Analgesia For Delivery Research Articles

Pharmacists in Trauma: a randomised controlled trial of emergency medicine pharmacists in trauma response teams

BackgroundAnalgesia is an important component for patient well-being, but commonly delayed during trauma resuscitation. The Pharmacists in Trauma trial assessed the effects of integrating pharmacists into trauma response teams to...

The application of DPE, CSEA, and EA in labor analgesia for nulliparous women and their impact on maternal and infant safety.

This work compared the effects of dural puncture epidural (DPE), combined spinal epidural analgesia (CSEA) and epidural analgesia (EA) on labor analgesia for primiparae and their impacts on maternal and infant safety. A total of 204 primiparae in need of labor analgesia for vaginal delivery were allocated to DPE, CSEA and EA groups. At 10 min, 30 min and 1 h after analgesia, the DPE and CSEA groups showed lower VAS scores and quicker onset of action than EA group. There was no significant difference in the duration of analgesia and labor and fetal decelerations among the 3 groups. At 1 min and 5 min after childbirth, the neonatal Apgar scores showed no significant difference between the 3 groups. The Bromage scores of DPE and EA groups were lower than those of CSEA group. The incidence of pruritus, hypotension, and postpartum headache in DPE and EA groups were lower than those in CSEA group. To sum up, the efficacy of DPE in labor analgesia for primiparae is similar to that of CSEA, with no obvious effect on labor stage and neonatal Apgar score, no additional complications and less LLMB, pruritus, hypotension and postpartum headache.

Feasibility and Analgesic Efficacy of Thoracolumbar Dorsal Ramus Nerve Block Using Multiorifice Pain Catheters for Scoliosis Surgery: A Prospective Cohort Study.

Approximately 38,000 scoliosis surgery correction operations are performed annually in the United States; these operations are associated with considerable postoperative pain which can be difficult to manage. This is largely attributed to an incision spanning multiple vertebral segments with paraspinal muscle dissection and retraction to facilitate the implantation of segmental hardware and rods. Frequently utilized analgesic modalities include intravenous patient-controlled analgesia and epidural analgesia, often in combination. We sought to ascertain the feasibility and analgesic efficacy of continuous thoracolumbar dorsal ramus nerve (TDRN) block using surgically placed multiorifice catheters. Forty-two patients diagnosed with idiopathic scoliosis who underwent a posterior spinal fusion (PSF) were enrolled after consent was obtained. Patients were managed utilizing a standardized Enhanced Recovery After Surgery) protocol including a perioperative opioid-sparing regimen. Data were collected at specified time intervals during the recovery period. These data points included pain scores using the Numeric Rating Scale. Parenteral or both oral and parenteral opioid consumption doses were also collected every 4 hours. Any significant postoperative adverse events were recorded as well. A total of 42 patients had surgically placed TDRN catheters, and 40 patients were included in this study. The patients all reported low to moderate pain scores with low opioid consumption postoperatively, while the TDRN catheter delivery of local anesthetic analgesics did not result in significant complications. A regional technique utilizing TDRN catheters could be a valuable component of the postoperative pain management protocols for PSF surgery, and additional studies are warranted. This study evaluated the feasibility and analgesic efficacy of TDRN catheters for postoperative pain control following multilevel PSF for idiopathic scoliosis. Continuous local anesthetic delivery through TDRN catheters is a feasible and safe technique for postoperative pain control in these patients. Selective blockade of the dorsal rami might have benefits over epidural analgesia or other regional techniques.

Incorporation, adaptation and rejection of obstetric practices during the implementation of the “Adequate Childbirth Program” in Brazilian private hospitals: a qualitative study

BackgroundThe “Adequate Childbirth Program” (PPA) is a quality improvement project that aims to reduce the high rates of unnecessary cesarean section in Brazilian private hospitals. This study aimed to analyze labor and childbirth care practices after the first phase of PPA implementation.MethodThis study uses a qualitative approach. Eight hospitals were selected. At each hospital, during the period of 5 (five) days, from July to October 2017, the research team conducted face to face interviews with doctors (n = 21) and nurses (n = 28), using semi-structured scripts. For the selection of professionals, the Snowball technique was used. The interviews were transcribed, and the data submitted to Thematic Content Analysis, using the MaxQda software.ResultsThe three analytical dimensions of the process of change in the care model: (1) Incorporation of care practices: understood as the practices that have been included since PPA implementation; (2) Adaptation of care practices: understood as practices carried out prior to PPA implementation, but which underwent modifications with the implementation of the project; (3) Rejection of care practices: understood as those practices that were abandoned or questioned whether or not they should be carried out by hospital professionals.ConclusionsAfter the PPA, changes were made in hospitals and in the way, women were treated. Birth planning, prenatal hospital visits led by experts (for expecting mothers and their families), diet during labor, pharmacological analgesia for vaginal delivery, skin-to-skin contact, and breastfeeding in the first hour of life are all included. To better monitor labor and vaginal birth and to reduce CS without a clinical justification, hospitals adjusted their present practices. Finally, the professionals rejected the Kristeller maneuver since research has demonstrated that using it’s harmful.

