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Prophylactically-administered rectal acetaminophen does not reduce postoperative opioid requirements in infants and
D H Bremerich1, G Neidhart, K Heimann
1Clinics of Anesthesiology, Intensive Care Medicine, and Pain Therapy, Johann Wolfgang Goethe-Universität Frankfurt, Germany. Bremerich@em.uni-frankfurt.de
Insights
Rectal acetaminophen did not reduce opioid needs in children after cleft palate repair. Intravenous opioids provided effective pain relief, indicating rectal acetaminophen lacks proven efficacy in this pediatric population.
Area of Science:
- Anesthesiology
- Pediatric Pain Management
- Pharmacology
Background:
- Rectal acetaminophen is commonly used for pediatric postoperative pain.
- It is believed to reduce the need for opioids (opioid-sparing effect).
- Efficacy in infants and young children undergoing specific procedures remains unclear.
Purpose of the Study:
- To evaluate the opioid-sparing effect of prophylactic rectal acetaminophen.
- To assess early postoperative pain and opioid requirements in children.
- To determine if rectal acetaminophen achieves therapeutic plasma concentrations.
Main Methods:
- Double-blinded, prospective, randomized study.
- 80 children (ASA I, 11.4 ± 9.9 months) undergoing cleft palate repair.
- Three doses of rectal acetaminophen (10, 20, 40 mg/kg) vs. placebo.
Main Results:
- No significant difference in pain scores or cumulative opioid requirements between groups.
- Maximal plasma acetaminophen concentrations were subtherapeutic.
- Intravenous opioid boluses effectively managed pain when needed.
Conclusions:
- Rectal acetaminophen up to 40 mg/kg lacks demonstrated efficacy for postoperative pain.
- It does not provide an opioid-sparing effect in this pediatric surgical group.
- Intravenous opioids are effective for rapid and reliable pain relief.
Unlabelled:
Rectal acetaminophen (Ac) is often administered prophylactically at anesthesia induction for postoperative pain management in small children and is thought to have an opioid-sparing effect. We assessed in this double-blinded, prospective, randomized study early opioid requirements after three doses of Ac (10, 20, and 40 mg/kg versus placebo) in 80 children (ASA physical status I, age 11.4 +/- 9.9 mo) undergoing cleft palate repair. Single Ac plasma concentrations were measured. Pain scores assessed in the postanesthesia care unit of > or = 4 of 10 resulted in the IV administration of 25 microg/kg piritramide, a popular European mu receptor agonist (lockout time, 10 min; maximum 0.125 mg/kg). There were no significant differences between groups with regard to the early postoperative pain scores and the overall cumulative IV opioid requirements. Maximal plasma concentrations achieved were only subtherapeutic (Ac 10 mg/kg: 8 microg/mL; Ac 20 mg/kg: 13 microg/mL; Ac 40 mg/kg: 21 microg/mL after 122, 122, and 121 min, respectively). We conclude that rectal Ac up to 40 mg/kg has no opioid-sparing effect, does not result in analgesic Ac plasma concentrations, and lacks proof of its efficacy in infants and small children undergoing cleft palate repair, whereas titrated IV opioid boluses produced rapid and reliable pain relief.
Implications:
Acetaminophen is widely used prophylactically for postoperative analgesia in children and is thought to have an opioid-sparing effect. We showed that rectal acetaminophen up to 40 mg/kg administered at anesthesia induction lacked proof of efficacy, whereas IV opioid boluses resulted in reliable pain relief in children undergoing cleft palate repair.