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Kenney MO, Smith WR. Moving Toward a Multimodal Analgesic Regimen for Acute Sickle Cell Pain with Non-Opioid Analgesic Adjuncts: A Narrative Review. J Pain Res 2022; 15:879-894. [PMID: 35386424 PMCID: PMC8979590 DOI: 10.2147/jpr.s343069] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/04/2022] [Indexed: 12/13/2022] Open
Abstract
Purpose of Review Sickle cell disease (SCD) is an inherited hemoglobinopathy with potential life-threatening complications that affect millions of people worldwide. Severe and disabling acute pain, referred to as a vaso-occlusive crisis (VOC), is a fundamental symptom of the disease and the primary driver for acute care visits and hospitalizations. Despite the publication of guidelines for VOC management over the past decade, management of VOCs remains unsatisfactory for patients and providers. Recent Findings Acute SCD pain includes pain secondary to VOCs and other forms of acute pain. Distinguishing VOC from non-VOC pain may be challenging for both patients and clinicians. Further, although opioids have been the gold-standard for VOC pain management for decades, the current highest standard of care for all acute pain is a multimodal approach that is less dependent on opioids, and, instead incorporates analgesics and adjuvants from different mechanistic pathways. In this narrative review, we focus on a multimodal pharmacologic approach for acute SCD pain management and explore the evidence for existing non-opioid pharmacological adjuncts. Moreover, we present an explanatory model of pain, which is not only novel in its application to SCD pain but also captures the multidimensional nature of the SCD pain experience and supports the need for such a multimodal approach. This model also highlights opportunities for new investigative and therapeutic targets - both pharmacological and non-pharmacological. Summary Multimodal pain regimens that are less dependent on opioids are urgently needed to improve acute pain outcomes for individuals with SCD. The proposed explanatory model for SCD pain offers novel opportunities to improve acute pain management for SCD patients.
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Affiliation(s)
- Martha O Kenney
- Division of Pediatric Anesthesiology, Department of Anesthesiology, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Wally R Smith
- Division of General Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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Weisman JK, Nickel RS, Darbari DS, Hanisch BR, Diab YA. Characteristics and outcomes of osteomyelitis in children with sickle cell disease: A 10-year single-center experience. Pediatr Blood Cancer 2020; 67:e28225. [PMID: 32065511 DOI: 10.1002/pbc.28225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 01/10/2020] [Accepted: 01/23/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Patients with sickle cell disease (SCD) are at increased risk for osteomyelitis (OM). Diagnosis of OM in SCD is challenging as the clinical presentation is similar to a vasoocclusive crisis (VOC) with no diagnostic gold standard. We report characteristics and outcomes of OM in SCD patients treated at our center over 10-year period. DESIGN/METHOD We conducted a retrospective analysis of patients with SCD who were treated for OM at our center over a 10-year period (2006-2016). Cases were identified utilizing radiology data mining software. Radiology reports and medical charts of potential OM cases were reviewed. RESULTS Twenty-eight children with SCD were treated for OM at our institution. Patients treated for OM were largely similar to patients treated for a VOC. However, patients treated for OM had significantly higher C-reactive protein (10 mg/dL vs 5.58 mg/dL, P = 0.03) and erythrocyte sedimentation rate (60 mm/h vs 47 mm/h, P = 0.02). Magnetic resonance imaging (MRI) findings were consistent with OM in 18 (64%) patients and indeterminate in the remaining. Based on clinical, laboratory, and radiological findings, the diagnosis of OM was considered confirmed in 3 patients, probable in 6 patients, and presumed in 19 patients. Nontyphoidal Salmonella was isolated from cultures in 9 (32%) patients, while no organism was identified in 19 (67%) patients. All patients were treated with antibiotics. Six patients (21%) required surgical interventions. CONCLUSIONS OM continues to pose diagnostic challenges. Most patients are treated for OM without definitive confirmation. Nontyphoidal Salmonella was the only organism identified in our cohort.
