Management of Acute Pain in SC patients

[HunterGatherer]

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How is acute pain managed in the sickle cell patient on an out patient basis? I'm talking about a patient being followed by a primary care physician and has documented history of SC and SC complications not someone walking into an ER with undocumented history or PC care. I'm imagining large doses of NSAIDS in acute episodes would be dangerous due to increased renal complications in this pt population. What are the alternatives? Thanks.

 

[Tenesma]

when i was at boston children's (during fellowship) it amazed me how many SC kids would come into the ER (routinely) and all would get treated with a demerol PCA - only to have a bunch of older SCers (early twenties) then coming in hooked on demerol....

treatment: Oxygen, Nsaids, Opioids, treat underlying infection (if there is one) or whatever else is stressing their body, ice/heat over their painful joints... make sure it isn't a crisis...

 

[lobelsteve]

when i was at boston children's (during fellowship) it amazed me how many SC kids would come into the ER (routinely) and all would get treated with a demerol PCA - only to have a bunch of older SCers (early twenties) then coming in hooked on demerol....

treatment: Oxygen, Nsaids, Opioids, treat underlying infection (if there is one) or whatever else is stressing their body, ice/heat over their painful joints... make sure it isn't a crisis...

Hydration.

From Emedicine:

Medical Care
Probably no other disease in existence has as much scientific information and knowledge available as SCD. The genetics, pathophysiology, and molecular biology of SCD are well established. Even so, no safe, effective, and curative therapy is available. The goals of treatment strategies are symptom control and management of disease complications. Treatment strategies include the following 7 goals: (1) management of vasoocclusive crisis, (2) management of chronic pain syndromes, (3) management of the chronic hemolytic anemia, (4) prevention and treatment of infections, (5) management of the complications and the various organ damage syndromes associated with the disease, (6) prevention of stroke, and (7) detection and treatment of pulmonary hypertension.


Vasoocclusive crisis is treated with vigorous hydration and analgesics.

Intravenous fluids should be of sufficient quantity to correct dehydration and to replace continuing loss, both insensible and due to fever.

Normal saline and 5% dextrose in saline may be used.

These fluids should be given intravenously, and treatment must be in an inpatient setting.

Pain control is best achieved by the administration of opioids.

Morphine is the drug of choice. Morphine dosing has to be individualized (vide infra).

It should be given intravenously, hourly at first. Once the effective dose is established, it should be administered every 3 hours via the intravenous regimen.

After 24-48 hours, as pain is controlled, equivalent doses of sustained-release oral morphine should be given.

When marked improvement occurs, the patient may be discharged home on sustained-release oral morphine, and the dose is reduced gradually over several days.

Morphine elixir can be used to control breakthrough pain.

Chronic pain is managed with long-acting oral morphine preparations and acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs).

NSAIDs are particularly effective in reducing deep bone pain. Many patients may require breakthrough oral opiates as well. The weak agents, codeine and hydrocodone, are used first. Sustained-release long-acting oral morphine is reserved for more severe cases.

The addition of tricyclic antidepressants may reduce the dose and need for opiates by interfering with pain perception. Many patients with chronic pain are depressed, and lifting the depression has a salutary effect on the pain.

Hydromorphone may be used but is considerably more expensive.

Meperidine should be avoided.

Nonpharmacological approaches to pain management are very important.

These include physical therapy, heat and cold application, acupuncture and acupressure, hypnosis, and transcutaneous electric nerve stimulation (TENS).

Support groups are also useful.

All of these modalities may have a substantial impact on pain reduction.

The authors suggest acupuncture and/or acupressure as treatment modalities. Obviously they are throwing in a kitchen sink mentality as there is no evidence to support these modalities for any condition at any time. If patients want to throw money away- they can just give it to me. I accept paypal.

 

[Tenesma]

sorry i forgot to mention hydration --- ....

 

[dc2md]

great overview steve and tenesma!!

about the O2 tenesma stated, do you just use NC O2 to keep sats above 92%? or make sure to keep it 98-100%?

for NSAIDs, are you talking indocin or something like ibuprofen/naproxen/meloxicam??