Morphine-sparing effect of acetaminophen in pediatric day-case surgery

Abstract

Background: Postoperative pain is a major problem in day-case surgery in children. Nonsteroidal antiinflammatory drugs have gained popularity in management of pediatric surgical patients to reduce the need for opioids. The aim of this study was to evaluate the efficacy of different doses of rectal acetaminophen in day-case surgery in children. Methods: A randomized, double- blinded, placebo-controlled study design was used. Patients (n = 120) were randomized to receive a single dose of 0, 20, 40, or 60 mg/kg of rectal acetaminophen after induction of anesthesia. General anesthesia was induced by mask ventilation with sevoflurane (7%) in nitrous oxide and oxygen and maintained with 2.5-4.0% end-tidal sevoflurane. Opioids or local anesthetics were not used. Postoperative pain was evaluated by behavioral assessment and physiologic measurements every 10 min after arrival at the postanesthesia care unit. The pain intensity was scored using a 0-100 visual analog scale used in the authors' clinic. The need for rescue medication, intravenous morphine 0.1 mg/kg, was decided by the nurse, who was unaware of the rectal acetaminophen dose. The parents were interviewed by phone after 24 h regarding pain and its treatment, nausea, and vomiting. Rescue analgesia at home was rectal ibuprofen, 10 mg/kg. Results: In the postanesthesia care unit pain scores were significantly lower in the 40- and 60-mg/kg groups compared with placebo and 20-mg/kg groups. Acetaminophen resulted in a dose-related reduction in the number of children who required postoperative rescue opioid, with significance reached with 40 or 60 mg/kg doses. Calculated dose of acetaminophen at which 50% of the children not requiring a rescue opioid was 35 mg/kg. The need for rescue analgesia at home during the first 24 h after surgery was also significantly less in patients in the 40- or 60-mg/kg groups than in the 0- or 20-mg/kg groups (20-17 vs. 80-63%). Thirty-three percent of patients receiving placebo had postoperative nausea and vomiting, compared with 0-3% in groups receiving 40 or 60 mg/kg acetaminophen. Conclusions: A single dose of 40 or 60 mg/kg of rectal acetaminophen has a clear morphine- sparing effect in day-case surgery in children if administered at the induction of anesthesia. Moreover, children with adequate analgesia with acetaminophen have less postoperative nausea and vomiting.