CLINICAL
AND
LABORATORY OBSERVATIONS
Management of Refractory Pain in Hospitalized Adolescents With Sickle Cell Disease: Changing From Intravenous Opioids to Continuous Infusion Epidural Analgesia Tamara New, MD,*w Claudia Venable, MD,*w Laura Fraser, MSN, CPNP,*w Erin Rosenberg, MD,*w Jennifer Schmidt, PhD,w Anne James-Herry, MD,*w Ifeyinwa Osunkwo, MD, MPH,*w and Carlton Dampier, MD*w
Background: Prolonged hospitalizations for sickle cell disease painful episodes are not uncommon, as analgesic options are often suboptimal. Observations: Seven patients (15.4 ± 3.7 y, 6 females) were treated with epidural analgesia for refractory pain. The median duration of epidural catheter placement was 4 days (interquartile range, 3 to 6 d). Mean pain scores changed from 6.8 ± 2.7 to 4.8 ± 2.2, whereas mean daily parenteral opioid requirements changed from 79.7 ± 100.4 to 13.0 ± 13.1 mg of morphine equivalents. Conclusion: Continuous epidural analgesia is an alternative to continuing intravenous opioids in sickle cell disease patients with refractory pain, and may reduce opioid-related side effects and facilitate transition to oral analgesics. Key Words: sickle cell disease, pain, epidural analgesia
(J Pediatr Hematol Oncol 2014;36:e398–e402)
A
dolescent patients with sickle cell disease (SCD) and acute painful episodes (vasoocclusive crises) are typically admitted to inpatient hospital settings for management of severe pain.1 Institutional protocols generally dictate pain management approaches with parenteral opioids and nonsteroidal anti-inflammatory analgesics given in the emergency department (ED) settings, followed by hospital admission if pain does not rapidly resolve. The typical inpatient continues intravenous (IV) medications, and in many settings will receive a patient-controlled analgesia (PCA) device, with or without a continuous rate infusion.2 Reflecting average length of stays for painful episodes of 3 to 4 days from national databases,3 most children with SCD have improved pain control after 24 to 72 hours, and are transitioned to oral analgesics and home therapy.2 There are limited therapeutic options, however, for patients who have continued or escalating pain while on substantial opioid doses, as there is little evidence-based practice for additional analgesics or adjuvant medications. Switching to alternative opioids, or continuing to escalate
Received for publication December 19, 2012; accepted August 20, 2013. From the *Emory University School of Medicine; and wChildren’s Healthcare of Atlanta, Atlanta, GA. C.D. has received honoraria from Glycomimetics Inc. as Chair of their Phase II trial DSMB. The remaining authors declare no conflict of interest. Reprints: Tamara New, MD, Children’s Healthcare of Atlanta, 1001 Johnson Ferry Rd. NE, Atlanta, GA 30342 (e-mail: tamara.new@ choa.org). Copyright r 2013 by Lippincott Williams & Wilkins
e398 | www.jpho-online.com
opioid doses are the usual practice options with increasing risk of adverse effects as patients becoming more sedated. Some patients may experience subsequent respiratory depression that contributes to hypoxia and development of further pain, or pulmonary complications such as acute chest syndrome. Unfortunately, excessive sedation also prevents use of important efficacious nonpharmacologic pain treatment such as cognitive-behavioral and physical therapies.4 Analgesics delivered by the epidural route have been used commonly in the management of postoperative pain in children and adolescents,5 and have a number of benefits: superior pain control, little to no sedation, and minimal respiratory depression. Opioids, with or without local anesthetics, are given using an epidural catheter that can be placed either under sedation in a minor procedure room, or depending on the monitoring capability, in a procedure room on the floor. A number of previous case reports and small case series have described the use of epidural analgesia during painful episodes,6–9 however, this technique has not been widely adopted in this setting. We present our clinical experience in 7 of our sickle cell patients who received epidural analgesia for persistent refractory pain. We suggest epidural analgesia as an alternative therapeutic option for patients with refractory pain and problematic opioid-related adverse effects from IV opioid therapy, which we believe represents a clinical situation with a more acceptable clinical risk/benefit for this procedure.
