Right dose, right monitoring, right rotation — paediatric opioid stewardship

Candidate brief

You are the paediatric registrar on the ward overnight. A nine-year-old girl, 30 kg, has just returned from theatre after internal fixation of a displaced femoral fracture. She is on a morphine patient-controlled analgesia device set up by the acute pain team, with a background infusion running. The ward nurse asks you to confirm the PCA parameters and the monitoring, and to set the plan for the night. Two hours later the nurse calls you urgently: the child is hard to rouse, with a respiratory rate of 8 per minute and a sedation score of 3. ^[1]

You have ten minutes to: confirm the PCA parameters and the multimodal opioid-sparing backbone; set the monitoring that gates every dose; respond to the over-sedation event with titrated naloxone and a plan for recurrence; and prepare the next-day rotation to an oral opioid with the cross-tolerance reduction and a safe discharge prescription. ^{[1] [8]}