Efficacy of Trans Abdominis Plane (TAP) Block for Post-caesarean Delivery Analgesia: A Prospective Randomized Controlled Study

Background: Caesarean delivery is a major surgical procedure after which substantial post-operative pain and discomfort can be anticipated. A substantial component of pain experienced by patients is derived from abdominal wall incision. Currently multimodal analgesia technique involving abdominal field block with parenteral analgesia are becoming popular for these patients. Transversus abdominal plane (TAP) blockcan relieve pain associated with abdominal incision. We carried out this study to evaluate the efficacy of TAP block in providing post operativepain relief and the cumulative requirement of analgesic over first 48 hour in patients who underwent LSCS under spinal anaesthesia.Methods: This prospective randomized controlled study was carried out with 60 patients posted for electivecaesarean section, two groups with 30 patients each. Both groups were compared to see the effectiveness of Trans Abdominis Plane (TAP) Block as a method for post-operative multimodal analgesia technique using VAS score. Total number of rescue analgesia required upto 48hrs and total dose of rescue analgesia given in both the groups was also compared.Results: The mean VAS score at rest andon movement was decreased significantly after Trans Abdominis Plane (TAP) Block. The total dose and number of rescue analgesia was also decreased significantly.Conclusions: TAP block as a component of multimodal analgesia after caesarean section was effective in providing analgesia with delayed time for 1st rescue analgesia and reduction in total analgesic requirement in 1st 48 hr.

Comparison of ultrasound-guided erector spinae plane block versus transmuscular quadratus lumborum block for postoperative analgesia after caesarean delivery: A prospective randomized non-inferiority clinical trial.

Regional techniques are a part of multimodal analgesia following cesarean delivery. Cesarean delivery warrants a regional technique, which can provide somatic and visceral analgesia-like quadratus lumborum block (QLB) and erector spinae plane block (ESPB). In this study, we investigated the non-inferiority of ESPB at T12 and transmuscular-QLB (TQLB) at L2-L3 for postoperative analgesia in cesarean delivery. In this prospective, randomized, non-inferiority trial, 124 patients undergoing cesarean delivery were enrolled to receive bilateral TQLB or ESPB with 20 mL of 0.25% ropivacaine on each side. All patients received prophylactic acetaminophen and ketorolac for 2 days. Our primary objective was to compare the total tramadol consumption in the first 48 h between the two groups. Secondary objectives were to compare cumulative tramadol consumption, postoperative Numeric Rating Scale (NRS) score at rest, and with movement at various time points, the time for first rescue analgesic requirement, development of complications related to the block, and patient satisfaction with analgesia between the two groups. The total tramadol consumption in 48 h (47.3 ± 34.9 mg in ESPB and 50.9 ± 38.7 mg in TQLB), duration of first rescue analgesic (22.8 ± 15.8 h in ESPB and 22.7 ± 15.6 h in TQLB), and patient satisfaction were similar between the two groups. Both groups had similar pain scores except at rest at 6 h and on movement at 4 h, 6 h, and 36 h, whereas the ESPB group had lower NRS scores (P < 0.05). The analgesic effect of bilateral ESPB at T12 was non-inferior to that of bilateral TQLB post-caesarean delivery.

Neuraxial clonidine is not associated with lower post-cesarean opioid consumption or pain scores in parturients on chronic buprenorphine therapy: a retrospective cohort study.

