title: Epidural analgesia in the management of severe vaso-occlusive sickle cell crisis.
abstract: OBJECTIVE
  To determine whether continuous epidural analgesia could effectively decrease pain and thereby improve the management of severe vaso-occlusive crisis in children with sickle cell disease who were unresponsive to conventional analgesic therapy.
  
  
  METHODS
  Retrospective observational study.
  
  
  METHODS
  A tertiary care hospital with a large pediatric sickle cell patient referral population.
  
  
  METHODS
  The study describes nine children in 11 painful vaso-occlusive crises, unresponsive to high-dose systemic opioids, nonsteroidal anti-inflammatory drugs, and adjunctive measures, who underwent continuous epidural analgesia to control pain.
  
  
  METHODS
  Subjective pain scores, arterial oxygen saturation monitoring, and plasma lidocaine levels.
  
  
  METHODS
  Placement of an epidural catheter for the administration of a continuous infusion of local anesthetic, alone, or in combination with fentanyl, in the management of vaso-occlusive crisis.
  
  
  RESULTS
  An initiation of epidural analgesic therapy, 8 of 9 patients reported severe pain (8 to 10 on a scale of 0 to 10, 0 = no pain, 10 = the worst pain they ever experienced). Analgesic was immediate (pain score 0 to 2) in 8 of 9 patients, and continuously effective in 9 of 11 crises. Five patients required either the addition of fentanyl or changing the local anesthetic from lidocaine to bupivacaine to maintain analgesia for 2 to 5 days. In 7 of 9 patients, oxygen saturation dramatically increased from 87 to 95% to 99 to 100% after epidural analgesia was initiated. In all patients, plasma lidocaine levels ranged from 1.1 to 4.6 mg/L and dose-related toxicity did not occur. One patient developed hypotension secondary to high sympathetic blockade (T-4), one had an inadvertent dural puncture during insertion of the catheter, one had the epidural catheter removed for fever, and one achieved analgesia only transiently. There were no other complications, and epidural analgesia was not associated with sedation, respiratory depression, or limitation of movement. All epidural catheters were cultured on removal, and colonization did not occur.
  
  
  CONCLUSIONS
  Epidural analgesia with local anesthetics administered alone or in combination with fentanyl effectively and safely treats the pain of sickle cell vaso-occlusive crisis unresponsive to conventional pain management and does so without causing sedation, respiratory depression, or significant limitation on ambulation. Furthermore, early treatment of painful crisis with this technique may improve oxygenation, a critical factor in the evolution of further sickling.
authors.affiliation: Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: M
authors.initials: M
authors.lastname: Yaster
authors.forename: J R
authors.initials: JR
authors.lastname: Tobin
authors.forename: C
authors.initials: C
authors.lastname: Billett
authors.forename: J F
authors.initials: JF
authors.lastname: Casella
authors.forename: G
authors.initials: G
authors.lastname: Dover
mesh_terms: D015360:Analgesia, Epidural; D000755:Anemia, Sickle Cell / Q000150:complications*; D002648:Child; D004630:Emergencies; D005260:Female; D005283:Fentanyl / Q000627:therapeutic use; D006801:Humans; D008012:Lidocaine / Q000008:administration & dosage / Q000627:therapeutic use*; D008297:Male; D010146:Pain / Q000188:drug therapy* / Q000209:etiology; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D008012:Lidocaine; D005283:Fentanyl