title: Pain management in adults with sickle cell disease in a medical center emergency department.
abstract: Guidelines for pain management in adult sickle cell patients with vaso-occlusive crises suggest prompt, frequent administration of parenteral opioids. Neither the ability to implement these guidelines in a busy urban emergency department nor opioid dose requirements in uncomplicated vaso-occlusive crisis have been previously documented. Thus, a retrospective review of vaso-occlusive crisis treated in an urban medical center emergency department in 2005 was performed to define opioid requirements and barriers to guideline implementation. Fifty-seven visits by 19 patients were evaluable. Opioid treatment was not initiated for more than 2 hours during 30% of visits; the interval between the first and second opioid doses exceeded 1 hour in 26% of visits and increased with subsequent doses; and total treatment time was less than 1 hour during 21% of visits (median, 2.2 hours). Opioid doses (as intravenous morphine equivalents) ranged from 4 to 26.7 mg (0.05-0.50 mg/kg) and exceeded 10 mg during 40 visits (70%) and in 10 patients (53%). Hospitalization occurred on 25 occasions with 48% of patients admitted after 3 or fewer opioid doses and 50% of patients admitted after less than 3 hours of treatment. Moreover, return emergency department visits occurred within 3 days after 9 of 32 home discharges (28%) with treatment times uniformly less than 3 hours during the preceding visit. It is concluded that: (1) opioid dose requirements vary widely, often exceeding guideline recommendations; and (2) treatment time and timely opioid administration are often compromised, resulting in delayed pain control and premature decisions on disposition with early return visits and possibly avoidable hospital admissions.
authors.affiliation: Adult Sickle Cell Disease Program, Sections of Hematology and Palliative Care, Department of Medicine, Yale University School of Medicine, 333 Cedar St, PO Box 208201, New Haven, CT 06520-8021, USA. lawrence.solomon@yale.edu
authors.forename: Lawrence R
authors.initials: LR
authors.lastname: Solomon
mesh_terms: D000328:Adult; D000701:Analgesics, Opioid / Q000008:administration & dosage / Q000627:therapeutic use*; D000755:Anemia, Sickle Cell / Q000150:complications / Q000188:drug therapy*; D016009:Chi-Square Distribution; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000188:drug therapy* / Q000209:etiology; D010147:Pain Measurement; D010343:Patient Admission / Q000706:statistics & numerical data; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D016896:Treatment Outcome
chemical_list: D000701:Analgesics, Opioid