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Affiliation(s)
- Julie K Weisman
- Division of Hematology, Children's National Health System, Washington, DC
| | - Robert Sheppard Nickel
- Division of Hematology, Children's National Health System, Washington, DC.,The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Deepika S Darbari
- Division of Hematology, Children's National Health System, Washington, DC
| | - Benjamin R Hanisch
- The George Washington University School of Medicine and Health Sciences, Washington, DC.,Division of Infectious Disease, Children's National Health System, Washington, DC
| | - Yaser A Diab
- Division of Hematology, Children's National Health System, Washington, DC.,The George Washington University School of Medicine and Health Sciences, Washington, DC
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Abstract
Acute chest syndrome (ACS) and transfusion requirements are common and difficult to predict during hospitalizations for acute vaso-occlusive episodes (VOE) among individuals with sickle cell disease (SCD). This study examined the relationship between nucleated red blood cell (NRBC) counts during hospitalization for VOE and development of ACS or transfusion requirement among children with SCD. Retrospective chart review was performed for 264 encounters of patients with SCD hospitalized for uncomplicated VOE who had NRBC count data at admission during a 5-year period. Multivariable logistic regression analysis was conducted to determine the relationship of admission and change in NRBC ([INCREMENT]NRBC) to ACS/transfusion requirement. Overall, 44 of 264 (16.7%) encounters resulted in ACS, transfusion, or both. Admission NRBC was not associated with development of ACS/transfusion requirement. Among 125 of 264 (47.3%) encounters in which a subsequent CBC was obtained, greater increases in NRBCs and greater decrease in hemoglobin were significantly associated with ACS/transfusion requirement (OR, 2.72; 95% CI, 1.16, 6.35; P=0.02 and OR, 2.52; 95% CI, 1.08, 5.89; P=0.03, respectively). Our finding that an increase in NRBC counts was associated with development of ACS/transfusion requirement suggests that [INCREMENT]NRBCs may represent a useful biomarker for predicting complications in children with SCD hospitalized for VOE.
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Abstract
The primary β-globin gene mutation that causes sickle cell disease (SCD) has significant pathophysiological consequences that result in hemolytic events and the induction of the inflammatory processes that ultimately lead to vaso-occlusion. In addition to their role in the initiation of the acute painful vaso-occlusive episodes that are characteristic of SCD, inflammatory processes are also key components of many of the complications of the disease including autosplenectomy, acute chest syndrome, pulmonary hypertension, leg ulcers, nephropathy and stroke. We, herein, discuss the events that trigger inflammation in the disease, as well as the mechanisms, inflammatory molecules and cells that propagate these inflammatory processes. Given the central role that inflammation plays in SCD pathophysiology, many of the therapeutic approaches currently under pre-clinical and clinical development for the treatment of SCD endeavor to counter aspects or specific molecules of these inflammatory processes and it is possible that, in the future, we will see anti-inflammatory drugs being used either together with, or in place of, hydroxyurea in those SCD patients for whom hematopoietic stem cell transplants and evolving gene therapies are not a viable option.
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Affiliation(s)
- Nicola Conran
- Hematology Center, University of Campinas - UNICAMP, Cidade Universitária, Campinas-SP, Brazil
| | - John D Belcher
- Department of Medicine, Division of Hematology, Oncology and Transplantation, Vascular Biology Center, University of Minnesota, Minneapolis, MN, USA
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Binding A, Valentine K, Poon MC, Sayani FA. Adult Sickle Cell Disease Epidemiology and the Potential Role of a Multidisciplinary Comprehensive Care Center in a City with Low Prevalence. Hemoglobin 2014; 38:312-5. [DOI: 10.3109/03630269.2014.954048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Frei-Jones MJ, Baxter AL, Rogers ZR, Buchanan GR. Vaso-occlusive episodes in older children with sickle cell disease: emergency department management and pain assessment. J Pediatr 2008; 152:281-5. [PMID: 18206703 PMCID: PMC2359225 DOI: 10.1016/j.jpeds.2007.06.040] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Revised: 04/30/2007] [Accepted: 06/28/2007] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To describe emergency department (ED) management of older children with sickle cell disease (SCD) experiencing a vaso-occlusive episode (VOE) and factors associated with disposition and ED return. STUDY DESIGN We retrospectively reviewed ED visits of children age >/=8 years with SCD over the course of 1 year. Data were collected from the electronic medical record and the SCD database. RESULTS VOE was diagnosed 279 times in 105 patients; 45 of the patients had 1 ED visit, 25 had 2 ED visits, and 16 had >/=5 ED visits. The overall admission rate was 178/279 (64%), 166 on the first ED visit and 12 on a return visit within 72 hours. Use of home opioids, duration of VOE, and hemoglobin concentration were not associated with disposition. Discharge after 2 doses of intravenous (IV) morphine occurred in 33 patients. Pain relief after 1 dose, using a FACES scale of 1 to 5, differed significantly between the admitted patients and the discharged patients (1.1 vs 2.5; P < .0001). CONCLUSION Suboptimal pain relief after 1 dose of IV morphine was associated with admission from the ED. Further investigation of pain relief, using validated pain assessment scales, as an outcome in VOE management is warranted.
