Sr Jenni Prince
Aboriginal Health
Anaesthetics
Acute Pain
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In August 1994 an Acute Pain Service was created at Lismore Base Hospital to improve the analgesia prescribed for acute and postoperative pain. A patient survey had previously identified this as an area requiring improvement. From small beginnings we have developed a service that co-ordinates a range of modalities comparable to any metropolitan or teaching hospital. We have recently gained approval for some of these modalities to be available throughout the Richmond sector of the Northern Rivers Area Health Service, including Ballina, Casino, Byron Bay and Mullumbimby. To ensure the safety and familiarity of these analgesic modalities we emphasise education, provided by the Acute Pain Service nurse co-ordinator Sr Jenni Prince for nursing staff, and Department of Anaesthesia LBH for medical staff.
We would like to introduce some of our techniques through MedicineAu and encourage you to contact us for more information.
We strongly encourage the use of needle-free systems for the
provision of pain relief in this era of life-threatening blood-borne
infections.
Doses should be assessed on:
Oral & rectal analgesia
Oral analgesia is the most common form of analgesia prescribed
outside the hospital setting but often poorly prescribed and
administered within the hospital. We encourage oral analgesia to be
given when the patient is able to absorb fluids. Rectal analgesia is
a useful route of administration particularly in patients suffering
nausea or anorexia.
There are a number of advantages of oral analgesia :
When parenteral analgesia is no longer required, conversion to
oral doses of analgesia is quite straightforward. The dose should be
individualised for each patient and administered at regular intervals
to maintain a plasma level within the analgesic corridor. Controlled
release preparations are designed to produce slow, uniform absorption
for eight or more hours.
N.B.
There is considerable literature that supports the use of NSAIDS and
paracetamol to reduce opiate requirements. Prescribing a regimen that
includes regular oral or rectal analgesia plus parenteral opiates is
recommended.
N.B. The use of "PRN" orders in hospital patients is
discouraged as the drugs are usually administered at infrequent
intervals and often only after a patient request. This usually
produces inadequate analgesia.
A suggestion is to prescribe for a set time interval and a given
number of doses or days e.g. Digesic 1- 2 tablets 4 - 6 hourly x 36
hours. The drugs should be regularly reviewed for efficacy and side
effects.
Types of oral analgesia :
1. Opiates
Equianalgesic doses
OPIOID
TRADE NAME
I.M.(mg)
ORAL(mg)
DOSE PO
Morphine
Morph mix
MS Contin
10
30 - 60
10-20 mg 4-6hrly
30 mg 12hrly
Physeptone
Methadone
10
20
5-10mg 6-8hrly
Codeine
Codeine Phos
130
200
10-60 mg 4-6hrly
Oxycodone
Endone
Prolodone
15
30
5 mg 6hrly
Determine the parenteral dose of morphine or pethidine administered
in the previous 24 hours to convert to the equivalent dose of
oxycodone.
MORPHINE
PETHIDINE
OXYCODONE
10 - 20 mg / last 24 hours
75 - 150 mg / last 24 hours
5 mg 6 hourly
20 - 30 mg / last 24 hours
150 - 225 mg /last 24 hours
5 mg 4 hourly
30 - 40 mg / last 24 hours
225 - 300 mg / last 24 hours
10 mg 6 hourly
40 - 50 mg / last 24 hours
300 - 375 mg / last 24 hours
10 mg 4 hourly
> 50 mg / last 24 hours
> 375 mg / last 24 hours
continue current regime
2. Nonsteroidal Anti-inflammatory Drugs (NSAIDS)
NSAID
TRADE NAME
ROUTE
DOSE
Paracetamol
Panadol, Setamol
Dymadon
PO
PR
paed :15mg/kg 4hrly; max 100mg/kg/d
7-12yrs : 250mg 4-6hrly; max 1500mg/d
adults : 0.5-1g 4-6hrly; max 5mg/d
Aspirin
Dispirin, Aspro
PO
adults : 300-900mg 4-6hrly, max 4g/d
Diclofenac
Voltaren,Fenac
PO,PR
adults : po 50mg 8hrly; pr 100-200mg/d
Indomethacin
Indocid
PO,PR
adults : po 25-50mg 8hrly; pr 100mg/d
Naproxen
Naprosyn
PO,PR
adults : po250mg 6-8hrly; pr 500mg/d
Piroxicam
Feldene
PO
adults : 10-20mg/d (once daily)
Many others exist
3. Combination Drugs
DRUG
TRADE NAME
ROUTE
DOSE
Dextropropoxyphene
+ paracetamol
Digesic, Paradex
Capadex
PO
1-2 tabs 4hrly
Paracetamol 500mg + Codeine 8mg
Panadeine
Codalgin
PO
7-12yrs : 0.5-1 tab 4hrly
adults : 2 tabs 4hrly
Paracetamol 500mg + Codeine 30mg
Panadeine Forte
PO
7-12yrs : 250mg 4-6hrly
adults : 1-2 tabs 4-6hrly
Morphine 5mg + Aspirin 250mg
Morphalgin
PO
adults : 1-2 tabs 4-6hrly
Intravenous (IV) Opiates
Opiates may be endogenous or exogenous, but they all act on opiate
receptors throughout the body to reduce the transmission of pain
signals to the brain. We are encouraging the use of IV opiates as
this has proven to be a safe and efficacious method of obtaining
rapid analgesia.
