CRU RAX215DC Manuale di installazione - Pagina 7
Sfoglia online o scarica il pdf Manuale di installazione per Cremagliere e cavalletti CRU RAX215DC. CRU RAX215DC 10. Usb upgrade kit
Stampa la paginatablet and intravenous formulations. It is used to close
patent ductus arteriosus (PDA) and as pain reliever in
perioperative in neonates and children weighing greater
than 7 kg. It is available as different dosage form such
as oral suspensions, tablets, infant drops and intravenous
preparations with a dose of 30 mg/kg in 3-4 divided doses.
Besides, diclofenac is available like ibuprofen dosage
forms with the recommended dose to children at a dose
of 0.3–1 mg/kg with a maximum dose of 50 mg 3 times
daily. However, ketorolac is not approved for use in
children under 16 years of age. It only used for short term
interventions of acute post-operative pain at a dose of 10-
40 mg every 4-6 h for a maximum of 7 days [7,12,48].
Meta-analysis of studies comparing ibuprofen and
diclofenac reveal that both drugs work well and that
choosing between them is an issue of dose, safety and
cost. An oral ibuprofen dose of 30-40 mg/kg per day
appears to render equivalent analgesia to oral/rectal
diclofenac 2-3 mg/kg per day. No difference in safety
has been documented in these dose ranges [27]. Clinical
pharmacology understanding for non-opioid analgesics
is required for optimal administration. Because, for
patients with post-operative pain, the minimal effective
for analgesic dose and toxic dose is not known certainly.
These doses may be higher or lower than the usual dose
ranges recommended for the drug involved. On top of that,
NSAIDs and acetylsalicylic acid have a potential toxicity,
most commonly bleeding diathesis due to inhibition
of platelet aggregation, renal impairment and gastro
duodenopathy due to prostaglandin inhibition [12].
Opioids
Like adult population, management of acute pain in
pediatric is also targeted with opioids. The analgesic
effect comes through binding the mu-opioid receptor
which is widely distributed at sites of peripheral
inflammation and throughout the CNS. The variation in
pharmacological response of opioids in pediatrics leads to
adjustment based on clinical response, age and presence
of side effects [7,27]. The indications for opioids include
postoperative pain, pain due to sickle cell disease, and
pain due to cancer [49]. A study in the Canadian teaching
hospitals confirms that opioids are mainly used in severe
pain and shows an improvement in all patients from
the their experience of severe pain received an opioid
treatment [14]. Most currently practiced guidelines in
recent advanced pediatric hospitals are commonly used
the following opioids in the management moderate to
severe pain in pediatrics (Tables 5-7).
Morphine: It is the most commonly used phenanthrene
derivative opioid in children with severe pain.
Pharmacokinetics disparity (Table 5) exists for this drug
between age groups. Because the plasma concentrations
of morphine in neonates and infants display a prolonged
half-lives (2-3fold) difference even with administration of
constant infusion [7,12,27].
154
Codeine: It is a prodrug which activated to morphine by
the enzyme cytochrome CYP2D6. However, the activity of
this enzyme is highly variable and shows inter-individual
variation which leads to a variation in analgesic effect of
codeine [7,10]. Caucasian population are considered as
'Super Metabolizers' whose approximately carry 10% of
this variant. Therefore, even low dose codeine put them at
risk of respiratory depression and excess sedation. Indeed,
codeine is now infrequently prescribed in Australia [7,27].
Tramadol: It is structurally related to morphine which
has a central analgesic effect by the formation of
O-desmethyl-tramadol with a mu-opioid receptor affinity
200 times greater due to biotransformation in the liver by
cytochrome P450(10). A dose of 50–100 mg every 4 h to a
maximum of 400 mg per day is recommended to children
between 12–18 years [7]. However, now a day's tramadol
does not recommend for pediatrics under 12 years of age.
Fentanyl: Even though it is metabolized to inactive
metabolites, fentanyl has 100 times more effect of analgesic
than morphine. Commonly it used by the trans mucosal,
intravenous, inhalational or intra-nasal and transdermal
routes for procedural related pains in surgery due to
its rapid onset and offset [7]. Case series and outcome
studies of children not undergoing intubation suggest a
higher frequency of opioid-induced respiratory depression
among neonates than among infants over six months
of age or older children [27]. In addition to the use of
naloxone 10-20 mcg /kg for urgent situations, deep breath
encouragement, awakening of the patient and withholding
further doses may manage mild respiratory depression in
children. Non-respiratory side effects of opioids, including
nausea, ileus, itching, and urinary retention, are common
among infants and children and may cause considerable
distress. Many opioid side effects can be ameliorated by
drug therapy directed at the side effect (e.g. antiemetic's to
treat nausea and vomiting, antihistamines to treat itching
and laxatives to treat constipation) [12,49].
Generally, WHO guideline recommends analgesic
treatment in two steps according to the child's level of
pain severity [15,24,48].
Table 5. Pharmacokinetics of morphine [27]
Volume of
Age Group
Distribution
(l/kg)
Preterm neonate
1.8-5.2
Term neonate
2.9-3.4
1-8 Years
1.4-3.1
Adult
1.1-2.1
Table 6. Dose administration of morphine [7,12]
Age
1-6 Month
6 Month-12 years
12-18 years
Curr Pediatr Res 2017 Volume 21 Issue 1
Kahsay
Clearance
Half Life
(ml/kg/min)
(Hours)
2.7-9.6
7.4-10.6
2.3-20
6.7-13.9
6.2-56.2
0.8-1.2
Dec 34
1.4-3
Appropriate Initial Dose
50-150 µg/Kg every 4 h
100-300 µg/Kg every 4 h
3-20 mg every 4 h