The utility of screening laboratory studies in pediatric patients with sickle cell pain episodes

Moving Toward a Multimodal Analgesic Regimen for Acute Sickle Cell Pain with Non-Opioid Analgesic Adjuncts: A Narrative Review

Purpose of Review

Sickle cell disease (SCD) is an inherited hemoglobinopathy with potential life-threatening complications that affect millions of people worldwide. Severe and disabling acute pain, referred to as a vaso-occlusive crisis (VOC), is a fundamental symptom of the disease and the primary driver for acute care visits and hospitalizations. Despite the publication of guidelines for VOC management over the past decade, management of VOCs remains unsatisfactory for patients and providers.

Recent Findings

Acute SCD pain includes pain secondary to VOCs and other forms of acute pain. Distinguishing VOC from non-VOC pain may be challenging for both patients and clinicians. Further, although opioids have been the gold-standard for VOC pain management for decades, the current highest standard of care for all acute pain is a multimodal approach that is less dependent on opioids, and, instead incorporates analgesics and adjuvants from different mechanistic pathways. In this narrative review, we focus on a multimodal pharmacologic approach for acute SCD pain management and explore the evidence for existing non-opioid pharmacological adjuncts. Moreover, we present an explanatory model of pain, which is not only novel in its application to SCD pain but also captures the multidimensional nature of the SCD pain experience and supports the need for such a multimodal approach. This model also highlights opportunities for new investigative and therapeutic targets - both pharmacological and non-pharmacological.

Summary

Multimodal pain regimens that are less dependent on opioids are urgently needed to improve acute pain outcomes for individuals with SCD. The proposed explanatory model for SCD pain offers novel opportunities to improve acute pain management for SCD patients.

Changes in platelet count as a predictive tool in sickle cell acute vaso-occlusive crises: a pediatric study

OBJECTIVE

Studies have shown that platelets play an important role in the pathophysiology of vaso-occlusive crises (VOC) in sickle cell disease. This study investigates whether changes in platelet indices from baseline can be predictive of complications during acute pain crisis.

METHODS

Data were obtained from pediatric sickle cell patients in the well-clinic setting and compared with data gathered during VOC (n = 67). Primary outcome was complicated (admission, acute chest syndrome, transfusion, etc) versus uncomplicated (discharge from emergency department without subsequent return) course.

RESULTS

Patients with uncomplicated courses had larger platelet declines (53.7) than those with complicated courses (14.8, P = .005).

CONCLUSIONS

The study suggests that patients with uncomplicated VOC are more likely to experience a larger decline in platelets. The predictive value is limited by the need to have preexisting steady-state data and relatively small decline. Ongoing studies are needed to identify useful laboratory data to help predict severity of VOC.

Admission and length of stay due to painful vasoocclusive crisis in children

PURPOSE

To identify demographic, clinical, and laboratory characteristics associated with admission and a longer length of stay (LOS) due to vasoocclusive crisis (VOC) in children with sickle cell disease (SCD).

METHODS

Retrospective chart review at a large tertiary pediatric center. Patients younger than 18 years with VOC due to SCD presenting to the emergency department were included. We performed multivariate regression analyses to predict characteristics associated with admission and LOS of 4 days or more.

RESULTS

A total of 428 visits for VOC were documented in 2005 to 2006. In a multivariate regression analysis higher pain score at triage (P < .001), older age (P = .04), and increased systolic blood pressure (P = .02) were predictors of admission. Higher pain score at triage (P = .046), older age (P = .002), increased polymorphonuclear count (P = .02), and homozygous SCD type (P = .03) were associated with prolonged hospital LOS.

CONCLUSION

These characteristics will help healthcare providers predict and plan admission and management of children with SCD.

Vaso-occlusive episodes in older children with sickle cell disease: emergency department management and pain assessment

OBJECTIVE

To describe emergency department (ED) management of older children with sickle cell disease (SCD) experiencing a vaso-occlusive episode (VOE) and factors associated with disposition and ED return.

STUDY DESIGN

We retrospectively reviewed ED visits of children age >/=8 years with SCD over the course of 1 year. Data were collected from the electronic medical record and the SCD database.

RESULTS

VOE was diagnosed 279 times in 105 patients; 45 of the patients had 1 ED visit, 25 had 2 ED visits, and 16 had >/=5 ED visits. The overall admission rate was 178/279 (64%), 166 on the first ED visit and 12 on a return visit within 72 hours. Use of home opioids, duration of VOE, and hemoglobin concentration were not associated with disposition. Discharge after 2 doses of intravenous (IV) morphine occurred in 33 patients. Pain relief after 1 dose, using a FACES scale of 1 to 5, differed significantly between the admitted patients and the discharged patients (1.1 vs 2.5; P < .0001).

CONCLUSION

Suboptimal pain relief after 1 dose of IV morphine was associated with admission from the ED. Further investigation of pain relief, using validated pain assessment scales, as an outcome in VOE management is warranted.