Paediatric analgesia in the emergency department, are we getting it right?

Donald, Colin; Duncan, Russell A.; Blair, Lorraine; Thakore, Shobhan; Clark, Michael

doi:10.1097/mej.0b013e3280b17e36

Cited by 13 publications

(6 citation statements)

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“…Forty-four studies met our inclusion criteria; however, 21 did not report AEs (Figure 1) [36–56]. Therefore, we included 23 studies involving 2,300 patients: 17 randomized controlled trials, 2 nonrandomized controlled trials, 1 case report, 1 cross-sectional survey, 1 chart review, and 1 prospective cohort (Table 1) [13, 19, 27, 57–76].…”

Section: Resultsmentioning

confidence: 99%

How Safe Are Common Analgesics for the Treatment of Acute Pain for Children? A Systematic Review

Hartling

Ali

Dryden

et al. 2016

Pain Research and Management

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Background. Fear of adverse events and occurrence of side effects are commonly cited by families and physicians as obstructive to appropriate use of pain medication in children. We examined evidence comparing the safety profiles of three groups of oral medications, acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids, to manage acute nonsurgical pain in children (<18 years) treated in ambulatory settings. Methods. A comprehensive search was performed to July 2015, including review of national data registries. Two reviewers screened articles for inclusion, assessed methodological quality, and extracted data. Risks (incidence rates) were pooled using a random effects model. Results. Forty-four studies were included; 23 reported on adverse events. Based on limited current evidence, acetaminophen, ibuprofen, and opioids have similar nausea and vomiting profiles. Opioids have the greatest risk of central nervous system adverse events. Dual therapy with a nonopioid/opioid combination resulted in a lower risk of adverse events than opioids alone. Conclusions. Ibuprofen and acetaminophen have similar reported adverse effects and notably less adverse events than opioids. Dual therapy with a nonopioid/opioid combination confers a protective effect for adverse events over opioids alone. This research highlights challenges in assessing medication safety, including lack of more detailed information in registry data, and inconsistent reporting in trials.

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Section: Resultsmentioning

confidence: 99%

How Safe Are Common Analgesics for the Treatment of Acute Pain for Children? A Systematic Review

Hartling

Ali

Dryden

et al. 2016

Pain Research and Management

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“…Antibiotic monotherapy in uncomplicated appendicitis has been proposed as an alternative to traditional triple therapy to simplify ED processes, reduce error, and decrease antibiotic resistance. 30 In addition, the use of analgesia has been shown to be highly variable in multiple painful conditions presenting to the ED, [31][32][33][34][35] and appendicitis is likely no exception.…”

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confidence: 99%

Variation in the Diagnosis and Management of Appendicitis at Canadian Pediatric Hospitals

et al. 2015

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Objectives: The objective was to characterize the variations in practice in the diagnosis and management of children admitted to hospitals from Canadian pediatric emergency departments (EDs) with suspected appendicitis, specifically the timing of surgical intervention, ED investigations, and management strategies.Methods: Twelve sites participated in this retrospective health record review. Children aged 3 to 17 years admitted to the hospital with suspected appendicitis were eligible. Site-specific demographics, investigations, and interventions performed were recorded and compared. Factors associated with afterhours surgery were determined using generalized estimating equations logistic regression.Results: Of the 619 children meeting eligibility criteria, surgical intervention was performed in 547 (88%). After-hours surgery occurred in 76 of the 547 children, with significant variation across sites (13.9%, 95% confidence interval = 7.1% to 21.6%, p < 0.001). The overall perforation rate was 17.4% (95 of 547), and the negative appendectomy rate was 6.8% (37 of 547), varying across sites (p = 0.004 and p = 0.036, respectively). Use of inflammatory markers (p < 0.001), blood cultures (p < 0.001), ultrasound (p = 0.001), and computed tomography (p = 0.001) also varied by site. ED administration of narcotic analgesia and antibiotics varied across sites (p < 0.001 and p = 0.001, respectively), as did the type of surgical approach (p < 0.001). After-hours triage had a significant inverse association with after-hours surgery (p = 0.014).Conclusions: Across Canadian pediatric EDs, there exists significant variation in the diagnosis and management of children with suspected appendicitis. These results indicate that the best diagnostic and management strategies remain unclear and support the need for future prospective, multicenter studies to identify strategies associated with optimal patient outcomes.ACADEMIC EMERGENCY MEDICINE 2015;22:811-822 © 2015 by the Society for Academic Emergency Medicine A ppendicitis is the most common nontraumatic surgical emergency in children, 1,2 yet it continues to present diagnostic and management uncertainty.3 Current strategies for diagnosing appendicitis include the use of clinical scoring systems, 4-7 laboratory markers of infection and inflammation, [8][9][10] and

