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Telfer P, Anie KA, Kotsiopoulou S, Aiken L, Hibbs S, Burt C, Stuart-Smith S, Lugthart S. The acute pain crisis in sickle cell disease: What can be done to improve outcomes? Blood Rev 2024; 65:101194. [PMID: 38553339 DOI: 10.1016/j.blre.2024.101194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/19/2024] [Accepted: 03/17/2024] [Indexed: 04/21/2024]
Abstract
The acute pain crisis (APC) is the commonest complication of sickle cell disease (SCD). Severe episodes may require treatment in hospital with strong opioid analgesic drugs, combined with additional supportive care measures. Guidelines for APC management have been produced over the past two decades gathering evidence from published studies, expert opinion, and patient perspective. Unfortunately, reports from multiple sources indicate that guidelines are often not followed, and that acute care in emergency departments and on acute medical wards is suboptimal. It is important to understand what leads to this breakdown in health care, and to identify evidence-based interventions which could be implemented to improve care. This review focuses on recently published articles as well as information about on-going clinical trials. Aspects of care which could potentially make a difference to patient experience include availability and accessibility of individual care plans agreed between patient and treating specialist, innovative means of delivering initial opioids to reduce time to first analgesia, and availability of a specialist unit away from the ED, where expert care can be delivered in a more compassionate environment. The current evidence of improved outcomes and health economic advantage with these interventions is inadequate, and this is hampering their implementation into health care systems.
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Affiliation(s)
- Paul Telfer
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, UK; Department of Haematology, Royal London Hospital, Bart's Health NHS Trust, London, UK.
| | - Kofi A Anie
- Brent Sickle Cell & Thalassaemia Centre, London North West University Healthcare NHS Trust, London, UK
| | | | - Laura Aiken
- Department of Haematology, Royal London Hospital, Bart's Health NHS Trust, London, UK
| | - Stephen Hibbs
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | | | | | - Sanne Lugthart
- University of Bristol, School of Cellular and Molecular Medicine, Bristol, UK; Department of Haematology, University Hospitals of Bristol, Bristol, UK
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Kaçmaz M, İlhan G. A comparison of the mixed and sequential use of acetaminophen and dexketoprofen in painful vaso-occlusive crises. Eur J Clin Pharmacol 2024; 80:475-480. [PMID: 38245872 DOI: 10.1007/s00228-024-03630-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 01/17/2024] [Indexed: 01/23/2024]
Abstract
PURPOSE Opioids are widely used to treat painful vaso-occlusive crises (VOC) in sickle cell disease (SCD). However, due to opioids' significant adverse effect profiles, the search for alternative therapies continues from the past to the present. The study aimed to investigate the efficacy of acetaminophen and dexketoprofen in the treatment of painful VOC. METHODS This study is a single-center, prospective, non-randomized, single-blinded, controlled study. The study comprised two groups: the first administered acetaminophen and dexketoprofen mixed group, while the second received them sequential group. Opioids were used in patients with persistent pain despite these analgesics. Demographic and laboratory information, pain scores, opioid requirement, dose amount, side effects, and length of hospital stay of the patients were recorded. RESULTS The study comprised 56 (100%) patients with painful VOC, 29 (51.8%) from the mixed group, and 27 (48.2%) from the sequential group. Opioid use was seen in 16 (55.2%) patients in the mixed group and 21 (77.8%) patients in the sequential group (p = 0.074). The median amount of opioid used was significantly lower in the mixed group than in the sequential group (p < 0.001). Also, the median length of hospital stay was significantly lower in the mixed group than in the sequential group (p < 0.001). CONCLUSION Our study suggests that administering acetaminophen and dexketoprofen in the mix for the treatment of painful VOC in patients with SCD may be a more efficient approach compared to sequential administration. This approach appears to reduce opioid usage and shorten hospital stays.
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Affiliation(s)
- Murat Kaçmaz
- Department of Hematology, Diyarbakır Gazi Yaşargil Training and Research Hospital, Diyarbakır, Turkey.
| | - Gül İlhan
- Department of Hematology, Faculty of Medicine, Hatay Mustafa Kemal University, Hatay, Turkey
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3
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Song C, Wang D, Chen B. A systematic review and meta-analysis comparing the efficacy and safety of ketamine versus morphine for the treatment of acute pain. Minerva Anestesiol 2024; 90:77-86. [PMID: 37930103 DOI: 10.23736/s0375-9393.23.17561-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
INTRODUCTION Ketamine is reported as a potent opioid alternative that provides significant reduction in pain with no severe adverse events. However, some studies didn't find its use satisfactory and reported less reduction in pain score with ketamine. The purpose of this study is to compare the efficacy and safety of ketamine versus morphine for the treatment of acute pain in emergency situations. EVIDENCE ACQUISITION The PubMed, MEDLINE, PsycINFO EMBASE, Cochrane Library, PROSPERO registry platform, and ClinicalTrials.gov websites were queried in accordance with the PRISMA guidelines in order to locate relevant studies. According to the predefined PICOS criteria, articles were included and event data pertaining to changes in Visual Analog Scale or Numeric Rating Scale pain scales were extracted. Using RevMan and MedCalc, a meta-analysis was conducted to compare the effects of ketamine and morphine for the treatment of acute pain. EVIDENCE SYNTHESIS Twelve studies met the criteria for inclusion in this meta-analysis. Ketamine was found to be more effective than morphine at reducing pain scores, with an odds ratio of 0.60 (95% CI 0.48 to 0.76). Similarly, no severe adverse events related to ketamine were reported in any study, and it has a low-risk ratio of 0.78 (95% CI 0.70 to 0.87). Egger's Test P values (0.3052) and Begg's Test P values (0.3869) indicate a low risk of bias, and the Bland-Altman plot demonstrates a high degree of concordance. CONCLUSIONS Ketamine is a potent and effective alternative to morphine for the management of acute pain, and it reduces pain score significantly with minimal side effects.
