827 Observations, variations and challenges in managing continued opiate analgesia for children admitted with severe and persistent sickle cell crisis pain

Abstract

<h3>Background</h3> Vaso-occlusive crisis (VOC) is the commonest reason for hospitalisation in children with sickle cell disease. After initial management with emergency analgesia, a proportion of children with severe VOC will experience persisting pain requiring continued opiate analgesia. <h3>Objectives</h3> We evaluated our practice in prescribing opiate analgesia and relevant supportive medications for paediatric sickle cell cases admitted to our department with persisting pain from severe VOC. We also investigated the frequency of opiate-related side effects in different age groups. <h3>Methods</h3> Our paediatric sickle cell admissions database was used to identify all cases of severe VOC during the time period January 2018-December 2019. Data on opiate analgesia and supportive medication prescriptions, side effects, pain scores and length of stay (LOS) were extracted from electronic medical records. <h3>Results</h3> We identified 32 cases (58% female, mean age 10.8 years; range 2–18 years) of severe VOC out of 89 paediatric sickle cell admissions in the study period. All patients were prescribed opiate analgesia; 81% had modified release oral morphine (MROM) and 25% required intravenous Patient Controlled Analgesia (PCA). Oxycodone (immediate and modified release) was successfully used as an alternative to morphine in 6% of cases. Supportive medications were often not proactively prescribed together with opiates; Laxatives were prescribed in 80%, whereas antiemetics, naloxone and antihistamines were only prescribed in 52%, 55% and 48% of cases respectively. The majority of patients on MROM or PCA experienced side effects, with constipation being the commonest (41%), followed by nausea and vomiting (32%) and pruritus (19%). The rate of side effects was higher in the &gt;12 years group, particularly for nausea and vomiting (table 1). Mean time from admission to starting the PCA was 25 hours, and the mean duration of PCA was 25 hours (range 8–70 hours). In 38% of cases that PCA was commenced, it was discontinued prematurely due to inadequate utilisation and/or poor tolerance (75% of patients on PCA experienced side effects). Pain scores (1 to 10 scale) pre and post-PCA decreased by a mean of 2.1±1.5 points. Finally, the mean LOS (7.1 days) was significantly higher for the PCA group (mean difference 2.6 days, p=0.04). <h3>Conclusions</h3> We observed considerable variations in prescribing trends of opiate analgesia and supportive medications for paediatric sickle cell inpatients with severe VOC. Although intravenous PCA may have an important role in these cases, our study shows that it is linked with high failure rates and high incidence of side effects, particularly in teenagers. Further research and quality improvement efforts should focus on creating safe, effective and age-specific pathways of continued opiate analgesia and supportive care for children and young people admitted with severe and persistent sickle crisis pain.