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Paracetamol use limits morphine dose in PICU


Among infants undergoing major surgery, postoperative use of intermittent intravenous paracetamol (acetaminophen) for the management of pain resulted in a lower cumulative morphine dose over 48 hours, according to a study.

Opioid therapy for the treatment of pain is associated with adverse effects, and researchers are seeking alternative analgesic regimens in neonates and infants, according to background information in the article, which appears in the Jan. 9 issue of the Journal of the American Medical Association. Paracetamol has been proposed as an alternative, with a previous study showing promise.

Ilse Ceelie, MD, PhD, of Erasmus MC-Sophia Children’s Hospital in the Netherlands, and colleagues performed a trial with infants who had undergone major abdominal and thoracic surgery to determine whether intravenous paracetamol would reduce the cumulative morphine dose needed to provide adequate analgesia by at least 30%.

The randomized study was conducted in a pediatric ICU and included 71 patients (categorized as neonates or infants younger than 1 year) who underwent surgery between March 2008 and July 2010, with follow-up of 48 hours. All patients received a dose of morphine 30 minutes before the end of surgery, followed by continuous morphine or intermittent intravenous paracetamol up to 48 hours after surgery. Infants in both study groups received morphine as rescue medication based on the guidance of the validated pain assessment instruments.

The researchers found that the cumulative morphine dose in the paracetamol group was 66% lower than that in the morphine group. By age category, cumulative morphine dose was 49% lower than in the morphine group for neonates (0 through 10 days) and 73% lower for older infants (11 days to 1 year).

The authors also found that neither the total morphine rescue dose, the amount or number of morphine rescue doses nor the number of patients requiring rescue doses differed significantly between the paracetamol and morphine groups. Also, there were no significant differences for percentage of adverse effects or pain scores between treatment groups.

“This randomized controlled trial shows that infants who receive intravenous paracetamol as primary analgesic after major surgery require significantly less morphine than those who receive a continuous morphine infusion,” the authors wrote. “Judging from the rescue morphine doses, a similar level of analgesia was obtained in either group. These results suggest that intravenous paracetamol may be an interesting alternative as primary analgesic in neonates and infants.”

The study abstract is available at


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