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Affiliation(s)
- Cheng Song
- Department of Anesthesiology, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Dong Wang
- Department of Anesthesiology, First People's Hospital of Yongkang, Yongkang, China
| | - Bin Chen
- Department of Anesthesiology, Hospital of Integrated Traditional Chinese and Western Medicine of Taizhou, Taizhou, China -
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4
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Pribonic AP, Brancolini SA, Brea F, Cladis FP. Expanded indications of ketamine infusions for pediatric non-surgical pain: a 10 year, single-center experience. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1111-1113. [PMID: 37104745 DOI: 10.1093/pm/pnad052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 04/10/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023]
Affiliation(s)
- Anne P Pribonic
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Scott A Brancolini
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Fernando Brea
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Franklyn P Cladis
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15213, United States
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Sheriff MM, Alsharif AK, Almalki FA, Alqurashi WA, Alqurashi DA, Abusabah HH, Alshanbari RA, Alshalab FJ, Sindi HB, Bahrawi TA, Alqurashi AZ, Al Omar Y, Basalib SG. The Occurrence of Depression Among Adults With Sickle Cell Disease in Saudi Arabia. Cureus 2023; 15:e44595. [PMID: 37795058 PMCID: PMC10546232 DOI: 10.7759/cureus.44595] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2023] [Indexed: 10/06/2023] Open
Abstract
Introduction Sickle cell disease (SCD) is recognized as a widely prevalent genetic disorder that impacts individuals globally and is inherited within families. The primary cause of SCD is a singular genetic mutation that affects the globin chain of the hemoglobin protein. Depression and its symptoms are frequently observed in individuals with SCD. This observation has led to a higher probability of adverse health outcomes. Therefore, the primary objective of this study was to analyze depression among Saudi Arabian adults with sickle cell disease. Method The online survey questionnaire was administered in both Arabic and English to collect essential information regarding SCD distress among the urban adult population in Saudi Arabia, using a cross-sectional study design. Data analysis was conducted using IBM SPSS software version 25 (IBM Corp., Armonk, NY, USA) and Microsoft Excel (Microsoft Corporation, Redmond, WA, USA). The study was designed with a statistical power of 80% at a cut-off value of 0.05 and 0.2. Diverse statistical approaches have been utilized to examine the connection between independent variables, including methods such as Chi-square analysis and Pearson's statistical assessment. Result A total of 685 respondents were included in the survey for this study, with the majority of the participants from the eastern region (31%) and between the age groups of 25 and 30 years (34%) showing a lot of enthusiasm There was a clear dominance of the Saudi population (71%) who spoke Arabic (83%). Female (65%) participants showed more interest in this survey. The collected data were organized comprehensively in tables to facilitate a better understanding of the study's findings. P-values less than 0.05 were considered significant for the obtained results. Conclusion The study has shown that there were a variety of depression entanglements as a result of SCD, but they were handled well with the necessary measures by medical care professionals with much-needed psychological counseling and well-equipped medical facilities.
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Affiliation(s)
- Muazzam M Sheriff
- Microbiology and Immunology, Ibn Sina National College for Medical Studies, Jeddah, SAU
| | - Alhanouf K Alsharif
- Medicine and Surgery, Ibn Sina National College for Medical Studies, Jeddah, SAU
| | - Fai A Almalki
- Medicine, Ibn Sina National College for Medical Studies, Jeddah, SAU
| | - Wed A Alqurashi
- Medicine, Ibn Sina National College for Medical Studies, Jeddah, SAU
| | - Dhyy A Alqurashi
- Medicine, Ibn Sina National College for Medical Studies, Jeddah, SAU
| | - Hanin H Abusabah
- Medicine, Ibn Sina National College for Medical Studies, Jeddah, SAU
| | - Reem A Alshanbari
- Medicine, Ibn Sina National College for Medical Studies, Jeddah, SAU
| | | | - Heba B Sindi
- Medicine, Ibn Sina National College for Medical Studies, Jeddah, SAU
| | - Tasneem A Bahrawi
- Medicine, Ibn Sina National College for Medical Studies, Jeddah, SAU
| | - Alya Z Alqurashi
- Medicine, Ibn Sina National College for Medical Studies, Jeddah, SAU
| | - Youssof Al Omar
- Medicine, Ibn Sina National College for Medical Studies, Jeddah, SAU
| | - Samaher G Basalib
- Medicine, Ibn Sina National College for Medical Studies, Jeddah, SAU
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Lowe M, Bambhroliya Z, Patel H, Patel VJ, Vudugula SA, Cheruvu NP, Raza S, Okunlola OI. Emerging Therapies for the Management of Pain and Vaso-Occlusive Crises in Patients With Sickle Cell Disease: A Systematic Review of Randomized Controlled Trials. Cureus 2023; 15:e38014. [PMID: 37223201 PMCID: PMC10204617 DOI: 10.7759/cureus.38014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 04/23/2023] [Indexed: 05/25/2023] Open
Abstract
Sickle cell disease (SCD) is an inherited disorder that impairs red blood cells (RBCs) and disrupts the delivery of oxygen to tissues. There is currently no cure. Symptoms can appear as early as six months of age and include anemia, acute episodes of pain, swelling, infections, delayed growth, and vision problems. A growing number of therapies are being investigated for reducing these episodes of pain, also known as vaso-occlusive crises (VOCs). The research literature evidence, however, currently includes far more approaches that have not shown superiority versus placebo than ones that have been proven effective. The purpose of this systematic review is to evaluate the body of randomized controlled trials (RCTs) to determine the quality of support for and against the use of a variety of current and emerging therapies for treading SCD VOCs. Several important new papers have emerged since previous systematic reviews with similar objectives were published. This review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and focused on PubMed exclusively. Only RCTs were sought, and no other filters, except for a five-year historical timeline cut-off, were used. Of the 46 publications that were returned in response to the query, 18 were ultimately accepted as meeting the pre-established inclusion criteria. The Cochrane risk-of-bias tool was utilized as a quality assessment measure, and the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework was used to assess the certainty of the evidence. Among the included publications, five out of 18 featured positive results with superiority and statistical significance versus placebo for either reduction in pain score or number/duration of VOCs. The approaches featured therapies ranging from de novo molecules to currently available drugs approved for other indications to naturally occurring metabolites such as amino acids and vitamins. A single therapy, arginine, was supported for both clinical endpoints: pain score reduction and shortened VOC duration. Currently, two therapies are approved by the United States Food and Drug Administration (FDA) and are commercially available (crizanlizumab, ADAKVEO and L-glutamine, Endari). All other therapies are investigational only in nature. Several studies included measurement of biomarker endpoints as well as clinical outcomes. Generally, beneficial outcomes related to improving biomarker levels did not also translate into statistically significant reduction of pain scores or number/duration of VOCs. While measuring biomarkers may contribute to the understanding of pathophysiology, it does not appear to directly offer predictive value toward treatment success clinically. It can be concluded that there exists a specific opportunity to design, fund, and execute investigations that both compare emerging and existing therapies versus one another and compare combinational therapies versus placebo.
