Introduction: The literature on analgesia post intestinal transplant (IT) is limited though clinical experience suggests that patients with paediatric intestinal pseudo-obstruction (PIPO) may require a different approach to pain management than those with other diagnoses. The aim was to compare the required pain management of children with and without PIPO.

Methods: An electronic case notes review of 20 patients who received IT in a single centre between 2009 and 2018. Patients were divided into two groups according to the underlying diagnosis of PIPO. Pain management from extubation to day 14 post IT was reviewed. Standard analgesia was regular intravenous (IV) paracetamol and morphine, either nurse or patient controlled according to age/ability.

Results: In the PIPO group 7 patients (4 male) underwent isolated IT (2), combined liver- IT (2), multivisceral transplant (3). In the non-PIPO group 13 patients (6 male) underwent isolated IT (6), combined liver-IT (4) or multivisceral IT (3). Diagnoses in the non - PIPO group were Mitchel-Riley syndrome (1), necrotizing enterocolitis (1), TTC7A deficiency (1), gastroschisis (3), long segment Hirschsprung’s (1), intestinal lymphangiectasia (1), antenatal volvulus and biliary atresia (1), microvillus inclusion disease (1), progressive familial intrahepatic cholestasis (1), intestinal ischaemia (2).

Median age (range) in the PIPO group was 7 years (1-16) and in the non-PIPO group 5 years (1-13).

71% of patients in the PIPO group had a pre-IT history of chronic pain (compared to 0 in the non- PIPO group) with 29% of patients on regular medications- gabapentin or pregablin and amitriptyline. These patients required increased and prolonged analgesia post-operatively.

43% of patients in the PIPO group and 15% in the non-PIPO group required escalation of pain management from standard medications to a more complex multi-modal approach. Escalation included IV buscopan, clonidine and fentanyl, with the addition of ketamine in the PIPO group. In all cases escalation of analgesia was planned by the specialist paediatric pain team in conjunction with the multi-disciplinary transplant team.

Conclusion: Patients with PIPO and those with a pre-transplant chronic pain management plan are more likely to require escalation of analgesia post IT. Access to a specialist pain management team may be helpful in these patients. A multi -centre study is required to help identify optimal pain management strategies for all IT patients.