Abstract
We evaluated a protocol comprising intranasal diamorphine (IND) combined with oral short and modified-release morphine for children at the emergency department (ED) with acute painful episodes of sickle cell disease (SCD). In a retrospective audit of 83 episodes in 38 children, the mean time between arrival in the treatment area and the administration of IND was 10 min (range <5 min to 1.39 h). IND was administered in <5 min in 43 (51.6%), and in <20 min in 75 (90.4%) episodes. Persisting pain, requiring background analgesia with modified-release oral morphine, was required in 25 (30.1%) episodes. Inadequate control of pain requiring a switch to intravenous morphine PCA was required in eight episodes in four patients. Acute chest syndrome (ACS) developed in four of 83 episodes (4.8%, 95% CI 0.2–9.4%) and in four of 38 children (10.5%, 95% CI 0.7–20.5%). In conclusion, this protocol enabled the rapid administration of strong opioid analgesia in an ED setting, and may reduce the short and long-term adverse effects associated with parenteral opioids in children. There was no evidence of an increased incidence of ACS associated with use of oral morphine.
Highlights
The painful crisis is the most frequent acute complication of sickle cell disease (SCD) in children and adults [1]
There were 96 presentations with acute pain, and intranasal diamorphine (IND) was given in 83 episodes in 38 children
This study shows that IND can be safely combined with oral morphine to provide safe analgesia without the need for intravenous opiates
Summary
The painful crisis is the most frequent acute complication of sickle cell disease (SCD) in children and adults [1]. We hypothesize that continued parenteral analgesia with bolus or continuous i.v. infusions may lead to a prolongation of, and dependence on, hospital based therapy for the management of acute painful episodes This might be mitigated by use of oral opioids. A small RCT comparing continuous i.v. infusion with oral controlled release morphine for continued opioid analgesia during the pain episode in children showed a reduction in the length of hospital stay with oral opioids, this difference was not statistically significant [9] These data support the use of oral analgesia regimes as an alternative to parenteral regimes, but it is clear that further studies are needed and should start with preliminary work to develop safe and effective protocols, which could be used as comparators in future randomized controlled trials. The evaluation of the full analgesia protocol and patient questionnaire were considered audit projects, and were approved by our institutional audit office
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