Question about opioid and Precedex dosing in peds

[Dantrolene FC]

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General anesthesiologist here. Recent grad.

How much narcotic do you give for peds laparoscopic cases? Here’s some recent cases I’ve had.

1. 4 month old born at 29 weeks gestation for a laparoscopic inguinal hernia repair.

Is it necessary to give any narcotic for this case? I did an inhaled induction and gave 2.5 mg/kg of propofol and 1 mg/kg of roc for the intubation. I gave 0.5 mcg/kg of fentanyl at incision. No other narcotic, just IV Tylenol and local infiltration by the surgeon (he prefers to avoid caudals for these cases).

The case went smooth and the kid was awake and extubated within 2-3 minutes of the drapes coming down. I was happy. But wondering if the narcotic is necessary.

2. 4 year old lap appy. I took over part way through the case. He received 2 mcg/kg of fentanyl at induction. I gave 0.05 mg/kg of morphine and 0.5 mcg/kg of Precedex.

Is the morphine and Precedex necessary for this? The surgeon only sent them home with Tylenol and ibuprofen. I didn’t give Tylenol or Toradol because they were given in the ED already, but otherwise would have.

3. T&A

I tend to give 0.1 mg/kg of morphine for these. Is the long acting narcotic necessary? Should I just give fentanyl? How much?

I give somewhere between 0.3-0.5 mcg/kg of Precedex for the 3-8 year olds. How often and how much Precedex are you giving these kids?

4. Adenoidectomy
Do you give any narcotic for these? I vaguely remember we just did Tylenol in residency. We didn’t give Toradol to ENT in residency, but my surgeons like it here, so I’ve been giving Toradol for adenoids and T&As.

 

[kidthor]

1. 4 month old born at 29 weeks gestation for a laparoscopic inguinal hernia repair.

Is it necessary to give any narcotic for this case? I did an inhaled induction and gave 2.5 mg/kg of propofol and 1 mg/kg of roc for the intubation. I gave 0.5 mcg/kg of fentanyl at incision. No other narcotic, just IV Tylenol and local infiltration by the surgeon (he prefers to avoid caudals for these cases).

The case went smooth and the kid was awake and extubated within 2-3 minutes of the drapes coming down. I was happy. But wondering if the narcotic is necessary.

I would give opioid - either fentanyl or morphine, and I would give tylenol. With a caudal you could get away with no opioid, but with surgeon local I think they need something.

2. 4 year old lap appy. I took over part way through the case. He received 2 mcg/kg of fentanyl at induction. I gave 0.05 mg/kg of morphine and 0.5 mcg/kg of Precedex.

Is the morphine and Precedex necessary for this? The surgeon only sent them home with Tylenol and ibuprofen. I didn’t give Tylenol or Toradol because they were given in the ED already, but otherwise would have.

That seems like a lot of opioid (plus precedex), but it's not unreasonable. Personally I would give either fentanyl 1mcg/kg or morphine 0.1mg/kg but probably not both. The precedex is OK but maybe isn't necessary. It all would depend too on how bad the appy is - in a decent number of kids it's perforated and they can be really uncomfortable, so they might need more.

3. T&A

I tend to give 0.1 mg/kg of morphine for these. Is the long acting narcotic necessary? Should I just give fentanyl? How much?

I give somewhere between 0.3-0.5 mcg/kg of Precedex for the 3-8 year olds. How often and how much Precedex are you giving these kids?

For T&A I stick to fentanyl 0.5mcg/kg up front and potentially add another 0.5mcg/kg if needed. For intraoral ENT I usually give precedex 0.5mcg/kg up front and consider adding up to another 0.5mcg/kg if they need more (sometimes even more than that - I usually err on giving more precedex over more opioids). I leave morphine for PACU, if needed. In my experience fentanyl plus generous precedex plus tylenol and a good steroid dose is enough to have them comfortable on emergence. Many people go straight to morphine intraop - I just think it slows emergence and isn't per se necessary.

4. Adenoidectomy
Do you give any narcotic for these? I vaguely remember we just did Tylenol in residency. We didn’t give Toradol to ENT in residency, but my surgeons like it here, so I’ve been giving Toradol for adenoids and T&As.

Yes - I definitely give fentanyl for an adenoid. We don't give toradol where I work, but I imagine it would help quite a bit. An alternative is ibuprofen liquid in PACU.