Improved Management of sickle cell pain crisis in a Pediatric Emergency Department through Use of Intranasal Fentanyl.

Abstract

Introduction: National Heart, Lung, and Blood Institute recommends giving the first dose of opioids within 30 minutes of presentation to the emergency department for sickle cell disease patients with moderate to severe vaso-occlusive crisis. Intranasal fentanyl has been used extensively and shown to reduce time to the first dose of analgesic, improve pain scores at 20 minutes, and increase the odds of getting discharged from the emergency department. Material and methods: For phase one of the project, baseline data was collected. The new pain algorithm was introduced at the start of the second phase, which involved giving intranasal fentanyl as the first analgesic for vaso-occlusive crisis in the emergency department. After the intervention, the second analysis compared outcomes with phase one. Wilcoxon-Mann-Whitney tests were used for comparing data between phase one and phase two and Wilcoxon signed-rank tests (paired version) were used for comparing pain scores before and after analgesic. Results: Visits at phase two had significantly lower hospitalization rate [phase one 53.5% vs. phase two 34.2%(p value 0.005)], more fentanyl use [phase one 1.5% vs. phase two 50.6% (p< 0.001)], less patient-controlled-analgesia (PCA) opioid use after admission [phase one 13.0% vs. phase two 2.53% (p= 0.016)], higher compliance with outpatient visits [phase one 61.3% vs. phase two 98.7% (p < 0.001)], shorter length of hospital stay [phase one 117.6 ± 112.7 hours vs. phase two 68.3 ± 47.2 hours (p-value 0.01)], decrease in the time to first analgesic after coming to the emergency department (phase one 78.2 ± 131.2 minutes vs. phase two 38.3 ± 31.2 minutes (p 0.85)], and decrease in the mean pain score after first medication in the emergency department [phase one 5.48 ± 3.12 vs. phase two 4.46 ± 2.88 (p value 0.021)] Conclusion: Intranasal fentanyl led to more effective and timely management of vaso-occlusive crisis with improvement in clinical outcomes compared to standard management.