Trusted Resources: Evidence & Education
Scientific literature and patient education texts
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)
source: The American Society of Pediatric Hematology/Oncology Conference
authors: Kirshma Khemani, Lankala Reddy, Shabnam Jain, Amanda Mallino, Courtney E. McCracken, April Zmitrovich, Bolanle Akinsola, Lakshmanan Krishnamurti, Claudia R. Morrissummary/abstract:
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.
To evaluate PED utilization of INF & its effect on intravenous (IV) opioid administration and pain control for the treatment of VOE.
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.
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.
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.
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