Introduction: Nalbuphine has a well-documented use for managing moderate postoperative pain. It exhibits minimal serious opioid-related side-effects and undergoes hepatic metabolism to conjugates considered pharmacologically inactive. Nalbuphine’s pharmacokinetic profile in patients with renal insufficiency is possibly not significantly altered, and no nephrotoxicity has been reported.
Method: Through the Pediatric Renal Transplantation Program at ‘LAIKO’ Hospital, Athens, Greece, 23 children (age: 13.65 ±2.08 years weight: 44.21 ±13.93 kg) underwent renal transplantation. General anesthesia with desflurane (0.7 - 1.0 MAC) and fentanyl (2 - 4 mcg/kg IV) was used for the operation (duration: 235 ±24 min). Approximately 25 min before extubation, nalbuphine 0.1 mg/kg IV and paracetamol 15 mg/kg (max. 1 g) IV were administered, and local infiltration (ropivacaine 2 mg/kg) of the surgical site was performed. After extubation and during the next hour, additional nalbuphine (0 - 0.3 mg/kg IV) was administered as deemed necessary. During the hospitalization period, analgesia included paracetamol (10 - 15 mg/kg IV TID) and, if the Numerical Rating Scale [NRS] score was >4, nalbuphine (0.1 - 0.2 mg/kg IV every 6h PRN).
Results: NRS scores and total dose of IV nalbuphine given at the end of the first postoperative hour were 3.26 ±1.05 and 0.23 ±0.07 mg/kg respectively, and at the end of the first postoperative day 2.05 ±0.65 and 0.31 ±0.11 mg/kg respectively. No patient required nalbuphine afterwards. Excluding episodes of mild desaturation in one patient with a known history of obstructive sleep apnea, no adverse reactions were observed.
Discussion: This is the first report of nalbuphine analgesia on children undergoing renal transplantation. Its favorable properties, patient monitoring and NRS scores enabled safe and adequate first-day postoperative pain control.

References
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Vincent Launay-Vacher, Svetlana Karie, Jean-Baptiste Fau, Hassane Izzedine, Gilbert Deray. Treatment of Pain in Patients With Renal Insufficiency: The World Health Organization Three-Step Ladder Adapted. The Journal of Pain, Vol 6, No 3, 2005: pp 137-148