scholarly journals Evaluation of Vaso-occlusive Crisis Management With Patient-Controlled Analgesia in Children With Sickle Cell Disease Requiring Hospitalization

2021 ◽  
Vol 26 (6) ◽  
pp. 615-623
Author(s):  
Claire Arbitre ◽  
Yves Pastore ◽  
Benoit Bailey ◽  
Niina Kleiber ◽  
Nancy Robitaille ◽  
...  
Keyword(s):  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Pediatric Patients ◽  
Acute Chest Syndrome ◽  
Cell Disease ◽  
Patient Controlled Analgesia ◽  
Pain Scores ◽  
A Prospective Study ◽  
Reduced Time ◽  
Median Pain

OBJECTIVE The aim of this study was to review the use of patient-controlled analgesia (PCA) in sickle cell disease (SCD) for pediatric patients with vaso-occlusive crisis (VOC) in our institution and to compare the effect of early vs late PCA start on pain relief and LOS. METHODS This retrospective study included all pediatric patients treated with PCA for a severe VOC from 2010 to 2016. “Early-PCA” was defined as start of PCA within 48 hours of arrival. Time to reach adequate analgesia was defined as the time to reach 2 consecutive pain scores less than 5/10 at 4-hour interval. RESULTS During the study period, 46 patients presented 87 episodes of VOC treated with PCA. Sixty-three patients with VOC were treated with Early-PCA and 24 with Late-PCA. Both groups were comparable except for median pain score at admission; the Early-PCA group had higher scores: 9.0/10 vs 7.0/10. Time to reach adequate analgesia could be evaluated only in a subset of patients (n = 32) but was shorter in the Early-PCA group with a median difference of 41.0 hours (95% CI −82.0 to −6.0). Early-PCA was associated with a median reduction in LOS of 3.4 days (95% CI −4.9 to −1.9). There was no difference between the 2 groups in terms of side effects and occurrence of acute chest syndrome during hospitalization. CONCLUSIONS In this study, a reduced time to reach adequate analgesia and LOS was noted in the Early-PCA group for severe VOC. A prospective study is required to confirm these results.

Accuracy of Point-of-care Lung Ultrasonography for Diagnosis of Acute Chest Syndrome in Pediatric Patients with Sickle Cell Disease and Fever

2016 ◽  
Vol 23 (8) ◽  
pp. 932-940 ◽  
Author(s):  
Dina D. Daswani ◽  
Vaishali P. Shah ◽  
Jeffrey R. Avner ◽  
Deepa G. Manwani ◽  
Jessica Kurian ◽  
...  
Keyword(s):  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Pediatric Patients ◽  
Point Of Care ◽  
Acute Chest Syndrome ◽  
Lung Ultrasonography ◽  
Cell Disease

Implementation of a Pediatric Observation Unit for Children with Sickle Cell Disease

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 4838-4838
Author(s):  
Sophia Sharifali ◽  
Lashon Sturgis ◽  
Cindy Neunert ◽  
Natalie Lane ◽  
Robert Gibson ◽  
...  
Keyword(s):  
Sickle Cell Disease ◽  
Sample Size ◽  
Sickle Cell ◽  
Pediatric Patients ◽  
Acute Chest Syndrome ◽  
Care Hospital ◽  
Cell Disease ◽  
Observation Unit ◽  
Exclusion Criteria ◽  
Direct Admission

