ESRD – Careful use or best to avoid
ESRD – Careful use, may accumulate but dialyzable
ESRD – Best to avoid
CKD, chronic kidney disease; ESRD, end stage renal disease.
There are a few opioid analgesics that should be used cautiously or avoided altogether in patients with significantly reduced GFRs. Morphine, the most widely used opioid medication in the world, has an active metabolite morphine-6-glucuronide which, while dialyzable, will accumulate in patients with reduced GFRs. This active metabolite can often cause over-sedation as it accumulates, making morphine an opiate to avoid if better alternatives are available. Opioid medications that should certainly be avoided are meperidine, codeine, and propoxyphene.[9] These three medications all have toxic metabolites that will accumulate in these patients.
Overall, many of the commonly used opioid medications can be used safely in patients with chronic kidney disease (CKD) or dialysis. The overall safety of these medications often rests with judicious use and monitoring by the administering clinicians.
Special considerations for the pediatric population
Postoperative pain management of the pediatric population can prove to be very challenging and is further complicated by the inability to adequately communicate in many of the patients. Still, it is imperative to achieve adequate analgesia in the pediatric population as inadequate analgesia may lead to hypersensitivity or altered development of neuroanatomy and subsequent psychological or behavioral problems.[10] As no single assessment tool exists, familiarity with developmental milestones, subjective pain assessment by the patient, and observational cues collected by parents and nursing staff as well as physical signs of pain must be used in order to properly quantify pain and guide treatment in pediatric patients.
Although PCA may be difficult to use for pediatric patients, it has been shown to be effective in children older than 5 years of age, but proper education of the parents and child is necessary.[11] In addition, non-opioids and regional analgesia should be included in a multimodal approach whenever possible. Regardless of technique, providers must be vigilant of pediatric dosing of each medication administered.
References
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