Improved Management of sickle cell pain crisis in a Pediatric Emergency Department through Use of Intranasal Fentanyl.
Article Sidebar
Downloads
Submit your own article
Register as an author to reserve your spot in the next issue of the Medical Research Archives.
Author RegistrationJoin the Society
The European Society of Medicine is more than a professional association. We are a community. Our members work in countries across the globe, yet are united by a common goal: to promote health and health equity, around the world.
Join Europe’s leading medical society and discover the many advantages of membership, including free article publication.
MembershipMain Article Content
Abstract
Introduction: National Heart, Lung, and Blood Institute recommends giving the first dose of opioids within 30 minutes of presentation to the emergency department for sickle cell disease patients with moderate to severe vaso-occlusive crisis. Intranasal fentanyl has been used extensively and shown to reduce time to the first dose of analgesic, improve pain scores at 20 minutes, and increase the odds of getting discharged from the emergency department.
Material and methods: For phase one of the project, baseline data was collected. The new pain algorithm was introduced at the start of the second phase, which involved giving intranasal fentanyl as the first analgesic for vaso-occlusive crisis in the emergency department. After the intervention, the second analysis compared outcomes with phase one. Wilcoxon-Mann-Whitney tests were used for comparing data between phase one and phase two and Wilcoxon signed-rank tests (paired version) were used for comparing pain scores before and after analgesic.
Results: Visits at phase two had significantly lower hospitalization rate [phase one 53.5% vs. phase two 34.2%(p value 0.005)], more fentanyl use [phase one 1.5% vs. phase two 50.6% (p< 0.001)], less patient-controlled-analgesia (PCA) opioid use after admission [phase one 13.0% vs. phase two 2.53% (p= 0.016)], higher compliance with outpatient visits [phase one 61.3% vs. phase two 98.7% (p < 0.001)], shorter length of hospital stay [phase one 117.6 ± 112.7 hours vs. phase two 68.3 ± 47.2 hours (p-value 0.01)], decrease in the time to first analgesic after coming to the emergency department (phase one 78.2 ± 131.2 minutes vs. phase two 38.3 ± 31.2 minutes (p 0.85)], and decrease in the mean pain score after first medication in the emergency department [phase one 5.48 ± 3.12 vs. phase two 4.46 ± 2.88 (p value 0.021)]
Conclusion: Intranasal fentanyl led to more effective and timely management of vaso-occlusive crisis with improvement in clinical outcomes compared to standard management.
Article Details
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
2. Glassberg JA. Improving Emergency Department-Based Care of Sickle Cell Pain. Hematology Am Soc Hematol Educ Program. 2017;2017(1):412-417. doi:10.1182/asheducation-2017.1.412
3. Daniel M. Fein et al. Intranasal Fentanyl for initial Treatment of a Vaso-Occlusive Crisis: A Randomized, Double-blind, Placebo controlled Trial. Pediatrics, September 2017,140 (1 Meeting Abstract) 11.
4. Smith WR. Treating pain in sickle cell disease with opioids: clinical advances, ethical pitfalls. J Law Med Ethics 2014;42(2):139”’46.
5. Ballas SK, Lusardi M. Hospital readmission for adult acute sickle cell painful episodes: frequency, etiology, and prognostic significance. Am J Hematol. 2005;79(1):17-25. 144.
6. Jacob E, Beyer JE, Miaskowski C, Savedra M, Treadwell M, Styles L. Are there phases to the vaso-occlusive painful episode in sickle cell disease? J Pain Symptom Manage. 2005;29(4):392-400. 145.
7. Smith WR, Penberthy LT, Bovbjerg VE, McClish DK, Roberts JD, Dahman B, et al. Daily assessment of pain in adults with sickle cell disease. Ann Intern Med. 2008;148(2):94-101.
8. Zempsky WT. Evaluation and Treatment of Sickle Cell Pain in the Emergency Department: Paths to a Better Future. Clin Pediatr Emerg Med. 2010;11(4):265-273.
9. Claudia R. Morris et al. Pediatric Emergency Department Use of Intranasal Fentanyl to Treat Pain in Children with Sickle Cell Disease and Its Impact on Discharge Rates: A Multicenter Perspective. Blood 2016; 128 (22): 1306.
10. Kavanagh PL, Sprinz PG, Wolfgang TL, et al. Improving the management of vaso-occlusive episodes in the pediatric emergency department. Pediatrics. 2015;136(4): e1016-e1025.
11. Brandow AM, Nimmer M, Simmons T, et al. Impact of emergency department care on outcomes of acute pain events in children with sickle cell disease. Am J Hematol. 2016;91(12):1175-1180.
12. Barrett, M.J., Cronin, J., Murphy, A. et al. Intranasal fentanyl versus intravenous morphine in the emergency department treatment of severe painful sickle cell crises in children: Study protocol for a randomised controlled trial. Trials 13, 74 (2012).