Abstract Acute vaso-occlusive crisis (VOC), the most common manifestation of Sickle Cell Disease (SCD), is the number one cause for visits to the Emergency Department (ED). Pediatric patients differ from adult patients with SCD due to variations in opioid tolerance and age-specific complications. Many pediatric patients can be sent home after evaluation and treatment in an ED, however, others will need hospitalization for further pain management as well as continued evaluation. Observation Units (OUs), ED-associated units for evaluation and protocol management of short-term conditions (<24 hours), have successfully provided more rapid care while still maintaining quality. At our institution, using an OU-based protocol, we have demonstrated improved care with decreased resource utilization in an adult population with SCD experiencing VOC. However, there is limited data for the use of OU in pediatric patients with VOC. Our objective was to determine the feasibility of a pediatric OU for the evaluation and treatment of patients with uncomplicated VOC. A retrospective, descriptive chart review study was conducted on all pediatric patients (<18 years) with SCD between July 1, 2012 to June 30, 2013. The study was conducted in an academic pediatric tertiary care hospital (annual volume 27k/year). A medical record search was conducted using ICD-9 codes and SCD related DRG codes. The cohort was then limited to patients who received care in the academic ED or were transferred from another hospital for direct admission (DA). The cohort was limited to visits with pain related to VOC. Patients with a complication other than VOC were excluded as well as patients admitted to the intensive care unit. Cohort data as well as exclusion criteria are in table 1. Visits that were admitted to the floor (either as a direct admission or admitted from the ED) with a length of stay (LOS) less than 48 hours were included in the analysis. Patients were grouped into categories based on LOS: < 24 hours, <36 hours, and <48 hours Though the OU will only manage up to 24 hours, categories of LOS longer than 24 hours were included in order to capture elements that may lengthen a patients stay such as waiting time, time until disposition and discharge. Table 1. Sample Size and Exclusion Criteria # of Patients treated for Sickle Cell Between 7/1/2012 - 6/30,2012 197 patients Limiting to patients seen in ED or having a DA 119 patients Limiting to confirmed diagnosis of SCD (multiple genotypes) = 6 113 patients Limiting to reason of visit to a pain complaint = 6 107 patients Limiting to reason of pain to VOC = 3 104 patients Limited or no data in EMR (left prior to treatment) = 3 101 patients Exclusion of patients with visits only for complications of SCD* = 21 80 patients Final Sample Size for analysis 80 patients *Complications include acute chest syndrome, sepsis, splenic sequestration, fever, infiltrates, and infection 80 patients had 160 visits for uncomplicated VOC from 7/1/2012 - 6/30/2012. Of the 160 visits, the patient was admitted53.8% (86) of the time. Of the 86 visits resulting in admission, 30 (34.9%) were DA and 56 (65.1%) were admitted from the academic ED. LOS of the admission by DA or from the academic ED is in table 2. Table 2. LOS for Admissions DA to Floor 30 total visits LOS < 24 Hours 5 (16.6%) visits LOS < 36 Hours 10 (33.3%) visits LOS < 48 Hours 17 (56.7%) visits ED to Floor 56 total visits LOS < 24 Hours 4 (7.1%) visits LOS < 36 Hours 10 (17.9%) visits LOS < 48 Hours 21 (37.5%) visits OU's are ideal for the evaluation and management of patients requiring more than a few hours of ED treatment but less than 24 hours of hospital therapy. Our study shows that there is a large number of patients with SCD and VOC are admitted (53.8%). Based on our study, 44% of admissions have a LOS less than 48 hours. We believe that 48 hours is a reasonable cutoff for consideration of OU care as disposition decisions on the floor occur at 12-hour and sometimes 24-hour intervals leading to an increase in LOS beyond the actual treatment time. All patients, including DA patients, should be eligible for OU treatment if they meet inclusion criteria. This is evidenced by the finding that the LOS is shorter for DA patients (56.7%) versus admissions from the academic ED (37.5%). Overall, pediatric SCD patients would benefit from the presence of a pediatric OU by potentially decreasing the rate of inpatient admissions. An observation unit should therefore be strongly considered in centers with large volume SCD. Disclosures No relevant conflicts of interest to declare.

scholarly journals Patient Controlled Analgesia for Adults with Sickle Cell Disease Awaiting Admission from the Emergency Department

2016 ◽  
Vol 2016 ◽  
pp. 1-5 ◽  
Author(s):  
Josue Santos ◽  
Sasia Jones ◽  
Daniel Wakefield ◽  
James Grady ◽  
Biree Andemariam
Keyword(s):  
Emergency Department ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Treatment Algorithm ◽  
Retrospective Chart Review ◽  
Cell Disease ◽  
Patient Controlled Analgesia ◽  
Analgesic Treatment ◽  
Pain Scores ◽  
Ed Visits

Background.A treatment algorithm for sickle cell disease (SCD) pain in adults presenting to a single emergency department (ED) was developed prioritizing initiation of patient controlled analgesia (PCA) for patients awaiting hospitalization.Objectives.Evaluate the proportion of ED visits in which PCA was started in the ED.Methods.A two-year retrospective chart review of consecutive SCD pain ED visits was undertaken. Data abstracted included PCA initiation, low versus high utilizer status, pain scores, bolus opioid number, treatment times, and length of hospitalization.Results.258 visits resulted in hospitalization. PCA was initiated in 230 (89%) visits of which 157 (68%) were initiated in the ED. Time to PCA initiation was longer when PCA was begun after hospitalization versus in the ED (8.6 versus 4.5 hours,p<0.001). ED PCA initiation was associated with fewer opioid boluses following decision to admit and less time without analgesic treatment (allp<0.05). Mean pain intensity (MPI) reduction did not differ between groups. Among visits where PCA was begun in the ED, low utilizers demonstrated greater MPI reduction than high utilizers (2.8 versus 2.0,p=0.04).Conclusions.ED PCA initiation for SCD-related pain is possible and associated with more timely analgesic delivery.