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Affiliation(s)
- Michael Lowe
- Seeking Anesthesiology, Ross University School of Medicine, Fort Lauderdale, USA
| | - Zarna Bambhroliya
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Hesha Patel
- Internal Medicine, Capital Health Medical Center, New Jersey, USA
| | - Vishva J Patel
- Medicine, Gujarat Medical Education and Research Society (GMERS) Medical College, Vadodara, IND
| | | | | | - Shafaat Raza
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Nobrega R, Carullo V, Thein SL, Quezado ZM. Subanesthetic ketamine: the way forward for pain management in sickle cell disease patients? Expert Rev Hematol 2022; 15:887-891. [PMID: 36191299 PMCID: PMC9985469 DOI: 10.1080/17474086.2022.2131523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/28/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Patients with sickle cell disease (SCD) present recurrent episodes of acute pain, the hallmark of the disease, and some will also develop chronic pain. Currently, the treatment of SCD acute pain only targets its symptoms, rather than underlying mechanisms, and is directed by expert and consensus guidelines. AREAS COVERED While opioids remain the mainstay of therapy for acute pain and are also used to treat SCD-related chronic pain, in some patients, opioids are ineffective or are associated with severe undesirable side effects. In those instances, clinicians caring for patients with SCD face an unmet need for effective non-opioid analgesics. Recently, the use of subanesthetic ketamine has been explored as a strategy to meet this need. While definitive evidence of its efficacy is lacking, some information exists suggesting that subanesthetic ketamine improves pain control and may have opioid-sparing effects in SCD-related acute pain. However, ketamine can also yield undesirable psychotomimetic and cardiovascular effects. EXPERT OPINION After weighing potential risks and benefits, in the absence of better alternatives and in settings where it can be administered safely, ketamine may be a reasonable option for patients with SCD-related acute refractory pain.
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Affiliation(s)
- Raissa Nobrega
- Department of Anesthesiology & Critical Care Medicine, George Washington School of Medicine & Health Sciences, Washington, DC 20052, USA
| | - Veronica Carullo
- Departments of Anesthesiology & Pediatrics, University of Mississippi Medical Center, Jackson, MS 39157, USA
| | - Swee Lay Thein
- Sickle Cell Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Zenaide M.N. Quezado
- Sickle Cell Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
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8
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Anghelescu DL, Ryan S, Wu D, Morgan KJ, Patni T, Li Y. Low-dose ketamine infusions reduce opioid use in pediatric and young adult oncology patients. Pediatr Blood Cancer 2022; 69:e29693. [PMID: 35373875 PMCID: PMC9329174 DOI: 10.1002/pbc.29693] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Ketamine is an NMDA-receptor antagonist with analgesic and opioid-sparing properties. Although well studied in adults, more robust evidence supporting ketamine's use for pediatric pain management is needed. This retrospective study evaluates ketamine's opioid-sparing effectiveness in pediatric and young adult oncology and hematology patients. PROCEDURE Continuous ketamine infusions administered for pain management between 2010-2020 were reviewed. Data including demographic characteristics, oncology/hematology and pain diagnoses, concurrent pain medications, and ketamine infusions' dose and duration were collected. Opioid consumption data based on delivery via patient-controlled analgesia were collected 1 day before (D1), all days during (cumulatively named D2), and 1 day after (D3) ketamine infusions and calculated as morphine-equivalent doses (mg/kg/day). Data were reported for the entire study group as well as for distinct oncology and end-of-life categories, and short-term acute pain circumstances which included vaso-occlusive crises in hematology patients. Side effects were reviewed. RESULTS Significantly lower daily opioid consumption was noted in the oncology group, while decreases were not significant in the end-of-life group and in the overall study population. The acute pain group did not show an opioid reduction associated with the ketamine infusions. A largely tolerable side-effect profile was observed, with no differences among each group's incidence. CONCLUSIONS Ketamine infusions were associated with significantly reduced opioid consumption for oncology patients. The opioid-sparing effects of ketamine may vary according to clinical diagnoses and circumstances of use. Overall, low-dose ketamine infusions present an acceptable safety profile in pediatric and young adult patients; nevertheless, individual risks and benefits should be considered.
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Affiliation(s)
| | - Stephanie Ryan
- St. Jude Children's Research Hospital, Memphis, Tennessee
- Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Diana Wu
- St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Kyle J Morgan
- St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Tushar Patni
- St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Yimei Li
- St. Jude Children's Research Hospital, Memphis, Tennessee
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Tolu SS, Van Doren L. Acute and chronic pain management in patients with sickle cell disease in the modern era: A comprehensive review. Transfus Apher Sci 2022; 61:103533. [DOI: 10.1016/j.transci.2022.103533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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10
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Alenzi E. The effectiveness of ketamine compared to opioid analgesics for management of acute pain in children in the emergency department: systematic review. Am J Emerg Med 2022; 61:143-151. [DOI: 10.1016/j.ajem.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/27/2022] [Accepted: 08/03/2022] [Indexed: 10/31/2022] Open
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Kenney MO, Becerra B, Mallikarjunan A, Shah N, Smith WR. Early Initiation of Sub-Anesthetic Ketamine Infusion in Adults with Vaso-Occlusive Crises Is Associated with Greater Reduction in Sickle Cell Pain Intensity: A Single Center's Experience. PAIN MEDICINE 2022; 23:2042-2049. [PMID: 35708641 PMCID: PMC9959999 DOI: 10.1093/pm/pnac094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 05/04/2022] [Accepted: 05/28/2022] [Indexed: 11/14/2022]
Abstract
OBJECTIVES Recurrent, severely painful episodes, known as vaso-occlusive crises (VOCs) are the hallmark of sickle cell disease (SCD) and the primary reason for hospitalization. Opioids have been the gold standard for VOC treatment without significant improvement pain outcomes. To aid analgesia and combat opioid related adverse effects (ORAEs), some SCD clinicians have trialed infusions of sub-anesthetic ketamine along with opioids to treat VOCs. In this retrospective analysis, we compared adult SCD patients who received early vs late adjunctive sub-anesthetic ketamine infusions for VOCs. METHODS We identified adult SCD patients (age 18-50 years) who presented to Duke University with a VOC and received sub-anesthetic ketamine infusions from July 2015 to June 2019. We assessed both daily opioid consumption (measured as oral morphine milligram equivalents (MME)) and self-reported 0-10 numeric pain ratings (NPR) at 1, 2, and 3 days after infusion initiation, as well as 1 day after discontinuation. RESULTS A total of 56 patients were identified with a median age of 30 years. Compared to late administration, early infusion of sub-anesthetic ketamine was associated with a 24.5% (P = .0003) and 25.9% (P = .0006) reduction, respectively, in median NPR at 1 day and 2 days after infusion initiation but did not persist at 3 days following initiation of the infusion. A statistically significant reduction in MME was not observed. CONCLUSIONS In a nonrandomized study of sickle cell patients with VOCs, early sub-anesthetic ketamine infusion led to greater reduction in subjective pain intensity than late initiation of the infusion. Randomized studies should further explore whether early vs late ketamine infusion improves management of acute SCD pain.