Adequate post-cesarean delivery analgesia can be difficult to achieve for women diagnosed with opioid use disorder receiving buprenorphine. We sought to determine if neuraxial clonidine administration is associated with decreased opioid consumption and pain scores following cesarean delivery in women receiving chronic buprenorphine therapy. This was a retrospective cohort study at a tertiary care teaching hospital of women undergoing cesarean delivery with or without neuraxial clonidine administration while receiving chronic buprenorphine. The primary outcome was opioid consumption (in morphine milligram equivalents) 0-6h following cesarean delivery. Secondary outcomes included opioid consumption 0-24h post-cesarean, median postoperative pain scores 0-24h, and rates of intraoperative anesthetic supplementation. Multivariable analysis evaluating the adjusted effects of neuraxial clonidine on outcomes was conducted using linear regression, proportional odds model, and logistic regression separately. 196 women met inclusion criteria, of which 145 (74%) received neuraxial clonidine while 51 (26%) did not. In univariate analysis, there was no significant difference in opioid consumption 0-6h post-cesarean delivery between the clonidine (8 [IQR 0, 15]) and control (1 [IQR 0, 8]) groups (P = 0.14). After adjusting for potential confounders, there remained no significant association with neuraxial clonidine administration 0-6h (Difference in means 2.77, 95% CI [-0.89 to 6.44], P = 0.14) or 0-24h (Difference in means 8.56, 95% CI [-16.99 to 34.11], P = 0.51). In parturients receiving chronic buprenorphine therapy at the time of cesarean delivery, neuraxial clonidine administration was not associated with decreased postoperative opioid consumption, median pain scores, or the need for intraoperative supplementation.

Association of free maternal and fetal ropivacaine after epidural analgesia for intrapartum caesarean delivery: a prospective observational trial

BackgroundRopivacaine is present in plasma in both protein-bound and free forms. The free form is responsible for the occurrence of toxic side effects. During obstetric epidural analgesia, free ropivacaine enters the fetal circulation depending on various factors. The aim of this study was to analyse a potential association between ropivacaine concentrations in maternal and fetal plasma and hence the extent of fetal exposure to ropivacaine. MethodsIn this prospective monocentre study, parturients who met the following criteria were included in the study: 1. epidural administration as part of obstetric anaesthesia, and 2. subsequent intrapartum caesarean delivery, which 3. was performed after an epidural bolus administration of ropivacaine within the existing epidural analgesia. Total and free ropivacaine concentrations were analysed in maternal blood at baseline, prior to epidural bolus administration for caesarean delivery, and in maternal and fetal (umbilical venous, oxygenated) blood at delivery. The results are presented as mean ± SD or median (25/75th percentile). ResultsWe screened 128 parturients who went into labour at term and requested epidural analgesia, of whom 39 were ultimately included in the study. An intrapartum caesarean delivery was performed after the epidural application of 207 (166/276) mg ropivacaine during an epidural treatment period of 577 (360/1010) min. Total and free ropivacaine concentrations were 1402 ± 357 ng/ml and 53 ± 46 ng/ml, respectively, in maternal venous blood and 457 ± 243 ng/ml and 43 ± 27 ng/ml, respectively, in fetal blood. The maternal total and free ropivacaine concentrations were significantly correlated (r = 0.873; P < 0.0001). ConclusionThe results of the present study suggest that determining the concentration of free ropivacaine in maternal blood may be a feasible option for estimating neonatal exposure to ropivacaine.

A Review on Advanced Transdermal Paches and Their Evaluation

Transdermal patches are an innovative method of delivering medication directly into the bloodstream through the skin. In 1979, the United States authorized the use of the initial transdermal technique for systemic delivery—a three-day patch that administers scopolamine to alleviate motion sickness. The initial breakthrough in transdermal delivery came with the introduction of nicotine patches. This paved the way for greater awareness and acceptance of transdermal technology in the medical field and among the general population, gaining significant popularity a decade later. Currently, there are 19 different transdermal delivery methods available for medications such as oestradiol, fentanyl, lidocaine, and testosterone. Additionally, there are combination patches available that contain multiple medications for hormone replacement and contraception. There are also iontophoretic and ultrasonic analgesia delivery systems that can be used. They provide several benefits compared to conventional oral medication, such as improved patient adherence, regulated drug delivery, and reduced side effects. The medication is typically contained within a matrix or reservoir within the patch, and is gradually released over a period of time. The patch may require periodic changes, typically every few days or weeks, depending on the specific medication and dosage. Transdermal patches have a broad range of applications, encompassing painkillers, hormones, and nicotine replacement therapy. They are widely regarded as safe and effective, with minimal side effects. It is important to carefully adhere to the instructions for use to avoid potential skin irritation or other issues.

