Postoperative breakthrough pain in paediatric cardiac surgery not reduced by increased morphine concentrations

Sjoerd de Hoogd, Sebastiaan C. Goulooze, Abraham J. Valkenburg, Elke H.J. Krekels, Monique van Dijk, Dick Tibboel, Catherijne A.J. Knibbe*

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

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Abstract

Background: Morphine is commonly used for postoperative analgesia in children. Here we studied the pharmacodynamics of morphine in children after cardiac surgery receiving protocolized morphine. Methods: Data on morphine rescue requirements guided by validated pain scores in children (n = 35, 3–36 months) after cardiac surgery receiving morphine as loading dose (100 μg kg−1) with continuous infusion (40 μg kg−1 h−1) from a previous study on morphine pharmacokinetics were analysed using repeated time-to-event (RTTE) modelling. Results: During the postoperative period (38 h (IQR 23–46)), 130 morphine rescue events (4 (IQR 1–5) per patient) mainly occurred in the first 24 h (107/130) at a median morphine concentration of 29.5 ng ml−1 (range 7–180 ng ml−1). In the RTTE model, the hazard of rescue morphine decreased over time (half-life 18 h; P < 0.001), while the hazard for rescue morphine (21.9% at 29.5 ng ml−1) increased at higher morphine concentrations (P < 0.001). Conclusions: In this study on protocolized morphine analgesia in children, rescue morphine was required at a wide range of morphine concentrations and further increase of the morphine concentration did not lead to a decrease in hazard. Future studies should focus on a multimodal approach using other opioids or other analgesics to treat breakthrough pain in children. Impact: In children receiving continuous morphine infusion, administration of rescue morphine is an indicator for insufficient effect or an event.Morphine rescue events were identified at a wide range of morphine concentrations upon a standardized pain protocol consisting of continuous morphine infusion and morphine as rescue boluses.The expected number of rescue morphine events was found to increase at higher morphine concentrations. Instead of exploring more aggressive morphine dosing, future research should focus on a multimodal approach to treat breakthrough pain in children.

Original languageEnglish
Pages (from-to)1201-1206
Number of pages6
JournalPediatric Research
Volume90
Issue number6
DOIs
Publication statusPublished - 18 Feb 2021

Bibliographical note

Publisher Copyright:
© 2021, The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.

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