Safety and Efficacy of Adjuvant Low-Dose Ketamine Therapy for Patients with Sickle Cell Disease

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 3226-3226 ◽  
Author(s):  
Caitlin M. Neri ◽  
Sophie Pestieau ◽  
Heather Young ◽  
Angelo Elmi ◽  
Deepika S. Darbari
Keyword(s):  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Pain Control ◽  
Low Dose ◽  
Red Blood Cell Transfusion ◽  
Bivariate Analysis ◽  
Acute Chest Syndrome ◽  
Cell Disease ◽  
Ketamine Infusion ◽  
Pain Scores

Abstract Abstract 3226 Background/Objectives: Opioids are the mainstay of therapy for painful vasoocclusive crises (VOCs) in sickle cell disease (SCD). For some patients, opioid-induced hyperalgesia caused by activation of N-methyl-D-aspartate (NMDA) receptors has been considered to contribute to poor analgesia. Ketamine, an NMDA receptor antagonist, could be a useful adjunct therapy; however safety concerns remain with its use. We examined records of SCD patients at our institution who received ketamine as an adjuvant to opioids at the discretion of anesthesia pain services over the past 4 years. We sought to explore the safety of ketamine and determine its effect on daily opioid requirement in SCD patients hospitalized for VOCs. Methods: The Institutional Review Board at Children's National Medical Center approved this study. A retrospective case-crossover study was conducted through review of the electronic medical record. For each patient we selected 2-paired hospitalizations occurring within 2 years of each other. One hospitalization where the patient received low-dose ketamine infusion in addition to opioid patient controlled analgesia (PCA), and a second hospitalization where the same patient received opioid PCA alone. We compared clinical characteristics of hospitalizations where patients did or did not receive ketamine. Exploratory bivariate analysis (paired t-test and McNemar's test) was used to compare variables between the pairs. Results: Thirty-three patients were identified to have at least 2 hospitalizations for VOC within 20 months of each other where they received adjuvant ketamine infusion during one, while not during the other. Average age was 15.6 ± 3.4 years, 67 % were females, and 36 % were on hydroxyurea therapy. SCD genotypes included homozygous SS 70%, SC 24 %, S-beta-zero thalassemia 3%, and S-beta-plus thalassemia 3%. Mean number of admissions in the 6 months prior to the ketamine hospitalization was 2 (range 0–5) and 64 % had ≥ 2 prior admissions within 6 months. Ketamine dose was 0.1 mg/kg/h for all patients except one who briefly received 0.15 mg/kg/hr. During the ketamine and opioid PCA hospitalization patients reported overall higher pain scores (6.53 vs. 5.94 out of 10; p = 0.0356), required higher doses of opioid (0.0395 mg/kg/hr vs. 0.0323 mg/kg/hr; p = 0.0038), and had a longer length of stay (LOS) (5.6 vs. 4.4 days; p =0.0148) as compared to the PCA alone hospitalization. Patients were more likely to have a diagnosis of acute chest syndrome (ACS) at some point during the ketamine and opioid PCA hospitalization (42% vs. 15 %; p = 0.0126) as compared to the opioid PCA alone hospitalization. Patients were more likely to be treated with additional adjuvant pain control agents (diazepam, lorazepam, gabapentin, pregabalin, amitripyline, or duloxetine) during the ketamine and opioid PCA admission as compared with opioid PCA alone admissions (45% vs. 9% p = 0.0013). Rates of red blood cell transfusion and ICU transfer were not different between the hospitalizations. In 3 patients ketamine was discontinued due to vivid dreams delusions, or dizziness. Nausea, pruritis, sedation, and use of complementary therapies were similar between hospitalizations. Conclusions: We did not observe an opioid sparing effect of ketamine infusion as hypothesized in this group of frequently hospitalized patients. Low-dose ketamine is a safe adjuvant medication for SCD patients hospitalized for VOCs. Higher opioid use during ketamine and opioid PCA admissions is likely due to patients experiencing more severe VOCs as indicated by higher pain scores involving multiple sites, higher rates of ACS, and longer LOS. These severity measures may have contributed to the decision of the pain medicine service to add low-dose ketamine infusion to standard opioid PCA in this retrospective sample. Finally, VOCs in this group of frequently admitted individuals may represent chronic pain which is known to be minimally responsive to most pharmacologic therapies. Patients receiving ketamine appear to be using additional adjuvant pain agents and may be underutilizing hydroxyurea. Prospective randomized studies of adjuvant ketamine therapy in patients with SCD are warranted to determine true efficacy. Disclosures: Off Label Use: Ketamine is a non-barbiturate phencyclidine derivative that is approved for use as a surgical anesthetic. It is not approved for use in pain management, however is commonly used in low-doses as an adjunct to traditional pain control therapies.

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