Pediatrics : Routes and Methods of Analgesic Drug Administration

      • Routes and Methods of Analgesic Drug Administration
        • Oral
          • Oral route preferred because of convenience, cost, and relatively
          • steady blood levels
          • Higher dosages of oral form of opioids required for equivalent
          • parenteral analgesia
          • Peak drug effect occurring after 1 to 2 hours for most analgesics
          • Delay in onset a disadvantage when rapid control of severe or 
          • fluctuating pain is desired
        • Sublingual, Buccal, or Transmucosal
          • Tablet or liquid placed between cheek and gum (buccal) or under tongue (sublingual)
          • Highly desirable because more rapid onset than oral route
            • Produces less first-pass effect through liver than oral route, which normally reduces analgesia from oral opioids (unless sublingual or buccal form is swallowed, which occurs often in children)
          • Few drugs commercially available in this form 
          • Many drugs can be compounded into sublingual troche or lozenge.*
            • Actiq: Oral transmucosal fentanyl citrate in hard confection base on a plastic holder; indicated only for management of breakthrough cancer pain in patients with malignancies who are already receiving and are tolerant to opioid therapy, but can be used for preoperative or preprocedural sedation and analgesia
        • Intravenous (Bolus)
          • Preferred for rapid control of severe pain
          • Provides most rapid onset of effect, usually in about 5 minutes
          • Advantage for acute pain, procedural pain, and breakthrough pain
          • Needs to be repeated hourly for continuous pain control
          • Drugs with short half-life (morphine, fentanyl, hydromorphone) preferable to avoid toxic accumulation of drug
        • Intravenous (Continuous)
          • Preferred over bolus and intramuscular (IM) injection for
          • maintaining control of pain
          • Provides steady blood levels
          • Easy to titrate dosage
        • Subcutaneous (Continuous)
          • Used when oral and intravenous (IV) routes not available
          • Provides equivalent blood levels to continuous IV infusion
          • Suggested initial bolus dose to equal 2-hour IV dose; total 24-hour dose usually requires concentrated opioid solution to minimize infused volume; use smallest-gauge needle that accommodates infusion rate
        • Patient-Controlled Analgesia
          • Generally refers to self-administration of drugs, regardless of route
          • Typically uses programmable infusion pump (IV, epidural, subcutaneous [SC]) that permits self-administration of boluses of medication at preset dose and time interval (lockout interval is time between doses)
          • Patient-controlled analgesia (PCA) bolus administration often combined with initial bolus and continuous (basal or background) infusion of opioid
          • Optimum lockout interval not known but must be at least as long as time needed for onset of drug
            • Should effectively control pain during movement or procedures
            • Longer lockout provides larger dose

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