J. E. Dalton, E. Walton, R. Newton

UH Sussex NHS Foundation Trust, Brighton, UK

Intraoperative intravenous paracetamol (IVP) has become the standard route of administration in our paediatric theatres due to its pharmacology and ease of delivery. This poses a significant cost and environmental burden. Best available evidence shows that the efficacy of oral paracetamol is broadly equivalent to the IV route [1]. IVP is associated with greater lifecycle carbon dioxide equivalent emissions (eCO2) when compared with equivalent doses of tablet and oral liquid formulations (12-fold and 4-fold respectively) [2].

The operating departments in University Hospitals Sussex used 90,930g of IVP in 2020-2021 costing £100,000. Oral liquid paracetamol is 50% and tablets are 1% of the cost of IVP. Shortages of IVP in recent months has put strain on use. We aim to encourage the use of an oral paracetamol premed (‘para-premed’) thirty minutes pre-operatively for appropriate paediatric cases.

The PDSA method was used to implement and assess change:

  1. Education: formal and informal for anaesthetists and nursing teams in the day case ward and theatres.
  2. Prompting: posters on the ward and in anaesthetic rooms with stickers on the front of drug charts prompting anaesthetists to prescribe oral paracetamol.
  3. Communication: regular formal (surveys) and informal dialogue with anaesthetists and ward staff to identify challenges and ideas.
  4. Audit: to measure change.

After ‘para-premed’ implementation the initial audit captured 137 children. Oral paracetamol was prescribed in 50.4% cases and accepted by the child in 98%. Frequent reasons for not prescribing were prioritisation of anxiolytic premedication, lack of time to administer or unavailable weight. Children undergoing laparoscopic surgery had higher pain scores than expected, and it was hypothesised that this could be due to fewer children receiving intraoperative NSAIDs (often co-administered with IVP).

The second audit captured 53 children. Oral paracetamol was prescribed in 64% of cases and all children accepted the dose. There appeared to be no association in this sample between laparoscopic cases and increased pain scores. There were no concerns from the nursing staff or anaesthetists about safety or efficacy during this audit period.

Procurement records demonstrated an average 22% reduction in procurement of IVP to theatres with an associated increase in procurement of liquid oral paracetamol after the PDSA interventions.  Should this be sustained we expect this to generate a saving of £2500 and 345kg eCO2 per year.

We have challenged the myth of IVP being superior to oral paracetamol and demonstrated scalable financial and carbon savings. There is more progress to be made away from IVP use whilst accepting that there will always be some cases where this is appropriate. Success relies on engagement of all team members. We will aim to introduce this to our adult services.


  1. Mallama et al. A systematic review and trial sequential analysis of intravenous vs. oral peri-operative paracetamol.  Anaesthesia.  2021, 76. pp270-276
  2. Davies et al. Environmental and financial impacts of perioperative paracetamol use: a multicentre international life-cycle analysis.  BJA.  30 Jan 2024.  URL: https://www.bjanaesthesia.org/article/S0007-0912(23)00725-0/fulltext Accessed online 8.2.24
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