13. Tanabe P, Artz N, Mark Courtney D, et al. Adult emergency department patients with sickle cell pain crisis: a learning collaborative model to improve analgesic management. Acad Emerg Med. 2010;17(4):399-407.
14. Tanabe P, Hafner JW, Martinovich Z, Artz N. Adult emergency department patients with sickle cell pain crisis: results from a quality improvement learning collaborative model to improve analgesic management. Acad Emerg Med. 2012;19(4):430-438.
15. Yusuf HR, Atrash HK, Grosse SD, Parker CS, Grant AM: Emergency department visits made by patients with sickle cell disease: a descriptive study, 1999–2007. Am J Prev Med. 2010, 38: S536-541.
16. McClain BC, Kain ZN: Pediatric palliative care: a novel approach to children with sickle cell disease. Pediatrics. 2007, 119: 612-614.
17. Platt OS, Brambilla DJ, Rosse WF, Milner PF, Castro O, Steinberg MH, Klug PP: Mortality in sickle cell disease. Life expectancy and risk factors for early death. N Engl J Med. 1994, 330: 1639-1644.
18. Shapiro BS, Benjamin LJ, Payne R, Heidrich G: Sickle cell-related pain: perceptions of medical practitioners. J Pain Symptom Manage. 1997, 14: 168-174.
19. Kirsh KL, Whitcomb LA, Donaghy K, Passik SD: Abuse and addiction issues in medically ill patients with pain: attempts at clarification of terms and empirical study. Clin J Pain. 2002, 18: S52-60.
20. Solomon LR: Treatment and prevention of pain due to vaso-occlusive crises in adults with sickle cell disease: an educational void. Blood. 2008, 111: 997-1003.
21. Barrett, M.J., Cronin, J., Murphy, A. et al. Intranasal fentanyl versus intravenous morphine in the emergency department treatment of severe painful sickle cell crises in children: Study protocol for a randomised controlled trial. Trials 13, 74 (2012).
22. Daniel M. Fein, Kathryn Scharbach, Deepa Manwani, Jeffrey R. Avner, Hnin Khine; Intranasal Fentanyl for Initial Treatment of a Vaso-Occlusive Crisis: A Randomized, Double-Blind, Placebo Controlled Trial. Pediatrics September 2017; 140 (1_MeetingAbstract): 11. 10.1542/peds.140.1MA.11
23. Paquin H, Trottier ED, Pastore Y, Robitaille N, Dore Bergeron MJ, Bailey B. Evaluation of a clinical protocol using intranasal fentanyl for treatment of vaso-occlusive crisis in sickle cell patients in the emergency department. Paediatr Child Health. 2020 Aug;25(5):293-299. Epub 2019 Mar 7.
24. Rees, CA, Brousseau, DC, Ahmad, FA, et al. Intranasal fentanyl and discharge from the emergency department among children with sickle cell disease and vaso-occlusive pain: A multicenter pediatric emergency medicine perspective. Am J Hematol. 2023; 98 (4): 620- 627.
25. Mathias MD, McCavit TL. Timing of opioid administration as a quality indicator for pain crises in sickle cell disease. Pediatrics. 2015; 135:475-482.
26. Michelson KA, Bachur RG, Levy JA. The impact of critically ill children on paediatric ED medication timeliness. Emerg Med J. 2017; 34:8-12.22.
27. Shenoi R, Ma L, Syblik D, Yusuf S. Emergency department crowdingand analgesic delay in pediatric sickle cell pain crises. Pediatr EmergCare. 2011; 27:911-917
28. Rees CA, Brousseau DC, Fahd A, et al. Adherence to NHLBI guidelines for the emergent management of vaso-occlusive episodes in children with sickle cell disease: a multicenter perspective. Am J Hematol. 2022; 97: E412-E415.
29. National Heart Lung, and Blood Institute. Evidence-Based Management of Sickle Cell Disease: Expert Panel Report, 2014. Accessed July 23, 2021. https://www.nhlbi.nih.gov/health-topics/all-publications-and-resources/evidence-based-management-sickle-cell-disease-expert-0.
30. Brandow AM, Carroll CP, Creary S, et al. American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain. Blood Adv. 2020; 4:2656-2701.
31. American College of Emergency Physicians. Managing Sickle Cell Disease in the ED. 2021. Accessed September 26, 2022. https://www.acep.org/patient-care/sickle-cell/.
32. Wolfe TR, Braude DA: Intranasal medication delivery for children: a brief review and update. Pediatrics. 2010, 126: 532-537. 10.1542/peds.2010-0616.
33. Andrews C: P-R: Fentanyl: a review. Clin Anaesthesiol. 1983, 1: 97-122.
34. Fowler M, Ali S, Gouin S, et al. Knowledge, attitudes and practices of Canadian pediatric emergency physicians regarding short-term opioid use: a descriptive, cross-sectional survey. Can Med Assoc Open Access. 2020; 8(1): E148-E15.