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Affiliation(s)
- Martha O Kenney
- Correspondence to: Martha O. Kenney, MD, Department of Anesthesiology, University of North Carolina at Chapel Hill School of Medicine, N2198 UNC Hospitals, Campus Box 7010, Chapel Hill, NC 27599, USA. Tel: 919-966-5136; E-mail:
| | - Benjamin Becerra
- Center for Health Equity, Department of Information & Decision Sciences, California State University, San Bernardino, California, USA
| | - Arvind Mallikarjunan
- Department of Pediatric Hematology/Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Nirmish Shah
- Department of Pediatric Hematology/Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Wally R Smith
- Division of General Internal Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
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12
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Wachnik AA, Welch-Coltrane JL, Adams MCB, Blumstein HA, Pariyadath M, Robinson SG, Saha A, Summers EC, Hurley RW. A Standardized Emergency Department Order Set Decreases Admission Rates and In-Patient Length of Stay for Adults Patients with Sickle Cell Disease. PAIN MEDICINE 2022; 23:2050-2060. [PMID: 35708651 PMCID: PMC9714532 DOI: 10.1093/pm/pnac096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/20/2022] [Accepted: 06/10/2022] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Pain associated with sickle cell disease (SCD) causes severe complications and frequent presentation to the emergency department (ED). Patients with SCD frequently report inadequate pain treatment in the ED, resulting in hospital admission. A retrospective analysis was conducted to assess a quality improvement project to standardize ED care for patients presenting with pain associated with SCD. METHODS A 3-year prospective quality improvement initiative was performed. Our multidisciplinary team of providers implemented an ED order set in 2019 to improve care and provide adequate analgesia management. Our primary outcome was the overall hospital admission rate for patients after the intervention. Secondary outcome measures included ED disposition, rate of return to the ED within 72 hours, ED pain scores at admission and discharge, ED treatment time, in-patient length of stay, non-opioid medication use, and opioid medication use. RESULTS There was an overall 67% reduction in the hospital admission rate after implementation of the order set (P = 0.005) and a significant decrease in the percentage admission rate month over month (P = 0.047). Time to the first non-opioid analgesic decreased by 71 minutes (P > 0.001), and there was no change in time to the first opioid medication. The rate of return to the ED within 72 hours remained unchanged (7.0% vs 7.1%) (P = 0.93), and the ED elopement rate remained unchanged (1.3% vs 1.85%) (P = 0.93). After the implementation, there were significant increases in the prescribing of orally administered acetaminophen (7%), celecoxib (1.2%), and tizanidine (12.5%) and intravenous ketamine (30.5%) and ketorolac (27%). ED pain scores at discharge were unchanged for both hospital-admitted (7.12 vs 7.08) (P = 0.93) and non-admitted (5.51 vs 6.11) (P = 0.27) patients. The resulting potential cost reduction was determined to be $193,440 during the 12-month observation period, with the mean cost per visit decreasing by $792. CONCLUSIONS Use of a standardized and multimodal ED order set reduced hospital admission rates and the timeliness of analgesia without negatively impacting patients' pain.
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Affiliation(s)
| | | | | | | | | | | | - Amit Saha
- Department of Anesthesiology and Pain Service Line
| | - Erik C Summers
- Department of Internal Medicine Section of Hospital Medicine
| | - Robert W Hurley
- Correspondence to: Robert W. Hurley, MD, PhD, FASA, Department of Anesthesiology, Neurobiology and Anatomy, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27051, USA. Tel: 336-716-2266; Fax: 336-716-8773; E-mail:
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13
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Cooper-Sood JB, Hagar W, Marsh A, Hoppe C, Agrawal AK. Adjuvant low-dose ketamine for paediatric and young adult sickle cell vaso-occlusive episodes in the emergency department. Br J Haematol 2022; 198:207-209. [PMID: 35396855 DOI: 10.1111/bjh.18201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/29/2022] [Accepted: 03/31/2022] [Indexed: 11/30/2022]
Affiliation(s)
- J Bryan Cooper-Sood
- Division of Emergency Medicine, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Ward Hagar
- Division of Hematology/Oncology, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Anne Marsh
- Division of Hematology/Oncology, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Carolyn Hoppe
- Division of Hematology/Oncology, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Anurag K Agrawal
- Division of Hematology/Oncology, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
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14
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Kanjee Z, Achebe MO, Smith WR, Burns RB. How Would You Treat This Patient With Acute and Chronic Pain From Sickle Cell Disease? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2022; 175:566-573. [PMID: 35404671 DOI: 10.7326/m22-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Sickle cell disease is prevalent in large numbers of patients in the United States and has a significant global impact. Its complications span numerous organs and lead to reduced life expectancy. Acute and chronic sickle cell pain is a common cause of patient suffering. The American Society of Hematology published updated guidelines on management of acute and chronic pain from sickle cell disease in 2019. Several of the recommendations are conditional and leave specific decisions to the treating physician. These include conditional recommendations about the use of ketamine for acute pain and the initiation and discontinuation of long-term opioid therapy for chronic pain. Here, 2 hematologists discuss these guidelines and make contrasting recommendations for the management of acute and chronic pain for a patient with sickle cell disease.
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Affiliation(s)
- Zahir Kanjee
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Z.K., R.B.B.)
| | - Maureen Okam Achebe
- Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (M.O.A.)
| | - Wally R Smith
- Division of General Internal Medicine, Virginia Commonwealth University, Richmond, Virginia (W.R.S.)
| | - Risa B Burns
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Z.K., R.B.B.)
