AUDIT OF PARACETAMOL PRESCRIPTIONS IN PAEDIATRIC SURGICAL PATIENTS
Authors: McArtney Rowena , Atkinson Angharad 
Published: August 2016

Aim

Local Guidelines for peri-operative pain management in children published in 2012 recommended that paracetamol dosing was calculated using ideal body weight (IBW) to prevent inadvertent overdosing in overweight and obese children.1 The purpose of this audit was to establish compliance with these guidelines. The oral paracetamol dose recommended was 20–30 mg/kg as a single dose then 15–20 mg/kg every 4–6 hrs with a maximum of 90 mg/kg/day. IV paracetamol doses were as recommended in BNF for Children (BNFC).2 BNFC states that paracetamol doses totalling 150 mg/kg may cause severe hepatocellular necrosis and renal tubular necrosis but the potential for adverse effects in some children can be seen with doses as little as 75 mg/kg in 24 hrs.

Method

Paediatric Surgical patients prescribed paracetamol as an inpatient or on discharge over a 10 week period were included in the audit. For this audit patients were assessed as overweight or obese using age and gender specific UK growth charts endorsed by the Department of Health.

Audit standards

100% compliance with the following:

1. inpatient charts and discharge prescriptions document patient weight and height.

2. paracetamol prescriptions based on ideal weight for height in overweight and obese paediatric patients.

3. prescriptions have IV route prescribed independently to oral (PO) or rectal route.

4. patients prescribed IV paracetamol reviewed after 48 hrs for an oral switch.

Results

100 inpatient prescriptions (71 elective and 29 non-elective) and 35 discharge prescriptions were analysed.

1. Weight was annotated for 84% of inpatient prescriptions and 94% of discharge prescriptions; height was not documented for any patient. Therefore data was analysed basing IBW on 50th centile of the UK growth charts.

2. The following results are based on IBW:
▸ Six inpatients prescribed oral paracetamol were classified as overweight or obese; doses ranged from 17.4–30 mg/kg/dose.
▸ Four patients prescribed IV paracetamol were classified as overweight or obese; doses ranged from 20–23 mg/kg/dose.
▸ Four patients prescribed the combined route of PO/IV paracetamol were classified as overweight or obese; doses ranged from 18–24 mg/kg/dose.
▸ Six patients prescribed oral paracetamol on discharge were classified as overweight or obese; doses ranged from 13–33 mg/kg/dose.

3. Paracetamol was prescribed as IV/PO in 32 inpatients.

4. IV paracetamol was prescribed in 52 patients; 20 were not reviewed at 48 hrs for a switch to oral route. Of these, only 3 were appropriate prolonged IV prescriptions.Conclusion Audit findings showed inadequate compliance with local prescribing guidelines posing a risk of inappropriately high doses of paracetamol being prescribed to overweight and obese children. In addition, unnecessarily prolonged IV use was observed. Following feedback local guidelines were amended in 2015 to recommend that in obese children, dosing should reflect lean body mass and ideal weight for height. The maximum daily dose was also reduced to 75 mg/kg/day. Prescribers require education regarding this important issue.