BNF for Children (BNFC) 2018-2019

ANTIDOTES AND CHELATORS

Sugammadex

lINDICATIONS AND DOSE

Routine reversal of neuromuscular blockade induced by

rocuronium

▶BY INTRAVENOUS INJECTION

▶Child 2–17 years: 2 mg/kg (consult product literature)

IMPORTANT SAFETY INFORMATION

Should only be administered by, or under the direct

supervision of, personnel experienced in its use.

lCAUTIONSCardiovascular disease (recovery may be
delayed).pre-existing coagulation disorders.recurrence
of neuromuscular blockade—monitor respiratory function
until fully recovered.use of anticoagulants (unrelated to
surgery).wait 24 hours before re-administering
rocuronium

lINTERACTIONS→Appendix 1 : sugammadex

lSIDE-EFFECTS
▶Common or very commonAbdominal pain.arrhythmias.
cough.dizziness.headache.nausea.skin reactions.taste
altered.vomiting
▶UncommonHypersensitivity
▶Frequency not knownBronchospasm

lPREGNANCYUse with caution—no information available.

lRENAL IMPAIRMENTAvoid if estimated glomerular
filtration rate less than 30 mL/minute/ 1. 73 m

2
.
lDIRECTIONS FOR ADMINISTRATIONForintravenous
injectiondose may be diluted to a concentration of
10 mg/mL with Sodium Chloride 0. 9 %.

lNATIONAL FUNDING/ACCESS DECISIONS

Scottish Medicines Consortium (SMC) Decisions

TheScottish Medicines Consortium, has advised (February

2013 ) that sugammadex (Bridion®) is accepted for

restricted use within NHS Scotland for the routine reversal

of neuromuscular blockade in high-risk patients only, or

where prompt reversal of neuromuscular block is required.

lMEDICINAL FORMS
There can be variation in the licensing of different medicines
containing the same drug.
Solution for injection
ELECTROLYTES:May contain Sodium
▶Bridion(Merck Sharp & Dohme Ltd)
Sugammadex (as Sugammadex sodium) 100 mg per 1 mlBridion
500 mg/ 5 ml solution for injection vials| 10 vialP£ 1 , 491. 00
(Hospital only)
Bridion 200 mg/ 2 ml solution for injection vials| 10 vialP£ 596. 40
(Hospital only)

1.3 Peri-operative analgesia

Peri-operative analgesia

Non-opioid analgesics

Since non-steroidal anti-inflammatory drugs (NSAIDs) do
not depress respiration, do not impair gastro-intestinal
motility, and do not cause dependence, they may be useful
alternatives or adjuncts to opioids for the relief of
postoperative pain. NSAIDs may be inadequate for the relief
of severe pain.
Diclofenac sodium p. 652 , diclofenac potassium p. 651 ,
ibuprofen p. 655 , paracetamol p. 271 , and ketorolac
trometamol below, are used to relieve postoperative pain in
children; diclofenac sodium and paracetamol can be given

parenterally and rectally as well as by mouth. Ketorolac

trometamol is given by intravenous injection.

Opioid analgesics

Opioid analgesics are now rarely used as premedicants; they

are more likely to be administered at induction. Pre-

operative use of opioid analgesics is generally limited to

children who require control of existing pain. The main side-

effects of opioid analgesics are respiratory depression,

cardiovascular depression, nausea, and vomiting; see

general notes on opioid analgesics and their use in

postoperative pain.

See the management of opioid-induced respiratory

depression in Pre-medication and peri-operative drugs

p. 809.

Intra-operative analgesia

Opioid analgesics given in small doses before or with

induction reduce the dose requirement of some drugs used

during anaesthesia.

Alfentanil p. 818 , fentanyl p. 279 , and remifentanil p. 819

are particularly useful because they act within 1 – 2 minutes

and have short durations of action. The initial doses of

alfentanil or fentanyl are followed either by successive

intravenous injections or by an intravenous infusion;

prolonged infusions increase the duration of effect.

In contrast to other opioids which are metabolised in the

liver, remifentanil undergoes rapid metabolism by

nonspecific blood and tissue esterases; its short duration of

action allows prolonged administration at high dosage,

without accumulation, and with little risk of residual

postoperative respiratory depression. Remifentanil should

not be given by intravenous injection intraoperatively, but it

is well suited to continuous infusion; a supplementary

analgesic is given before stopping the infusion of

remifentanil.

ANALGESICS›NON-STEROIDAL ANTI-

INFLAMMATORY DRUGS

Ketorolac trometamol

lINDICATIONS AND DOSE

Short-term management of moderate to severe acute

postoperative pain only

▶BY INTRAMUSCULAR INJECTION, OR BY INTRAVENOUS

INJECTION

▶Child 16–17 years (body-weight up to 50 kg):Initially

10 mg, then 10 – 30 mg every 4 – 6 hours as required for

maximum duration of treatment 2 days, frequency may

be increased to up to every 2 hours during initial

postoperative period; maximum 60 mg per day

▶Child 16–17 years (body-weight 50 kg and above):Initially

10 mg, then 10 – 30 mg every 4 – 6 hours as required for

maximum duration of treatment 2 days, frequency may

be increased to up to every 2 hours during initial

postoperative period; maximum 90 mg per day

▶BY INTRAVENOUS INJECTION

▶Child 6 months–15 years:Initially 0. 5 – 1 mg/kg (max. per

dose 15 mg), then 500 micrograms/kg every 6 hours

(max. per dose 15 mg) as required for maximum

duration of treatment 2 days; maximum 60 mg per day

lUNLICENSED USENot licensed for use in children under

16 years.

lCONTRA-INDICATIONSActive or history of gastro-

intestinal bleeding.active or history of gastro-intestinal

ulceration.coagulation disorders.complete or partial

syndrome of nasal polyps.confirmed or suspected

cerebrovascular bleeding.dehydration.following

operations with high risk of haemorrhage or incomplete

BNFC 2018 – 2019 Peri-operative analgesia 817

Anaesthesia

15