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15
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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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Chumpitazi CE, Chang C, Atanelov Z, Dietrich AM, Lam SH, Rose E, Ruttan T, Shahid S, Stoner MJ, Sulton C, Saidinejad M. Managing acute pain in children presenting to the emergency department without opioids. J Am Coll Emerg Physicians Open 2022; 3:e12664. [PMID: 35310402 PMCID: PMC8918119 DOI: 10.1002/emp2.12664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/12/2021] [Accepted: 01/03/2022] [Indexed: 02/06/2023] Open
Abstract
Pediatric pain is challenging to assess and manage. Frequently underestimated in children, untreated pain may have consequences including increased fear, anxiety, and psychological issues. With the current opioid crisis, emergency physicians must be knowledgeable in both pharmacologic and non‐pharmacologic approaches to address pain and anxiety in children that lead to enhanced patient cooperation and family satisfaction. This document focuses pain management and distress mitigation strategies for the brief diagnostic and therapeutic procedures commonly performed.
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Affiliation(s)
- Corrie E. Chumpitazi
- Department of Pediatrics Division of Emergency Medicine, Baylor College of Medicine, Texas Children's Hospital Houston Texas USA
| | - Cindy Chang
- Department of Pediatrics, Division of Emergency Medicine Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine Cincinnati Ohio USA
| | - Zaza Atanelov
- North Florida Regional Medical Center Emergency Department HCA/University of Central Florida College of Medicine Consortium Florida USA
| | - Ann M. Dietrich
- Department of Pediatrics and Emergency Medicine University of South Carolina College of Medicine Greenville North Carolina USA
| | - Samuel Hiu‐Fung Lam
- Department of Emergency Medicine Sutter Medical Center Sacramento Sacramento California USA
| | - Emily Rose
- Keck School of Medicine of the University of Southern California Los Angeles California USA
| | - Tim Ruttan
- Dell Children's Medical Center, Department of Pediatrics The University of Texas at Austin Dell Medical School, US Acute Care Solutions Austin Texas USA
| | - Sam Shahid
- American College of Emergency Physicians Irving Texas USA
| | - Michael J. Stoner
- Nationwide Children's Hospital The Ohio State University College of Medicine Columbus Ohio USA
| | - Carmen Sulton
- Emory University School of Medicine Children's Healthcare of Atlanta Atlanta Georgia USA
| | - Mohsen Saidinejad
- Department of Emergency Medicine Harbor UCLA Medical Center Torrance California USA
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17
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Brandow AM, Liem RI. Advances in the diagnosis and treatment of sickle cell disease. J Hematol Oncol 2022; 15:20. [PMID: 35241123 PMCID: PMC8895633 DOI: 10.1186/s13045-022-01237-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/15/2022] [Indexed: 12/12/2022] Open
Abstract
Sickle cell disease (SCD), which affects approximately 100,000 individuals in the USA and more than 3 million worldwide, is caused by mutations in the βb globin gene that result in sickle hemoglobin production. Sickle hemoglobin polymerization leads to red blood cell sickling, chronic hemolysis and vaso-occlusion. Acute and chronic pain as well as end-organ damage occur throughout the lifespan of individuals living with SCD resulting in significant disease morbidity and a median life expectancy of 43 years in the USA. In this review, we discuss advances in the diagnosis and management of four major complications: acute and chronic pain, cardiopulmonary disease, central nervous system disease and kidney disease. We also discuss advances in disease-modifying and curative therapeutic options for SCD. The recent availability of L-glutamine, crizanlizumab and voxelotor provides an alternative or supplement to hydroxyurea, which remains the mainstay for disease-modifying therapy. Five-year event-free and overall survival rates remain high for individuals with SCD undergoing allogeneic hematopoietic stem cell transplant using matched sibling donors. However, newer approaches to graft-versus-host (GVHD) prophylaxis and the incorporation of post-transplant cyclophosphamide have improved engraftment rates, reduced GVHD and have allowed for alternative donors for individuals without an HLA-matched sibling. Despite progress in the field, additional longitudinal studies, clinical trials as well as dissemination and implementation studies are needed to optimize outcomes in SCD.
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Affiliation(s)
- A. M. Brandow
- grid.30760.320000 0001 2111 8460Department of Pediatrics, Section of Pediatric Hematology/Oncology/Bone Marrow Transplantation, Medical College of Wisconsin, Milwaukee, WI USA
| | - R. I. Liem
- grid.413808.60000 0004 0388 2248Division of Hematology, Oncology and Stem Cell Transplantation, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL USA
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18
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Alshahrani MS, AlSulaibikh AH, ElTahan MR, AlFaraj SZ, Asonto LP, AlMulhim AA, AlAbbad MF, Almaghraby N, AlJumaan MA, AlJunaid TO, Darweesh MN, AlHawaj FM, Mahmoud AM, Alossaimi BK, Alotaibi SK, AlMutairi TM, AlSulaiman PharmD DA, Alfaraj D, Alhawwas R, Mbuagbaw L, Lewis K, Verhovsek M, Crowther M, Guyatt G, Alhazzani W. Ketamine administration for acute painful sickle cell crisis: A randomized controlled trial. Acad Emerg Med 2022; 29:150-158. [PMID: 34449939 PMCID: PMC9292870 DOI: 10.1111/acem.14382] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/27/2021] [Accepted: 08/15/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The objective was to evaluate the efficacy and safety of single-dose ketamine infusion in adults with sickle cell disease (SCD) who presented with acute sickle vasoocclusive crisis (VOC). METHODS This study was a parallel-group, prospective, randomized, double-blind, pragmatic trial. Participants were randomized to receive a single dose of either ketamine or morphine, infused over 30 min. Primary outcome was mean difference in the numerical pain rating scale (NPRS) score over 2 h. NPRS was recorded every 30 min for a maximum of 180 min and secondary outcomes were cumulative dose of opioids, emergency department (ED) length of stay, hospital admission, change in vital signs, and drug-related side effects. Authors performed the analysis using intention-to-treat principle. RESULT A total of 278 adults with SCD and who presented with acute sickle VOC participated in this trial. A total of 138 were allocated to the ketamine group. Mean (±standard deviation [SD]) NPRS scores over 2 h were 5.7 (±2.13) and 5.6 (±1.90) in the ketamine and morphine groups. The ketamine group received significantly lower cumulative doses of morphine during their ED stay (mean ± SD = 4.5 ± 4.6 mg) than of the morphine group (mean ± SD = 8.5 ± 7.55 mg). Both groups had similar rates of hospital admission: 6.3% in the ketamine group had drug-related side effects compared to 2.2% in the morphine group. CONCLUSION Early use of ketamine in adults with VOC resulted in a meaningful reduction in pain scores over a 2-h period and reduced the cumulative morphine dose in the ED with no significant drug-related side effects in the ketamine-treated group.
