Paeds SAQs · pain-palliative-and-end-of-life-care
Opioid stewardship and complex analgesia — formative SAQs
Two MedVellum formative short-answer questions on paediatric opioid stewardship and complex analgesia: the weight-based morphine and patient- and nurse-controlled analgesia doses with the sedation-score monitoring, the multimodal opioid-sparing backbone, and the opioid rotation with the equianalgesic principle and the incomplete cross-tolerance reduction; and the recognition and titrated management of opioid-induced respiratory depression including the naloxone dose and the plan for recurrence. The marks and timing support transparent self-assessment. They are not an official board format or pass standard.
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SAQ 1 — Postoperative opioid stewardship in a school-age child
Question 1 — formative marks with a suggested time [1]
A school-age boy of stated weight is admitted overnight after open appendicectomy for perforated appendicitis. He is in moderate-to-severe pain and is started on a morphine patient-controlled analgesia device by the acute pain team. [1]
- State the weight-based intravenous and oral morphine doses, with the maximum and the monitoring. (2 marks)
- State the patient-controlled analgesia morphine bolus, lockout and background infusion parameters, and the age and understanding criteria for a PCA. (3 marks)
- State the non-opioid multimodal backbone that surrounds the opioid and the stewardship goal it serves. (2 marks)
- After more than a day the team rotates him to oral morphine. State the equianalgesic principle and the incomplete cross-tolerance reduction, and name one agent whose conversion is specialist-only and why. (3 marks) [7] [11]
Full-credit answer — SAQ 1
Reveal full-credit answer for SAQ 1ShowHide
1. Morphine dose
Morphine is dosed weight-based intravenously per the RCH schedule, titrated to the pain score and monitored with a sedation score and a respiratory rate; the bolus is calculated from the measured weight. The oral dose follows the RCH age-banded schedule every four hours, capped at the adult maximum, with a double-check and safe prescribing. [1]
2. PCA parameters
A PCA morphine device delivers a weight-based bolus with a lockout, per the RCH PCA prescription that prevents re-dosing within the window, and an optional low background infusion of 0 to 4 microgram per kg per hour. PCA is used for a child who can understand the device and press the button, commonly from about six or seven years; an infant or a child who cannot use a PCA receives nurse-controlled analgesia, and parent-controlled analgesia by proxy is not permitted outside an approved protocol. [1]
3. Multimodal backbone
The non-opioid multimodal backbone is regular paracetamol and an NSAID (where not contraindicated), a regional or local anaesthetic technique, an NMDA antagonist such as ketamine, and an alpha-2 agonist such as dexmedetomidine or clonidine, with a gabapentinoid for neuropathic pain. The stewardship goal is to minimise total opioid exposure, which both improves recovery and reduces opioid-related adverse effects, and it is the single most evidence-based stewardship move. [11]
4. Rotation and cross-tolerance
The equianalgesic principle uses the standard IV-to-oral ratio as a working figure. The crucial safety step is that the calculated equianalgesic dose of the new opioid is then reduced for incomplete cross-tolerance for incomplete cross-tolerance, because a child tolerant to one opioid is not fully tolerant to another and a straight equianalgesic conversion over-doses them. Methadone is the specialist-only exception: its conversion ratio to morphine is non-linear (it steepens as the prior opioid dose rises) and its long and variable half-life accumulates, so methadone rotation is undertaken only by the specialist pain or palliative team with a written protocol. [7]
References6ShowHide
- [1]Donado C, Solodiuk J, Rangel SJ, et al. Patient- and Nurse-Controlled Analgesia: 22-Year Experience in a Pediatric Hospital Hospital Pediatrics, 2019.PMID 30655310
- [7]Quigley C Opioid switching to improve pain relief and drug tolerability Cochrane Database of Systematic Reviews, 2004.PMID 15266542
- [8]Bateman JT, Saunders SE, Levitt ES, et al. Understanding and countering opioid-induced respiratory depression British Journal of Pharmacology, 2023.PMID 34089181
- [9]Saari TI, Strang J, Dale O, et al. Clinical Pharmacokinetics and Pharmacodynamics of Naloxone Clinical Pharmacokinetics, 2024.PMID 38485851
- [10]Hadland SE, Agarwal R, Raman SR, et al. Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings: Clinical Practice Guideline Pediatrics, 2024.PMID 39344439
- [11]Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council The Journal of Pain, 2016.PMID 26827847