revised: June 2017 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Paediatric Analgesia Guidelines Medical Practice Committee Anaesthetics Governance Leads Divisional Manager confirming approval processes Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Dr Nila Cota Not Required {Original Copy Signed} Name: {Original Copy Signed} Internet & Intranet Intranet Only Paediatrics Anaesthetics 19

20 Links to key external standards Related Documents: Training Need Identified? The Association of Paediatric Anaesthetists of Great Britain and Ireland References included within the document No, for reference purposes only. Version Control Table Date Version No Summary of Changes Changes Made by (Name and Job Title) July 11 V1.0 Initial Issue Dec 11 V2.0 Additional guidance introduced. Dr Julian Berry Lead For APPS Dr Julian Berry Lead for APPS Sept 12 V3.0 Change of format Update of guidance Dr Julian Berry Lead for APPS Sept 13 V3.1 Change in practice regarding Codeine Jan 15 V4.0 Update of guidance Dr Julian Berry Lead for APPS Dr Julian Berry Lead for APPS June 17 V5.0 Update of guidance including change of Diamorphine formulation. Removal of Diclofenac from coloured analgesia chart. Dr Julian Berry Lead for APPS July 17 V5.1 Change to intranasal Diamorphine priming Dr Julian Berry Lead for APPS Sept 2017 V5.2 Appendix3- Guidance for anticipatory prescribing and symptom control in paediatric patients Dr Julian Berry Sabrina Tierney All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. 20

21 Appendix 2. Initial Equality Impact Assessment Form This assessment will need to be completed in stages to allow for adequate consultation with the relevant groups. Name of Name of the strategy / policy /proposal / service function to be assessed Paediatric Analgesia Guidelines Directorate and service area: Is this a new or existing Policy? Anaesthesia/ APPS Existing Name of individual completing assessment: Telephone: Sarah Fox Policy Aim* To inform staff of the appropriate analgesia for paediatric patients. Who is the strategy / policy / proposal / service function aimed at? 2. Policy Objectives* To inform staff of the appropriate analgesia for paediatric patients. 3. Policy intended Outcomes* Improve post-operative analgesia for all children Standardise care for children 4. *How will you measure the outcome? Monitor through audit, incident reporting and case discussions at governance meetings 5. Who is intended to benefit from the policy? 6a Who did you consult with b). Please identify the groups who have been consulted about this procedure. What was the outcome of the consultation? All children who attend RCHT Workforce Patients Local groups Please record specific names of groups Medicines Practice Committee Anaesthetic Governance Policy agreed External organisations Other 21

22 7. The Impact Please complete the following table. If you are unsure/don t know if there is a negative impact you need to repeat the consultation step. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence Age Sex (male, female, trans-gender / gender reassignment) Race / Ethnic communities /groups Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions. Religion / other beliefs Marriage and Civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major this relates to service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. No areas indicated Signature of policy developer / lead manager / director Date of completion and submission 22

23 Names and signatures of members carrying out the Screening Assessment 1. Sarah Fox 2. Human Rights, Equality & Inclusion Lead Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD This EIA will not be uploaded to the Trust website without the signature of the Human Rights, Equality & Inclusion Lead. A summary of the results will be published on the Trust s web site. Signed Date June