Side effects of opiate administration
In equianalgesic doses the side effects are very similar
regardless of the drug chosen. These effects are usually dose related
so careful titration for the individual patient will reduce the
likelihood of these occurring.
Predictors of drug dose
There is very little correlation between the patients weight &
opiate requirements. Many of these drugs have wide interpatient dose
variability.
N.B. All opiate prescriptions must have the
duration or a maximum dose prescribed.This is a legal
requirement
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Infusion Regimen
Drug Concentration for a syringe pump:
Morphine 1mg/ml range : 1 - 4ml/hr Pethidine 10mg/ml range : 1 - 4ml/hr Drug Concentration for an infusion pump: Morphine 1mg/10ml range : 10 - 40ml/hr Pethidine 1mg/ml range : 10 - 40ml/hr |
Paediatric doses (<50 kg)
Bolus dose : pain management protocol (PMP)Prescribe one of the following drugs as 'opiate as per paediatric PMP' in the variable drug dose section of the medication chart.
In the further instruction box state the number of times the protocol is to be administered ie. 'x 2-3'.
Drug doses are found in the accompanying tables.
Paediatric Pain Protocol : IV
Morphine
|
WEIGHT (kgs) |
mg/ml Morphine in the syringe |
Normal Saline |
1 ml bolus |
|---|---|---|---|
| 12 - 18 kg | 2 mg morphine = 0.2 mls | 9.8 mls | 0.2 mg |
| 18 - 24 kg | 3 mg morphine = 0.3 mls | 9.7 mls | 0.3 mg |
| 24 - 30 kg | 4 mg morphine = 0.4 mls | 9.6 mls | 0.4 mg |
| 30 - 36 kg | 5 mg morphine = 0.5 mls | 9.5 mls | 0.5 mg |
| 36 - 42 kg | 6 mg morphine = 0.6 mls | 9.4 mls | 0.6 mg |
| 42 - 48 kg | 7 mg morphine = 0.7 mls | 9.3 mls | 0.7 mg |
| 48 - 54 kg | 8 mg morphine = 0.8 mls | 9.2 mls | 0.8 mg |
| 54 - 60 kg | 9 mg morphine = 0.9 mls | 9.1 mls | 0.9 mg |
| > 60 kg | adult dose |
| WEIGHT | mg/ml Pethidine in | Normal | 1 ml bolus | |
| (kg) | the syringe | Saline | dose equals | |
| 12 - 18 kg | 20 mg pethidine = 0.4 mls | 9.6 mls | 2 mg | |
| 18 - 24 kg | 30 mg pethidine = 0.6 mls | 9.4 mls | 2 mg | |
| 24 - 30 kg | 40 mg pethidine = 0.8 mls | 9.2 mls | 4 mg | |
| 30 - 36 kg | 50 mg pethidine = 1.0 mls | 9.0 mls | 5 mg | |
| 36 - 42 kg | 60 mg pethidine = 1.2 mls | 8.8 mls | 6 mg | |
| 42 - 48 kg | 70 mg pethidine = 1.4 mls | 8.6 mls | 7 mg | |
| 48 - 54 kg | 80 mg pethidine = 1.6 mls | 8.4 mls | 8 mg | |
| 54 - 60 kg | 90 mg pethidine = 1.8 mls | 8.2 mls | 9 mg | |
| > 60 kg | Adult dose |
Infusion regimen
Specific prescription and administration record forms for Paediatric Opioid Infusion have been produced to enable safe and efficacious administration of opioids in the paediatric population. These forms are available through stores at Lismore Base Hospital.
Protocols for delivery of opiate analgesia
Jenni Prince
For further information, contact Sr Jenni Prince, Acute Pain
Service co-ordinator, Lismore Base Hospital (page via switchboard ph
066 218 000), or the department of anaesthesia, Clover House, ph 221
285. (Director of anaesthesia, Dr Chris Lowry. Anaesthetists, Dr
Melissa Goldberg and Dr David Scott.)
Email : amprak@nor.com.au
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