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Affiliation(s)
- Melissa J. Frei-Jones
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Children’s Medical Center Dallas, Texas
| | - Amy L. Baxter
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Texas Southwestern Medical Center at Dallas, Children’s Medical Center Dallas, Texas
| | - Zora R. Rogers
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Texas Southwestern Medical Center at Dallas, Southwestern Comprehensive Sickle Cell Center, Children’s Medical Center Dallas, Texas
| | - George R. Buchanan
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Texas Southwestern Medical Center at Dallas, Southwestern Comprehensive Sickle Cell Center, Children’s Medical Center Dallas, Texas
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Bernard AW, Venkat A, Lyons MS. Best evidence topic report. Full blood count and reticulocyte count in painful sickle crisis. Emerg Med J 2006; 23:302-3. [PMID: 16549581 PMCID: PMC2579511 DOI: 10.1136/emj.2006.035154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Aaron W Bernard
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, USA
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Birkenmeier CS, Barker JE. Hereditary haemolytic anaemias: unexpected sequelae of mutations in the genes for erythroid membrane skeletal proteins. J Pathol 2004; 204:450-9. [PMID: 15495268 DOI: 10.1002/path.1636] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Although the haemolytic anaemia may be the primary concern for hereditary spherocytosis and elliptocytosis patients, it is clear that their situation can be compromised by primary and secondary defects in erythroid and non-erythroid systems of the body. All seven of the red cell membrane skeletal proteins discussed in this review are also expressed in non-erythroid tissues, and mutations in their genes have the potential to cause non-erythroid defects. In some instances, such as the protein 4.1R and ANK1 neurological deficits, the diagnosis is clear. In other instances, because of the complex expression patterns involved, the non-erythroid effects may be difficult to assess. An example is the large multidomain, multifunctional band 3 protein. In this case, the location of the mutation can cause defects in one functional domain or isoform and not the other. In other cases, such as the beta-adducin null mutation, other isoforms may partially compensate for the primary deficiency. In such cases, it may be that the effects of the deficit are subtle but could increase under stress or with age. To be completely successful, treatment strategies must address both primary and secondary effects of the anaemia. If gene replacement therapy is to be used, the more that is known about the underlying genetic mechanisms producing the multiple isoforms the better we will be able to design the best replacement gene. The various animal models that are now available should be invaluable in this regard. They continue to contribute to our understanding of both the primary and the secondary effects and their treatment.
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Wells BL, Vizioli TL, Counselman FL. The reticulocyte count: is it needed for evaluating typical sickle cell crisis presenting to the ED? Am J Emerg Med 2002; 20:69-70. [PMID: 11781929 DOI: 10.1053/ajem.2002.29563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Silbergleit R, Jancis MO, McNamara RM. Management of sickle cell pain crisis in the emergency department at teaching hospitals. J Emerg Med 1999; 17:625-30. [PMID: 10431951 DOI: 10.1016/s0736-4679(99)00050-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this study is to determine the frequency and variety of strategies being used in the Emergency Department (ED) management of sickle cell pain crisis (SCPC). One thousand randomly selected academic emergency physicians received a multiple-choice survey; 549 (55%) completed the survey. Forty-five percent of respondents treat patients with SCPC every week or almost every shift. Twenty percent use protocols for management of SCPC. Respondents consider pain refractory to outpatient treatment if it is persistent after two (23%) or three (53%) doses of parenteral analgesic. Meperidine or morphine is the most common initial analgesic. In the routine management of uncomplicated SCPC, i.v. analgesics, i.v. hydration, oxygen therapy, and complete blood counts are often or always used by 67, 71, 66, and 82% of respondents, respectively. Some patterns in the diagnostic and therapeutic management of patients with SCPC in the ED are identified, but overall practice is highly variable. Some popular elements of care are divergent from those suggested by the scientific literature.
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Affiliation(s)
- R Silbergleit
- Department of Surgery, University of Michigan, Ann Arbor 48109-0303, USA
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