Unilateral Horner syndrome and trigeminal palsy after lumbar epidural analgesia during labor

Case report: The present case report explains a rare and unusual complication of self-limiting unilateral Horner syndrome and trigeminal palsy after Lumbar Epidural analgesia for Normal delivery. A 22-year-old healthy primigravida at 38 weeks gestation, with an unremarkable medical history and prenatal course, was admitted to the hospital in active labor. Epidural anesthesia was administered during the first stage of labor under oxytocin infusion. The procedure was uneventful, with the patient experiencing good pain relief and no motor block. However, approximately 25 minutes after epidural placement, the patient reported left eyelid heaviness, decreased sensation on the left cheek, miosis, ptosis, and redness in the left eye. Neurologic symptoms were limited to this presentation, and the patient's blood pressure dropped briefly but returned to normal with ephedrine. The patient's symptoms resolved after about 3 hours. Later, the epidural catheter was repositioned, and the patient experienced pain relief for a limited time before again developing eye symptoms. Despite stable hemodynamics, the infusion was stopped, and the patient received Entonox for pain relief. Due to a failure to progress, a cesarean delivery was performed, and the patient fully recovered from the epidural block. No further signs or symptoms of Horner's syndrome or trigeminal nerve palsy were observed postoperatively. Conclusion: This case underscores the importance of recognizing and managing rare neurological complications, such as Horner's syndrome and trigeminal nerve palsy, in the context of epidural anesthesia during labor. While the symptoms observed were transient and resolved postpartum, healthcare providers should remain vigilant and ready to respond to such adverse events, ensuring the safety and well-being of both the mother and the newborn.

Comparison of Different Delivery Modalities of Epidural Analgesia and Intravenous Analgesia in Labor: A Systematic Review and Network Meta-analysis

(Can J Anesth/J Can Anesth. 2023;70:406–442) There is still no preferred method of delivering neuraxial analgesia to pregnant patients. There are options such as continuous epidural infusion (CEI) and intermittent epidural bolus which can be controlled by a machine (programmed intermittent epidural bolus—PIEB), demand from an anesthesia provider (demand intermittent epidural bolus—DIEB), or the patient themselves (patient-controlled epidural analgesia—PCEA). The use of opioids for labor analgesia is also common in those who cannot receive spinal analgesia. This study aimed to compare the relationship between different analgesia delivery methods on maternal, fetal, and neonatal outcomes.

Effects of combined spinal-epidural anesthesia on anxiety, labor analgesia and motor blocks in women during natural delivery

BACKGROUND The background of this study was analgesia in natural delivery. The combined spinal-epidural anesthesia has obvious analgesic effect on the parturients in natural labor, and combined spinal-epidural anesthesia has been widely used in anesthesia for various diseases. AIM To study the effects of combined spinal-epidural anesthesia on anxiety, labor analgesia, and motor blocks in parturients during natural delivery. METHODS A total of 120 women who gave birth at Changning District Maternal and Child Health Hospital between December 2021 to December 2022 were included; a random number table approach was employed to divide the women into a control group and a joint group, with each group consisting of 60 women. The control group was given epidural anesthesia, while the joint group was given combined spinal-epidural anesthesia. The visual analog scale (VAS) was used to evaluate the degree of maternal pain. Comparisons were made between the two groups’ conditions of childbirth and the duration of labor. Apgar scores were used to evaluate the status of the newborns at birth; Self-rating Anxiety Scale (SAS) and General Self-Efficacy Scale (GSES) scores, umbilical artery blood gas analysis indices and stress indices were compared between the two groups; and the frequencies of motor block and postpartum complications were analyzed. RESULTS In comparison to the control group, in the joint group, the VAS scores for the first, second, and third stages of labor were lower (P &lt; 0.05). The rates of conversion to cesarean section and postpartum blood loss in the joint group were lower than those in the control group (P &lt; 0.05). No significant differences were observed in the Apgar score, the duration of the first stage of labor, or the total duration of labor between the two groups (P &gt; 0.05). The second and third stages of labor in the joint group were shorter than those in the control group (P &lt; 0.05). When compared to the control group, the postpartum SAS score of the joint group was lower, while the GSES score was greater (P &lt; 0.05). Between the control group and the joint group, the differences observed in pH, arterial carbon dioxide partial pressure, arterial oxygen partial pressure, or arterial hydrogen ion concentration were not significant (P &gt; 0.05). Nitric oxide, cortisol, and adrenaline levels were lower in the joint group than in the control group (P &lt; 0.05). There were no substantial differences in Bromage grade or rate of complications between the two groups (P &gt; 0.05). CONCLUSION For parturients during natural delivery, combined spinal-epidural anesthesia can reduce anxiety, provide labor analgesia, shorten labor time, and reduce postoperative stress levels but did not result in a motor block.