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Affiliation(s)
- Mohammed S. Alshahrani
- Emergency and Critical Care Departments King Fahad Hospital of the University‐Imam Abdulrahman Bin Faisal University Dammam Kingdom of Saudi Arabia
| | - Amal H. AlSulaibikh
- Emergency Department King Fahad Hospital of the University‐Imam Abdulrahman Bin Faisal University Dammam Kingdom of Saudi Arabia
| | - Mohamed R. ElTahan
- Anesthesiology Department King Fahad Hospital of the University‐Imam Abdulrahman Bin Faisal University Dammam Kingdom of Saudi Arabia
| | - Sukayna Z. AlFaraj
- Emergency Department King Fahad Hospital of the University‐Imam Abdulrahman Bin Faisal University Dammam Kingdom of Saudi Arabia
| | - Laila P. Asonto
- Emergency and Critical Care Departments King Fahad Hospital of the University‐Imam Abdulrahman Bin Faisal University Dammam Kingdom of Saudi Arabia
| | - Abdullah A. AlMulhim
- Emergency Department King Fahad Hospital of the University‐Imam Abdulrahman Bin Faisal University Dammam Kingdom of Saudi Arabia
| | - Murad F. AlAbbad
- Emergency Department King Fahad Hospital of the University‐Imam Abdulrahman Bin Faisal University Dammam Kingdom of Saudi Arabia
| | - Nisreen Almaghraby
- Emergency Department King Fahad Hospital of the University‐Imam Abdulrahman Bin Faisal University Dammam Kingdom of Saudi Arabia
| | - Mohammed A. AlJumaan
- Emergency Department King Fahad Hospital of the University‐Imam Abdulrahman Bin Faisal University Dammam Kingdom of Saudi Arabia
| | - Thamir O. AlJunaid
- Emergency Department King Fahad Hospital of the University‐Imam Abdulrahman Bin Faisal University Dammam Kingdom of Saudi Arabia
| | - Moath N. Darweesh
- Emergency Department King Fahad Hospital of the University‐Imam Abdulrahman Bin Faisal University Dammam Kingdom of Saudi Arabia
| | - Faisal M. AlHawaj
- Emergency Department King Fahad Hospital of the University‐Imam Abdulrahman Bin Faisal University Dammam Kingdom of Saudi Arabia
| | - Alaa M. Mahmoud
- Emergency Department King Fahad Hospital of the University‐Imam Abdulrahman Bin Faisal University Dammam Kingdom of Saudi Arabia
| | - Bader K. Alossaimi
- Emergency Department King Fahad Hospital of the University‐Imam Abdulrahman Bin Faisal University Dammam Kingdom of Saudi Arabia
| | - Shaikhah K. Alotaibi
- Emergency Department King Fahad Hospital of the University‐Imam Abdulrahman Bin Faisal University Dammam Kingdom of Saudi Arabia
| | - Talal M. AlMutairi
- Emergency Department King Fahad Hospital of the University‐Imam Abdulrahman Bin Faisal University Dammam Kingdom of Saudi Arabia
| | - Duaa A. AlSulaiman PharmD
- Pharmacy Department King Fahad Hospital of the University‐Imam Abdulrahman Bin Faisal University Dammam Kingdom of Saudi Arabia
| | - Dunya Alfaraj
- Emergency Department King Fahad Hospital of the University‐Imam Abdulrahman Bin Faisal University Dammam Kingdom of Saudi Arabia
| | - Reem Alhawwas
- Emergency Department King Fahad Hospital of the University‐Imam Abdulrahman Bin Faisal University Dammam Kingdom of Saudi Arabia
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact McMaster University Hamilton Ontario Canada
| | - Kim Lewis
- Department of MedicineMcMaster UniversityHamiltonOntarioCanada
| | | | - Mark Crowther
- Department of MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact McMaster University Hamilton Ontario Canada
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence and Impact McMaster University Hamilton Ontario Canada
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Vujović KS, Vučković S, Stojanović R, Divac N, Medić B, Vujović A, Srebro D, Prostran M. Interactions between Ketamine and Magnesium for the Treatment of Pain: Current State of the Art. CNS & NEUROLOGICAL DISORDERS DRUG TARGETS 2022; 20:392-400. [PMID: 33475079 DOI: 10.2174/1871527320666210121144216] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/20/2020] [Accepted: 09/11/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Over the past three decades, NMDA-receptor antagonists have been shown to be efficient drugs for treating pain, particularly pain resistant to conventional analgesics. Emphasis will be on the old-new drugs, ketamine and magnesium, and their combination as a novel approach for treating chronic pain. METHODS The MEDLINE database was searched via PubMed for articles that were published up to March 1, 2020, with the keywords 'ketamine', 'magnesium', and 'pain' (in the title/abstract). RESULTS Studies in animals, as well as humans, have shown that interactions of ketamine and magnesium can be additive, antagonistic, and synergistic. These discrepancies might be due to differences in magnesium and ketamine dosage, administration times, and the chronological order of drug administration. Different kinds of pain can also be the source of divergent results. CONCLUSION This review explains why studies performed with a combination of ketamine and magnesium have given inconsistent results. Because of the lack of efficacy of drugs available for pain, ketamine and magnesium in combination provide a novel therapeutic approach that needs to be standardized with a suitable dosing regimen, including the chronological order of drug administration.
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Affiliation(s)
- Katarina S Vujović
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Sonja Vučković
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Radan Stojanović
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nevena Divac
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Branislava Medić
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Dragana Srebro
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milica Prostran
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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20
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Should Ketamine Not Be Banned? A Scoping Review. Disaster Med Public Health Prep 2021; 17:e47. [PMID: 34664549 DOI: 10.1017/dmp.2021.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Although the importance of ketamine in clinical practice and in resource-poor settings and disaster zones, several attempts were made to reschedule it because of the issues around its misuse. Resisting future moves to reschedule ketamine is important for its continuous availability where needed. This scoping review addresses the question of whether ketamine should or should not be banned and the state of preparedness of low resource settings if ketamine petitions become successful in the future. METHODS A search was performed using PubMed and Google Scholar to identify articles published in the English language from March 2015 to August 2020. The articles were searched with a wide range of priori search terms related to the research questions. The selection of articles was based on relevance and eligibility. RESULTS Seventy-five articles were selected and grouped into 4 ethical themes. The search revealed that several articles addressed the importance of ketamine, pharmacology, misuse, supply, and consequences of a ketamine ban; however, none addressed how resource-poor countries should prepare for a future without the overreliance of ketamine. CONCLUSION Four ketamine petitions in about 10 years are an indication that another may resurface soon; therefore, it is important to continue to study the clinical importance of ketamine while discouraging its overreliance for clinical practice.