24 Appendix 3 GUIDANCE FOR ANTICIPATORY PRESCRIBING AND SYMPTOM CONTROL IN PAEDIATRIC PATIENTS 24

25 GUIDANCE FOR ANTICIPATORY PRESCRIBING AND SYMPTOM CONTROL IN PAEDIATRIC PATIENTS 1 MONTH 16 YEARS (IF > 16 SEE ADULT GUIDELINE) For s/c doses see page 5 Symptom Drug Form Route Starting Dose Maximum TOTAL dose over 24 hours Pain NB If already on alternative opioids see conversion chart for appropriate dosing If renal impairment seek specialist advice Prescribe naloxone prn in case of opiate toxicity Morphine Buprenorphine NOTE: Only partially reversed by naloxone Fentanyl Oxycodone Diamorphine Hyoscine Butylbromide (for gut spasm) BUSCOPAN PRN/Breakthrough Regular Immediate release (Oral) Liquid (e.g. Oramorph)or tablets (Sevredol) Injection (IV) Modified release caps (Zomorph)/susp (MST) < 12 months: 50micrograms/kg 4 hourly 1 12 years: micrograms/kg 4 hourly > 12 years AND > 50kg: micrograms/kg 4 hourly (MAX DOSE 20MG) 6 months 12 years: 100micrograms/kg 4 hourly > 12 years AND > 50kg: 100micrograms/kg 4 hourly Dose calculated based on 24 hour opioid requirements Regular Patch Initial dose based on 24-hour opioid requirement see conversion chart NOT TO BE USED FOR UNSTABLE PAIN PRN/Breakthrough Regular PRN/Breakthrough Regular Intranasal spray Lozenges Patch NOTE: Matrifen brand can be cut Oral Standard release Injection (IV) Oral (Modified Release) 6 months 2 years: 1microgram/kg/dose > 2 years: 1-2micrograms/kg No more than 2 doses per pain episode. If more than 4 episodes of breakthrough pain/24 hours, increase background analgesia >2 years AND > 10kg: 15micrograms/kg/dose Dose to be given over 15mins and can be repeated. As above for frequency. Initial dose based on 24-hour opioid requirement see conversion chart NOT TO BE USED FOR UNSTABLE PAIN 1-12 months: micrograms/kg 4 hourly 1-12 years: micrograms/kg (max 5mg initial dose) 4 hourly years: 5mg 4 hourly 1-12 months: 30-75micrograms/kg 4 hourly 1-12 years: micrograms/kg (max 2.5mg initial dose) 4 hourly years: 2.5 mg 4 hourly 0-7 years: No dosing available 8-12 years: 5mg 12 hourly years: 10mg 12 hourly PRN/Breakthrough Intranasal See separate dosing schedule in paediatric analgesia policy Dose may be repeated 4 hourly. Oral/IM/IV 1 months- 4 years: micrograms/kg (max 5mg) 6 hourly 5-12 years: 5-10mg 6 hourly years: 10-20mg 6 hourly No upper limit No upper limit No upper limit No upper limit Max 50micrograms/ dose initially Max 400micrograms No upper limit No upper limit No upper limit No upper limit 25

26 GUIDANCE FOR ANTICIPATORY PRESCRIBING AND SYMPTOM CONTROL IN PAEDIATRIC PATIENTS 1 MONTH 16 YEARS (IF > 16 SEE ADULT GUIDELINE) Symptom Drug Route Starting Dose Maximum TOTAL dose over 24 hours Anxiety DO NOT PRESCRIBE MORE THAN ONE DRUG FROM THIS SECTION Lorazepam Midazolam * These doses are not suitable for seizure control- Please check whether seizure care plan is in place prior to prescribing S/L (use standard tablets) (Not to be used in gastric stasis use midazolam) Oral Injection (IV infusion) (Consider SC infusion if required) Doses to be given over 24 hours Buccal (May also be given intranasal) * In the event of toxicity may be reversed by flumazenil see BNFC for dosing. Stock held on CLIC 26 25micrograms/kg single dose < 2 years: 25micrograms/kg 8 hourly 2-5 years: 500micrograms 8 hourly 6-10 years: 750micrograms 8 hourly > 11 years: 1mg 8 hourly < 3 months 0.5-1mg 3-11 months 0.5-2mg 1-5 years 1-2.5mg 6-10 years 2.5-5mg > 11years 5-10mg <12months 25micrograms/kg stat 1-5 years 50 micrograms/kg stat > 6 years 100micrograms/kg stat May be repeated after 10 mins if required May be increased to 50micrograms/kg/dose, Max 1mg/dose Increase by 25-50% as needed Max 50mg/24hours Max 2.5mg if benzodiazepine naïve Max 5mg initial dose Nausea/Vomiting Ondansetron Injection (IV) 0.1mg/kg 8 hourly 4mg/dose In exceptional circumstances 8mg may be used (by infusion) Oral (as tablets, orodispersible tablets or liquid) < 14kg: 2mg 12 hourly Oral max doses as described < 35kg: 4mg 12 hourly > 35kg: 4-8mg 12 hourly Cyclizine (Not with metoclopramide) Metoclopramide (Not with Cyclizine) Levomepromazine (may also be used for anxiety & agitation) Hyoscine Hydrobromide (may also be used for excessive respiratory secretions) SCOPOLAMINE Injection (IV) or Oral Injection (IV, IM) or Oral (tablets, liquid) Monitor for neurological side effects MHRA recommends max 5 days tx except in palliative care Injection (IV infusion) 6 months 5 years: 1mg/kg 8 hourly 6 11 years: 25mg 8 hourly > 12 years: 50mg 8 hourly micrograms/kg 8 hourly (Max 10mg/dose, Max 1mg per dose if < 1 year or 10kg) 1 month - 12 years: 100micrograms/kg over 24 hours > 12 years: 5mg over 24 hours Max 75mg/day if under 12 years Max 150mg/day if > 12 years Usual maximum 500micrograms/kg/day up to 30mg/day 400micrograms/kg/24 hours or 25mg/24 hours Oral (tablets) 2-12 years: micrograms/kg 12 hourly Max 1mg per dose if < 1 year Injection may also be given orally >12 years: 3.125mg 12 hourly or 10kg Injection (IV)(for excessive secretions) 10 micrograms/kg every 4 hourly 600 micrograms per dose IV Patch (Can take up to 12 hours to take effect) In case of neurological toxicity stop treatment and consider using procyclidine. See BNFC for dosing. Stock kept on CLIC 1 month 2 years: 250micrograms every 72hrs 3 9 years 500micrograms every 72 hours years 1 mg every 72 hours