Peripheral Nerve Blocks for Cesarean Delivery Analgesia: A Narrative Review.

Effective postoperative analgesia using multimodal approach improves maternal and neonatal outcomes after cesarean delivery. The use of neuraxial approach (local anesthetic and opioids) and intravenous adjunctive drugs, such as nonsteroidal anti-inflammatory drugs and acetaminophen, currently represents the standard regimen for post-cesarean delivery analgesia. Peripheral nerve blocks may be considered in patients who are unable to receive neuraxial techniques; these blocks may also be used as a rescue technique in selected patients. This review discusses the relevant anatomy, current evidence, and advantages and disadvantages of the various peripheral nerve block techniques. Further research is warranted to compare the analgesic efficacy of these techniques, especially newer blocks (e.g., quadratus lumborum blocks and erector spinae plane blocks). Moreover, future studies should determine the safety profile of these blocks (e.g., fascial plane blocks) in the obstetric population because of its increased susceptibility to local anesthetic toxicity.

Patient and staff perceptions of short procedural sedation with propofol for joint and fracture reductions in the Emergency Department: A qualitative study

BackgroundEmergency Department (ED) propofol sedation is widely used to facilitate reduction of fractures and dislocations, but little is known about patient and staff perceptions of the practice. Better understanding of these aspects may improve patient care. MethodsA qualitative exploratory study involving semi-structured patient interviews and ED healthcare professional focus groups. Interviews with adult patients (≥16 years) >1 hour after their sedation episode were audio-recorded, anonymised and transcribed verbatim to an electronic database. Thematic analysis using a general inductive method led to development of codes and themes. ED focus groups recordings were similarly transcribed and triangulated to patient interview outcomes. ResultsData saturation was reached after 16 patient interviews. Emergent central themes from a patient perspective were: ‘fear of the unknown’ and ‘expressed relief that the procedure was comfortable.’ Key themes included ‘trust in the clinical team,’ ‘efficacy of pain management prior to sedation’ and ‘quality of the information delivered to patients.’ Focus group discussions around patient interview outcomes identified triage, analgesia delivery, communication, and consideration of the environment as areas for improvement. ConclusionsED procedural sedation with propofol is generally very well accepted by patients and clinical staff but there is scope to improve patient-focus and increase satisfaction.

Metoxifluran, an inhalation analgesic that opens up new possibilities in anesthesia

Although numerous clinical guidelines for pain management have been published over the past decade, inadequate pain relief remains a major public health problem. Currently, several methods of analgesia are available for the treatment of acute pain, including intravenous analgesia, epidural anesthesia, and oral administration of medications. However, the existing methods of analgesia still do not cover all the needs of proper analgesia, the search for new forms of release, methods of administration and methods of analgesia continues. Currently, non-invasive methods of analgesia are being actively implemented, which include a transdermal delivery system of analgesics (in particular, fentanyl hydrochloride), intranasal and inhalational analgesia, in which the delivery of analgesics is controlled by both the doctor and the patient. The purpose of this article is to review the inhaled analgesic methoxyflurane, which is administered by means of an individual inhaler and is used for the treatment of acute pain.

Ketamine versus Tramadol for Analgesia in Spontaneous Vaginal Delivery: A Randomized Clinical Trial

Ketamine versus Tramadol for Analgesia in Spontaneous Vaginal Delivery: A Randomized Clinical Trial