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“…1 On the 18th May 2011, the United States Food and Drug Administration (FDA) federal advisory panel unanimously recommended that paracetamol dosing for children be primarily based on weight instead of age due to safety concerns regarding age-based guidelines and the risk of overdose when recommended doses are exceeded. 8 The FDA will now move to enforce weight-based labels on all paracetamol packaging.…”

Section: Discussionmentioning

confidence: 99%

“…Age-based dosing has been found to be imprecise and can result in inaccurate dosing due to marked variations in weight of children of the same age. 1 The risks of both overdosing and underdosing have recently been demonstrated in an analysis of the age-based paracetamol dosing guidelines in the British National Formulary for Children (BNFC) 2010 -2011. 2 In order to improve the effectiveness and safety of paracetamol labelling, the Medicines and Healthcare products Regulatory Agency (MHRA) proposes to introduce new dosing instructions on all children's paracetamol products, to take effect by the end of 2011.…”

Section: Introductionmentioning

confidence: 99%

Proposed MHRA changes to UK children's paracetamol dosing recommendations: modelling study

et al. 2012

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SUMMARYObjectives Paracetamol is the most commonly administered medicine to children. A recent study highlighted the risk of overdose of paracetamol using British National Formulary for Children (BNFC) age-based dosing guidelines. This current study assesses the safety of changes to the UK paracetamol product dosing system proposed by the Medicines and Healthcare products Regulatory Authority (MHRA) which include a larger number of narrower age bands and a single dose per age band.Design Theoretical comparison of the proposed MHRA dosing system with the product dosing instructions of a commonly prescribed form of paracetamol in the UK. Setting United KingdomParticipants Proposed MHRA dosing recommendations and current product dosing instructions were compared using a previously validated model.Main outcome measures For both dosing recommendations, single and cumulative daily doses of paracetamol for boys and girls at the 9th, 50th and 91st centiles for weight were calculated for 3 month, 1 year, 6 year and 12 year age groups.Results With the current product dosing instructions, underweight children are at risk of receiving approximately two times the recommended single and cumulative daily dose of paracetamol, particularly at age 1 year and 6 years. This risk is negligible when the same model is applied to the proposed MHRA dosing system, whereby underweight, average weight and overweight children at all ages receive doses marginally above or within the recommended dose range or limit. ConclusionThe proposed MHRA dosing recommendations for paracetamol use in children are effective at reducing the risk of paracetamol overdose in children of all ages, when compared with current product dosing instructions. DECLARATIONS Competing interestsNone declared

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Paediatric analgesia in the emergency department, are we getting it right?

Abstract: Prescribing analgesia by age often results in significant underdosing in the paediatric population. Predicting a child's weight using the calculation may result in underdosing.

Cited by 13 publications

References 1 publication

How Safe Are Common Analgesics for the Treatment of Acute Pain for Children? A Systematic Review

How Safe Are Common Analgesics for the Treatment of Acute Pain for Children? A Systematic Review

Variation in the Diagnosis and Management of Appendicitis at Canadian Pediatric Hospitals

Proposed MHRA changes to UK children's paracetamol dosing recommendations: modelling study

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