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21
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Welch-Coltrane JL, Wachnik AA, Adams MCB, Avants CR, Blumstein HA, Brooks AK, Farland AM, Johnson JB, Pariyadath M, Summers EC, Hurley RW. Implementation of Individualized Pain Care Plans Decreases Length of Stay and Hospital Admission Rates for High Utilizing Adults with Sickle Cell Disease. PAIN MEDICINE (MALDEN, MASS.) 2021; 22:1743-1752. [PMID: 33690845 PMCID: PMC8346918 DOI: 10.1093/pm/pnab092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Patients with sickle cell disease (SCD) face inconsistent effective analgesic management, leading to high inpatient healthcare utilization and significant financial burden for healthcare institutions. Current evidence does not provide guidance for inpatient management of acute pain in adults with sickle cell disease. We conducted a retrospective analysis of a longitudinal cohort quality improvement project to characterize the role of individualized care plans on improving patient care and reducing financial burden in high healthcare-utilizing patients with SCD-related pain. METHODS Individualized care plans were developed for patients with hospital admissions resulting from pain associated with sickle cell disease. A 2-year prospective longitudinal cohort quality improvement project was performed and retrospectively analyzed. Primary outcome measure was duration of hospitalization. Secondary outcome measures included: pain intensity; 7, 30, and 90-day readmission rates; cost per day; total admissions; total cost per year; analgesic regimen at index admission; and discharge disposition. RESULTS Duration of hospitalization, the primary outcome, significantly decreased by 1.23 days with no worsening of pain intensity scores. Seven-day readmission decreased by 34%. Use of intravenous hydromorphone significantly decreased by 25%. The potential cost saving was $1,398,827 as a result of this quality initiative. CONCLUSIONS Implementation of individualized care plans reduced both admission rate and financial burden of high utilizing patients. Importantly, pain outcomes were not diminished. Results suggest that individualized care plans are a promising strategy for managing acute pain crisis in adult sickle cell patients from both care-focused and utilization outcomes.
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Affiliation(s)
- Jena L Welch-Coltrane
- Department of Anesthesiology, Section of Pain Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Anthony A Wachnik
- Department of Anesthesiology, Section of Pain Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Meredith C B Adams
- Department of Anesthesiology, Section of Pain Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Cherie R Avants
- Department of Anesthesiology, Section of Pain Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Howard A Blumstein
- Department of Emergency Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Amber K Brooks
- Department of Anesthesiology, Section of Pain Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Andrew M Farland
- Department of Hematology, Wake Forest School of Medicine, North Carolina, USA
| | - Joshua B Johnson
- Department of Internal Medicine Section of Hospital Medicine, Wake Forest University School of Medicine, North Carolina, USA
| | - Manoj Pariyadath
- Department of Emergency Medicine, Wake Forest School of Medicine, North Carolina, USA
| | - Erik C Summers
- Department of Internal Medicine Section of Hospital Medicine, Wake Forest University School of Medicine, North Carolina, USA
| | - Robert W Hurley
- Department of Anesthesiology, Section of Pain Medicine, Wake Forest School of Medicine, North Carolina, USA
- Department of Neurobiology and Anatomy, Wake Forest School of Medicine, North Carolina USA
- Correspondence to: Robert W. Hurley, MD, PhD, FASA, Department of Anesthesiology, Neurobiology and Anatomy, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157-1009, USA. Tel: 336-716-2266; Fax: 336-716-8773; E-mail:
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22
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Sagi V, Mittal A, Tran H, Gupta K. Pain in sickle cell disease: current and potential translational therapies. Transl Res 2021; 234:141-158. [PMID: 33711512 PMCID: PMC8217144 DOI: 10.1016/j.trsl.2021.03.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/02/2021] [Accepted: 03/06/2021] [Indexed: 12/26/2022]
Abstract
Pain is a major comorbidity of sickle cell disease (SCD). Patients with SCD may suffer from both acute and chronic pain. Acute pain is caused by recurrent and unpredictable episodes of vaso-occlusive crises (VOC), whereas the exact etiology of chronic pain is still unknown. Opioids are the mainstay for pain treatment, but the opioid epidemic has significantly altered access to prescription opioids and has brought concerns over their long-term use into the forefront, which have negatively impacted the treatment of sickle pain. Opioids remain potent analgesics but growing opioid-phobia has led to the realization of an unmet need to develop nonopioid therapies that can provide relief for severe sickle pain. This realization has contributed to the approval of 3 different drugs by the Food and Drug Administration (FDA) for the treatment of SCD, particularly to reduce VOC and/or have an impact on the pathobiology of SCD. In this review, we outline the challenges and need for validation of side-effects of opioids and provide an update on the development of mechanism-based translational therapies, specifically targeting pain in SCD.
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Affiliation(s)
- Varun Sagi
- School of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Aditya Mittal
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Huy Tran
- School of Medicine, Kansas City University, Joplin, Missouri
| | - Kalpna Gupta
- Hematology/Oncology, Department of Medicine, University of California, Irvine and Southern California Institute for Research and Education, VA Medical Center, Long Beach, California.
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Harris EM, Vilk E, Heeney MM, Solodiuk J, Greco C, Archer NM. A systematic review of ketamine for the management of vaso-occlusive pain in sickle cell disease. Pediatr Blood Cancer 2021; 68:e28989. [PMID: 33788404 DOI: 10.1002/pbc.28989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/21/2021] [Accepted: 02/15/2021] [Indexed: 01/13/2023]
Abstract
Vaso-occlusive episodes (VOEs) are a common complication of sickle cell disease (SCD) and a significant cause of morbidity. Managing VOE pain can be difficult and complex. Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, has been used to manage VOE pain. This systematic literature review synthesizes research published from 2010 to 2020 on the use of ketamine infusion to decrease VOE pain. The review demonstrates that ketamine, a safe and effective treatment for VOE pain, could be considered more widely. However, the significant variability among published clinical studies with regard to dosing, timing of initiation, duration of infusion, and timing of discontinuation highlights the need for standardized ketamine infusion protocols for the management of VOE pain. We conclude with a brief discussion of key components of a potential standardized protocol supported by the literature reviewed as well as areas for future investigation.
