Demand‐only patient‐controlled analgesia for treatment of acute vaso‐occlusive pain in sickle cell disease

Abstract

Background Sickle cell disease (SCD) is a chronic illness that is associated with frequent admissions for vaso‐occlusive episodes (VOE). Opioids are frequently utilized in pain management, but dosing is often provider dependent. Opioids cause both short‐term and long‐term side effects, so the minimal effective dose is desired. This study examined demand‐only patient‐controlled analgesia (PCA) in pediatric patients. Methods A new clinical practice guideline (CPG) for a single institution was implemented, which eliminated basal infusion dosing for PCAs on hospital admission. The primary aim of this retrospective study was to evaluate length of stay (LOS) before and after implementation of a CPG of demand‐only PCA and, in a selected subpopulation, addition of short‐term methadone. Secondary aims included opioid utilization, acute chest syndrome (ACS), and hypoxia. Inclusion criteria included SCD, ≤21 years of age, uncomplicated VOE admission, and ≥ 3 and ≤ 8 hospital admissions for SCD pain control within one calendar year. Results LOS decreased postintervention (7.2 ± 5.1 vs 4.5 ± 3.8 days, P < 0.001). Mean total opioid utilization in morphine equivalents mg/kg markedly decreased between the cohorts (13.3 ± 33.8 vs 3.6 ± 3.0, P < 0.001). ACS (21.9% vs 2.8%, P = 0.004) and hypoxia (28% vs 6.9%, P< 0.001) decreased significantly as well. Conclusion Bolus PCA dosing of opioids resulted in decreased LOS and reductions in opioid utilization, hypoxia, and ACS.

Still seeking balance in opioid management for acute sickle cell disease pain

“…In this issue of Pediatric Blood and Cancer , Carullo and colleagues have described their center's retrospective experience with a novel VOE management clinical practice guideline (CPG) 6 . Before their CPG implementation, individuals with VOE received PCA with continuous infusion opioids plus patient‐controlled bolus opioid doses.…”

“…In this issue of Pediatric Blood and Cancer, Carullo and colleagues have described their center's retrospective experience with a novel VOE management clinical practice guideline (CPG). 6 Before their CPG implementation, individuals with VOE received PCA with continuous infusion opioids plus patient-controlled bolus opioid doses. The novel CPG involved reliance on bolus dosing only, with the option to prescribe oral methadone, a long-acting mu-opioid receptor agonist and N-methyl-D-aspartic acid receptor (NMDA) antagonist, for patients whose pain did not improve rapidly.…”