• Gerdien Zeilmaker-Roest, Christine de Vries-Rink, Joost van Rosmalen, Monique van Dijk, Saskia N de Wildt, KnibbeCatherijne A JCAJDivision of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.Department of Clinical Pharmacy, St. Antonius Hospital Nieuwegein/Utrecht, Utrecht, The Netherlands., Erik Koomen, JansenNicolaas J GNJGDepartment of Pediatrics, Division of Pediatric Critical Care Medicine, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.Department of Pediatrics, Beatrix Children's Hospital, University Medi, KneyberMartin C JMCJDepartment of Pediatrics, Division of Pediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands., Sofie Maebe, Greet Van den Berghe, Renata Haghedooren, Dirk Vlasselaers, BogersAd J J CAJJCDepartment of Cardiothoracic Surgery, Erasmus MC, Rotterdam, The Netherlands., Dick Tibboel, and Enno D Wildschut.
• Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands. g.zeilmaker@erasmusmc.nl.
• Crit Care. 2024 Apr 30; 28 (1): 143143.

BackgroundTo determine whether intermittent intravenous (IV) paracetamol as primary analgesic would significantly reduce morphine consumption in children aged 0-3 years after cardiac surgery with cardiopulmonary bypass.MethodsMulti-center, randomized, double-blinded, controlled trial in four level-3 Pediatric Intensive Care Units (PICU) in the Netherlands and Belgium. Inclusion period; March 2016-July 2020. Children aged 0-3 years, undergoing cardiac surgery with cardiopulmonary bypass were eligible. Patients were randomized to continuous morphine or intermittent IV paracetamol as primary analgesic after a loading dose of 100 mcg/kg morphine was administered at the end of surgery. Rescue morphine was given if numeric rating scale (NRS) pain scores exceeded predetermined cutoff values. Primary outcome was median weight-adjusted cumulative morphine dose in mcg/kg in the first 48 h postoperative. For the comparison of the primary outcome between groups, the nonparametric Van Elteren test with stratification by center was used. For comparison of the proportion of patients with one or more NRS pain scores of 4 and higher between the two groups, a non-inferiority analysis was performed using a non-inferiority margin of 20%.ResultsIn total, 828 were screened and finally 208 patients were included; parents of 315 patients did not give consent and 305 were excluded for various reasons. Fourteen of the enrolled 208 children were withdrawn from the study before start of study medication leaving 194 patients for final analysis. One hundred and two patients received intermittent IV paracetamol, 106 received continuous morphine. The median weight-adjusted cumulative morphine consumption in the first 48 h postoperative in the IV paracetamol group was 5 times lower (79%) than that in the morphine group (median, 145.0 (IQR, 115.0-432.5) mcg/kg vs 692.6 (IQR, 532.7-856.1) mcg/kg; P < 0.001). The rescue morphine consumption was similar between the groups (p = 0.38). Non-inferiority of IV paracetamol administration in terms of NRS pain scores was proven; difference in proportion - 3.1% (95% CI - 16.6-10.3%).ConclusionsIn children aged 0-3 years undergoing cardiac surgery, use of intermittent IV paracetamol reduces the median weight-adjusted cumulative morphine consumption in the first 48 h after surgery by 79% with equal pain relief showing equipoise for IV paracetamol as primary analgesic. Trial Registration Clinicaltrials.gov, Identifier: NCT05853263; EudraCT Number: 2015-001835-20.© 2024. The Author(s).

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