27 GUIDANCE FOR ANTICIPATORY PRESCRIBING AND SYMPTOM CONTROL IN PAEDIATRIC PATIENTS 1 MONTH 16 YEARS (IF > 16 SEE ADULT GUIDELINE) OPIOID DOSE CONVERSION This chart should be used as a guide only dose conversions are not exact as individual patients metabolise different drugs at varying rates Patches can take hours to take effect. When transferring from 12 hourly MR morphine give last dose as you are applying the patch. For immediate release morphine continue given 4 hourly doses for the first 12 hours after applying the patch. Overlap may also be required when starting a syringe driver if patient stable it is recommended to start the syringe driver 1-2 hours before current medication is due to wear off Oral Morphine Subcutaneous Diamorphine Fentanyl Transdermal Subcutaneous Oxycodone Total dose (over 24 hours) 24 hr total dose (mg) Patch strength (micrograms/hr) 24 hr total dose (mg) Total Morphine requirement over 24 hours Approximate equivalent buprenorphine patch 12mg Butrans 5 7 day patch 24mg Butrans 10 7 day patch 48mg Butrans 20 7 day patch 84mg Butrans 35 7 day patch 126mg Transtec day patch 168mg Transtec 70 4 day patch 27

28 GUIDANCE FOR ANTICIPATORY PRESCRIBING AND SYMPTOM CONTROL IN PAEDIATRIC PATIENTS SUBCUTANEOUS DOSES FOR SYRINGE DRIVERS AND BREAKTHROUGH 1 MONTH 16 YEARS (IF > 16 SEE ADULT GUIDELINE) Check compatibilities and suitable diluents before combining medications. NB 10ml in a 10ml syringe, 17ml in a 20ml syringe, and 23ml in a 30ml syringe Symptom Drug S/C PRN dose for break through symptoms Pain Anxiety Nausea/ Vomiting Diamorphine If renal impairment seek specialist advice Oxycodone Midazolam Doses are not suitable for seizure control Cyclizine (in water for injection) (Not with metoclopramide) Metoclopramide (Not with Cyclizine) Monitor for signs of neurological side effects Levomepromazine (may also be used for anxiety & agitation see BNFC) Hyoscine Hydrobromide May also be used for respiratory secretions SCOPOLAMINE 1/6 th of 24hour subcutaneous opioid dose unless opioid naïve (see below) If opioid naïve: 6-12 months: 75micrograms/kg/dose >1 year: micrograms/kg/dose. Suggested initial max 2.5mg/dose 1/6 th of 24hour subcutaneous opioid dose unless opioid naïve (see below) If opioid naïve: 1-12 months: 30 75micrograms/kg/dose 1-12 years: micrograms/kg/dose > 12 years: 2.5mg Suggested initial max 2.5mg/dose Use buccal (see previous) Do not exceed maximum daily dose N/A Max dose in syringe driver N/A Max dose in syringe driver Starting Dose range over 24 hours in syringe driver (s/c) Initial dose based on 24-hour opioid requirement see conversion chart If opioid naïve: 7-25micrograms/kg over 24 hours (max 10mg) Initial dose based on 24-hour opioid requirement see conversion chart Doses to be given over 24 hours < 3months 0.5-1mg 3-11 months 0.5-2mg 1-5 years 1-2.5mg 6-10 years 2.5-5mg > 11years 5-10mg 1 23 months: 3 mg/kg over 24 hours (max 50mg/24 hours) 2 5 years: 50 mg over 24 hours 6 11 years: 75 mg over 24 hours years: 150 mg over 24 hours 1-12 months or <10kg: 200micrograms/kg/24 hours (max 2mg) 1-18 years & >10kg: micrograms/kg/ 24 hours 1 months - 12 yrs:100micrograms/kg over 24 hours > 12 yrs:5mg over 24 hours Maximum TOTAL dose over 24 hours No upper limit No upper limit Increase by 25-50% as needed Max 50mg/24hours 1 23 months: 3 mg/kg over 24 hours (max 50mg/24 hours) 2 5 yrs: 50 mg over 24 hours 6 11 yrs: 75 mg over 24 hours yrs: 150 mg over 24 hours Usual maximum 500micorgrams/kg/day (up to 30mg/day) 400micrograms/kg over 24 hours (Max 25mg over 24 hours) 40 micrograms/kg over 24 hours 60 micrograms/kg over 24 hours (up to 2.4mg/24 hours) 28