METHODS Clinical Management and Patient Selection Patients with SCD are generally admitted through our ED. According to our institutional policy, SCD patients who continue to report pain >5/10 following 2 doses of an IV opioid analgesic and 1 dose of IV NSAID are admitted for further pain management. Patients who have inadequate pain relief with scheduled opioid every 2 to 3 hours, who are older than 5 years, and have adequate cognitive abilities, are placed on a PCA pump. When patients consistently rate their pain as >7/10 after at least 48 to 72 hours of adequately dosed IV opioids, the clinical team will either change the patient to an alternate opioid (if one had not been previously tried) or refer the patient to the pain team for further pain management. Patients who continue to have escalating pain despite increasing opioid doses and/ or increased undesired opioid side effects are considered for epidural analgesia. This alternative strategy for achieving analgesia with using an epidural catheter is presented to the
J Pediatr Hematol Oncol
Volume 36, Number 6, August 2014
J Pediatr Hematol Oncol
Volume 36, Number 6, August 2014
patient and family by the pain service. Risks of the procedure are discussed with patients and their guardian by the attending anesthesiologist and included risk of infection, bleeding, and headache. Patients with fever, severe hypoxia (oxygen saturations
AND
LABORATORY OBSERVATIONS
Management of Refractory Pain in Hospitalized Adolescents With Sickle Cell Disease: Changing From Intravenous Opioids to Continuous Infusion Epidural Analgesia Tamara New, MD,*w Claudia Venable, MD,*w Laura Fraser, MSN, CPNP,*w Erin Rosenberg, MD,*w Jennifer Schmidt, PhD,w Anne James-Herry, MD,*w Ifeyinwa Osunkwo, MD, MPH,*w and Carlton Dampier, MD*w
Background: Prolonged hospitalizations for sickle cell disease painful episodes are not uncommon, as analgesic options are often suboptimal. Observations: Seven patients (15.4 ± 3.7 y, 6 females) were treated with epidural analgesia for refractory pain. The median duration of epidural catheter placement was 4 days (interquartile range, 3 to 6 d). Mean pain scores changed from 6.8 ± 2.7 to 4.8 ± 2.2, whereas mean daily parenteral opioid requirements changed from 79.7 ± 100.4 to 13.0 ± 13.1 mg of morphine equivalents. Conclusion: Continuous epidural analgesia is an alternative to continuing intravenous opioids in sickle cell disease patients with refractory pain, and may reduce opioid-related side effects and facilitate transition to oral analgesics. Key Words: sickle cell disease, pain, epidural analgesia
(J Pediatr Hematol Oncol 2014;36:e398–e402)
A
dolescent patients with sickle cell disease (SCD) and acute painful episodes (vasoocclusive crises) are typically admitted to inpatient hospital settings for management of severe pain.1 Institutional protocols generally dictate pain management approaches with parenteral opioids and nonsteroidal anti-inflammatory analgesics given in the emergency department (ED) settings, followed by hospital admission if pain does not rapidly resolve. The typical inpatient continues intravenous (IV) medications, and in many settings will receive a patient-controlled analgesia (PCA) device, with or without a continuous rate infusion.2 Reflecting average length of stays for painful episodes of 3 to 4 days from national databases,3 most children with SCD have improved pain control after 24 to 72 hours, and are transitioned to oral analgesics and home therapy.2 There are limited therapeutic options, however, for patients who have continued or escalating pain while on substantial opioid doses, as there is little evidence-based practice for additional analgesics or adjuvant medications. Switching to alternative opioids, or continuing to escalate
Received for publication December 19, 2012; accepted August 20, 2013. From the *Emory University School of Medicine; and wChildren’s Healthcare of Atlanta, Atlanta, GA. C.D. has received honoraria from Glycomimetics Inc. as Chair of their Phase II trial DSMB. The remaining authors declare no conflict of interest. Reprints: Tamara New, MD, Children’s Healthcare of Atlanta, 1001 Johnson Ferry Rd. NE, Atlanta, GA 30342 (e-mail: tamara.new@ choa.org). Copyright r 2013 by Lippincott Williams & Wilkins
e398 | www.jpho-online.com
opioid doses are the usual practice options with increasing risk of adverse effects as patients becoming more sedated. Some patients may experience subsequent respiratory depression that contributes to hypoxia and development of further pain, or pulmonary complications such as acute chest syndrome. Unfortunately, excessive sedation also prevents use of important efficacious nonpharmacologic pain treatment such as cognitive-behavioral and physical therapies.4 Analgesics delivered by the epidural route have been used commonly in the management of postoperative pain in children and adolescents,5 and have a number of benefits: superior pain control, little to no sedation, and minimal respiratory depression. Opioids, with or without local anesthetics, are given using an epidural catheter that can be placed either under sedation in a minor procedure room, or depending on the monitoring capability, in a procedure room on the floor. A number of previous case reports and small case series have described the use of epidural analgesia during painful episodes,6–9 however, this technique has not been widely adopted in this setting. We present our clinical experience in 7 of our sickle cell patients who received epidural analgesia for persistent refractory pain. We suggest epidural analgesia as an alternative therapeutic option for patients with refractory pain and problematic opioid-related adverse effects from IV opioid therapy, which we believe represents a clinical situation with a more acceptable clinical risk/benefit for this procedure.
METHODS Clinical Management and Patient Selection Patients with SCD are generally admitted through our ED. According to our institutional policy, SCD patients who continue to report pain >5/10 following 2 doses of an IV opioid analgesic and 1 dose of IV NSAID are admitted for further pain management. Patients who have inadequate pain relief with scheduled opioid every 2 to 3 hours, who are older than 5 years, and have adequate cognitive abilities, are placed on a PCA pump. When patients consistently rate their pain as >7/10 after at least 48 to 72 hours of adequately dosed IV opioids, the clinical team will either change the patient to an alternate opioid (if one had not been previously tried) or refer the patient to the pain team for further pain management. Patients who continue to have escalating pain despite increasing opioid doses and/ or increased undesired opioid side effects are considered for epidural analgesia. This alternative strategy for achieving analgesia with using an epidural catheter is presented to the
J Pediatr Hematol Oncol
Volume 36, Number 6, August 2014
J Pediatr Hematol Oncol
Volume 36, Number 6, August 2014
patient and family by the pain service. Risks of the procedure are discussed with patients and their guardian by the attending anesthesiologist and included risk of infection, bleeding, and headache. Patients with fever, severe hypoxia (oxygen saturations
