• Join Today!

Become a member and connect with:

  • An Active Online Community
  • Articles and Advice on SCD
  • Help Understanding Clinical Trials
abstracts & posters

Unanticipated consequences identified after implementation of a pediatric emergency department (PED)-based intranasal fentanyl (INF) protocol for the treatment of vaso-occlusive pain episodes (VOE) in children with sickle cell disease (SCD)

key information

source: The American Society of Pediatric Hematology/Oncology Conference

year: 2018

authors: Kirshma Khemani, Lankala Reddy, Shabnam Jain, Amanda Mallino, Courtney E. McCracken, April Zmitrovich, Bolanle Akinsola, Lakshmanan Krishnamurti, Claudia R. Morris

summary/abstract:

Background:

The 2014 National Heart Lung & Blood Institute(NHLBI) guidelines for acute management of VOE recommends rapid evaluation and treatment of pain, including administration of a parenteral opioid within 30-minutes of triage or 60-minutes from registration, pain reassessment & repeat opioid delivery within 15-30-minutes. INF use has been increasing in PEDs due to its rapid onset and ease of administration.

 

Objectives:

To evaluate PED utilization of INF & its effect on intravenous (IV) opioid administration and pain control for the treatment of VOE.

 

Design/Method:

A retrospective review of 250 EMR was performed on children with SCD±2years presenting to a PED with VOE (pain scores 6 on a 0-10 scale) from Jan-June 2017. Variables studied were median time (IQR, 95%CI) from PED arrival to first-parenteral-opioid-administration, time-to-first-IV-opioid, first & final pain score, disposition and readmission rate. Time-to-first-IV-opioid was also compared to historical data (Jan-Dec2012, n=231) prior to INF protocol initiation.

 

Results:

Mean age was 13±4years, 48% male and majority had HbSS (66%). Admission rate was 60%. Of 250 VOE episodes, 183(73%) received INF & 204 (82%) received an IV opioid. Both INF+IV opioid were given to 141 patients, while 42 (17%) patients received INF only. Time-to-first-parenteral-opioid administration for those treated with INF vs. IV opioid alone was 26 minutes (19-33) versus 74 minutes (46-10), p<0.01. Pain scores at disposition were lower in patients who received INF. Time-to-IV-opioid was longer in patients receiving INF vs. IV opioid alone (115 vs 83 minutes<0.01) & compared to historical date (35±18minutes). Additionally, 15% patients received IV opioids within 60 minutes of ED arrival in the INF+IV opioid vs. 40% in the IV opioids alone group (p<0.01). No differences in 72-hour-return-rates were found in any of the groups, including INF alone group.

 

Conclusion:

Use of INF in the PED for VOE is an excellent strategy to shorten time-to-first-parenteral-opioid-administration, improve pain scores & improve adherence to the NHLBI guidelines. However we had 2 distinct unexpected findings: (1) Delays in IV opioid delivery after INF use & (2) INF alone appeared to provide sufficient pain control without IV opioids for disposition home in 17% of VOE patients. Whether the latter reflects insufficient pain management or that there is a milder subgroup for which INF alone is sufficient, requires further investigation.

This study illustrates our experience with a PED-based INF protocol in terms of unanticipated delays in IV opioids and also discharges after INF alone. Efforts are underway to further improve use of INF in VOE management.

 

read more