858 The Effect of a ‘Rib Fracture Pathway’ on the Efficiency of Rib Block Delivery at a UK Major Trauma Centre

Abstract Aim Rib fractures carry a mortality rate of 10% which is doubled in the elderly population. They are common following blunt thoracic trauma and are a marker of injury severity. Timely delivery of regional analgesia is crucial to prevent secondary respiratory complications. We compare the time taken from admission to administration of a regional block in patients with &amp;gt;2 rib fractures before and after the implementation of a rib fracture pathway. Method Retrospective data was collected from 22 pre-pathway and 47 post-pathway patients who were given a regional block after suffering &amp;gt;2 rib fractures. Demographic data, ISS, length of stay and respiratory complications were collected. Need for block was determined by clinical factors including uncontrolled pain and limited respiratory effort. Results Time to block from admission was longer in pre-pathway patients (41.9±33.8 vs 23.9±21.2 hours, p = 0.03). There was no significant difference in length of stay (21.6±14.2 vs 19.9±14.5, p = 0.3). Pre-pathway patients were significantly younger (54.6±15.0 vs 66.8±17.4 years, p = 0.006) and had fewer rib fractures (5.4±2.3 vs 7.4±3.5, p = 0.02). The mean ISS was 24.1±10.3 and 18.1±8.5 in the pre- and post-pathway patients, respectfully (p = 0.02). There was no significant difference in post-admission chest infection rates (18.2% vs 23.4%, p = 0.4). Conclusions The time taken from admission to block in patients with multiple rib fractures significantly reduced following the implementation of a ‘Rib Fracture Pathway’ at a UK Major Trauma Centre. Further work is required to determine whether this will affect length of stay or patient outcomes.

1264 The Impact of ‘Rib Block’ Administration on Patients with Multiple Rib Fractures at a Major Trauma Centre: A Retrospective Observational Study

Abstract Aim Rib fractures carry a mortality rate of 10% which is doubled in the elderly population. They are common following blunt thoracic trauma and are a marker of injury severity. The timely delivery of regional analgesia is crucial to prevent pain induced hypoxia, atelectasis, pneumonia and respiratory failure. We compare the trauma-related injuries and outcomes between patients with &amp;gt;2 rib fractures who received regional analgesic blocks with those who didn’t receive blocks. Method Retrospective data was collected from 187 patients presenting as a trauma call with &amp;gt;2 rib fractures over a period of 18 months. Patient demographics, ISS, length of stay and respiratory complications were collected from electronic patient records (EPR). Results 69 patients received a regional rib block compared with 118 who did not. Patients who had a rib block were older compared to those who did not have a block (62.1±17.6 vs 55.4±18.2, p = 0.007). There was no significant difference in number of rib fractures (6.8±3.2, p&amp;lt;0.2), post-admission chest infection rate (23.1±42.5 vs 20.8±40.8, p&amp;lt;0.4), or length of hospital stay (18.7±13.3 vs 21.7±19.1, p&amp;lt;0.2). ISS score was significantly higher in non-blocked patients compared to blocked patients (27.4±14.3 vs 19.5±9.5, p&amp;lt;0.05). Conclusions Patients with significantly higher ISS scores did not receive a regional rib block, however this did not appear to impact on post-admission chest infection rate or length of stay. Further work is needed to identify the reasons behind this trend.

Bridging Old and New in Pain Medicine: An Historical Review.

Pain is both one of the oldest complaints known to medicine and a field for some of medicine's latest breakthroughs and innovations. Pharmacologic treatment of pain is one of the oldest remedies, and opioids have been used since ancient times as an effective pain reliever but with certain specific risks for abuse.Greater knowledge of opioids led to a more thorough understanding of the complexities of pain, which may have any number of mechanisms. A greater understanding of nerve fibers and pain signaling led to the development of more drugs and the more targeted delivery of analgesics using the hollow needle. The hollow needle changed pain treatment and led to percutaneous injections and what would later become interventional pain medicine with regional anesthesia and nerve blocks. Today, imaging can be combined with interventional techniques for more precise localization of nerves for diagnosis and treatment. The role of artificial intelligence in interventional pain medicine, especially in imaging for interventional procedures, remains unknown but will likely become extremely beneficial.

Managing intractable pain with neuraxial infusion at home.

A case study of a 9-year-old child with complex pain secondary to metastatic liver cancer, who eventually required intrathecal drug delivery (ITDD) of analgesia. Multi-modal symptom control strategies were deployed to achieve the child's and parental wishes for end-of-life care (EoLC) at home using ITDD. The following recommendations are made for nursing practice in paediatric palliative care (PPC); rigorous risk assessment, exemplary communication with the identification of a coordinating team, timely training needs assessment and the delivery of training from hospital based experts in ITDD practice, comprehensive symptom management plan and 24/7 access to specialist palliative care teams were essential for safe nursing practice. In this case, robust risk assessment and mitigations enabled challenges to be safely addressed with a successful outcome, extending the boundaries of PPC home care.