Opioid analgesics
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Refractory post-operative ileus: 3 case reports A case report series described three boys aged 9 months–12 years, who experienced severe refractory postoperative ileus secondary to combination therapy with fentanyl, hydromorphone, methadone or morphine for postoperative pain control following orthotopic liver transplantation [OLT; not all routes and dosages stated]. Case 1: A 12-year-old boy underwent urgent OLT for acute liver failure secondary to Wilson disease. Immediately after OLT, antibody‐mediated rejection became evident. During his treatment for the rejection, he underwent exploratory laparotomy. Over post-operative days 0–2, he received a fentanyl infusion at a maximum dose of 4 µg/kg/h. Over post-operative days 2–40, he received hydromorphone as pain-control analgesia (maximum dose 0.3mg basal; 0.35 mg/dose as required). Over post‐operative days 19–27, he received methadone at a maximal dose of 4mg twice daily. He also received IV bolus of fentanyl 1 µg/kg/dose as required and morphine 2 mg/dose every 2 hours as required. During this time, he had been maintained on dexmedetomidine. On post-operative day 28, he developed severe refractory post-operative ileus, which resulted in abdominal compartment syndrome. An emergent laparotomy was performed for abdominal decompression, following which he returned to the paediatric ICU. Meanwhile, he received bisacodyl, polyethylene glycol, enema and red rubber. A rectal tube was placed for rectal decompression, following which he was treated with methylnaltrexone resulting in stool output on post-operative day 31, after the first dose (but none thereafter). In view of the poor response to the aforementioned therapies, on post-operative day 31, he started receiving off-label neostigmine infusion 0.007 mg/kg/h, which was then titrated up by 0.001 mg/kg/h to effect. Maximum dose of neostigmine was 0.009 mg/kg/h. Within 2 hours of initiating the infusion, bowel movement occurred. The infusion lasted 2 hours and 40 minutes. Staged abdominal wall closure was performed on post-operative day 35 following resolution of the ileus. Definitive abdominal wall reconstruction and skin closure followed, on post-operative day 38. Full enteral feeds were achieved 7 days following administration of the neostigmine infusion, on post-operative day 41. Case 2: A 9-month-old boy underwent OLT for unresectable hepatoblastoma. On post-operative day 5, he developed non‐anastomotic intraparenchymal hepatic artery thrombosis and severe transaminitis. He underwent an emergent exploratory laparotomy, hepatic artery thrombectomy and direct thrombolysis. Over post-operative days 0–13, he received a fentanyl infusion at a maximum dose of 10 µg/kg/h. Over post-operative days 4–6, he received morphine as pain-control analgesia (maximum dose 0.01 mg/kg/h basal; 0.01 mg/kg/dose as required). Additionally, he also received morphine 0.1 mg/kg/dose every 2 hours as required. Over post-operative days 11–25, he received methadone at a maximal dose of 0.1 mg/kg every 12 hours. Meanwhile,
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