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Affiliation(s)
- Emily M Harris
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Emily Vilk
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Matthew M Heeney
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Jean Solodiuk
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Christine Greco
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Natasha M Archer
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
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Benini F, Congedi S, Giacomelli L, Papa S, Shah A, Milani G. Refractory symptoms in paediatric palliative care: can ketamine help? Drugs Context 2021; 10:dic-2021-2-5. [PMID: 34104198 PMCID: PMC8152774 DOI: 10.7573/dic.2021-2-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/15/2021] [Indexed: 01/12/2023] Open
Abstract
Background One of the main challenges for paediatric palliative care (PPC) is the management of concomitant, different and severe symptoms that frequently affect the quality of life of PPC patients and are often refractory to commonly used pharmacological treatments. Consequently, many efforts are still needed to find the best therapeutic options to handle these refractory conditions. Since the first synthesis of ketamine in the 1960s, its pharmacokinetic and pharmacodynamic properties have been largely investigated and its potential wide range of clinical applications has become clear. However, this molecule still receives poor attention in some areas, including in children and PPC. This narrative review analyses the use of ketamine in children and the potential extension of its applications in PPC in order to provide new options for treatment in the PPC setting. Methods Scientific papers published before October 2020 on MEDLINE, EMBASE and the Cochrane Library were considered. The cited references of the selected papers and the authors’ personal collections of literature were reviewed. The terms “palliative care”, “ketamine”, “neuropathic pain”, “procedural pain”, “status epilepticus”, “refractory pain” and “child”, adding “age: birth–18 years” on a further filter were used for the search. Discussion The use of ketamine in PPC should be more widely considered due to its overall favourable safety profile and its efficacy, which are supported by an increasing number of studies, although in settings different from PPC and of mixed quality. Ketamine should be proposed according to a case-by-case evaluation and the specific diagnosis and the dosage and route of administration should be tailored to the specific needs of patients. Furthermore, there is evidence to suggest that ketamine is safe and efficacious in acute pain. These findings can prompt further research on the use of ketamine for the treatment of acute pain in PPC. Conclusion Ketamine could be a suitable option after the failure of conventional drugs in the treatment of different refractory conditions in PPC.
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Affiliation(s)
- Franca Benini
- Centro Regionale Veneto di Terapia del Dolore and Cure Palliative Pediatriche, Hospice Pediatrico, Padua, Italy
| | - Sabrina Congedi
- Centro Regionale Veneto di Terapia del Dolore and Cure Palliative Pediatriche, Hospice Pediatrico, Padua, Italy
| | | | | | | | - Gregorio Milani
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy.,Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain. Blood Adv 2021; 4:2656-2701. [PMID: 32559294 DOI: 10.1182/bloodadvances.2020001851] [Citation(s) in RCA: 156] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/09/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The management of acute and chronic pain for individuals living with sickle cell disease (SCD) is a clinical challenge. This reflects the paucity of clinical SCD pain research and limited understanding of the complex biological differences between acute and chronic pain. These issues collectively create barriers to effective, targeted interventions. Optimal pain management requires interdisciplinary care. OBJECTIVE These evidence-based guidelines developed by the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in pain management decisions for children and adults with SCD. METHODS ASH formed a multidisciplinary panel, including 2 patient representatives, that was thoroughly vetted to minimize bias from conflicts of interest. The Mayo Evidence-Based Practice Research Program supported the guideline development process, including updating or performing systematic reviews. Clinical questions and outcomes were prioritized according to importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE evidence-to-decision frameworks, to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel reached consensus on 18 recommendations specific to acute and chronic pain. The recommendations reflect a broad pain management approach, encompassing pharmacological and nonpharmacological interventions and analgesic delivery. CONCLUSIONS Because of low-certainty evidence and closely balanced benefits and harms, most recommendations are conditional. Patient preferences should drive clinical decisions. Policymaking, including that by payers, will require substantial debate and input from stakeholders. Randomized controlled trials and comparative-effectiveness studies are needed for chronic opioid therapy, nonopioid therapies, and nonpharmacological interventions.
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Alshahrani MS, Alghamdi MA. Ketamine for Sickle Cell Vaso-Occlusive Crises: A Systematic Review. SAUDI JOURNAL OF MEDICINE AND MEDICAL SCIENCES 2021; 9:3-9. [PMID: 33519337 PMCID: PMC7839575 DOI: 10.4103/sjmms.sjmms_218_20] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/13/2020] [Accepted: 09/22/2020] [Indexed: 01/11/2023] Open
Abstract
Introduction: Vaso-occlusive crisis (VOC) is one of the main causes of hospital admission in patients with sickle cell disease (SCD). Ketamine is often used as an adjuvant to opioids to control sickle cell crisis; however, there is a lack of evidence about its safety and efficacy for VOC in SCD patients. Objective: To synthesize evidence from published reports about the efficacy and safety of ketamine in the management of acute painful VOC in both pediatric and adult SCD patients. Methods: A systematic literature search of PubMed, Scopus, Web of Science, EBSCO and Cochrane Library was conducted, up to March 2019. Studies reporting the analgesic effects and side effects of ketamine in the management of acute painful VOC in pediatric and adult SCD patients were included. The primary outcome measure was improvement in pain scale, and the secondary outcomes were reduction in opioid utilization and side effects. Studies were narratively summarized in this review. Results: Fourteen studies (with a total of 604 patients) were included in the final analysis. Several case reports and case series showed that ketamine significantly reduced pain scales and opioid utilization in both populations. The only randomized controlled trial available showed that ketamine was noninferior to morphine in reducing pain scores, but had a higher incidence of nonlife-threatening, reversible adverse effects. However, a retrospective study of 33 patients showed a higher pain score in the ketamine group with an acceptable short-term adverse effect. Conclusion: Ketamine has a potentially comparable efficacy with other opioids in reducing the pain during VOC in SCD patients. However, it also likely has a higher rate of transient adverse events. Owing to the lack of published randomized controlled trials, current evidence is not sufficient to confirm the safety and efficacy of ketamine. Future well-designed randomized controlled trials are strongly recommended.
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Affiliation(s)
- Mohammed S Alshahrani
- Department of Emergency Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Eastern Province, Saudi Arabia
| | - Mohannad A Alghamdi
- Department of Emergency Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Eastern Province, Saudi Arabia
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Prakash S, Gupta AK, Meena JP, Seth R. A review of the clinical applications of ketamine in pediatric oncology. Pediatr Blood Cancer 2021; 68:e28785. [PMID: 33128439 DOI: 10.1002/pbc.28785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/16/2020] [Accepted: 10/19/2020] [Indexed: 12/30/2022]
Abstract
Ketamine is a dissociative anesthetic agent with excellent analgesic properties and a favorable safety profile. The feasibility and efficacy of various routes of administration have been established, including intravenous (IV), intramuscular (IM), oral, intranasal, rectal, and transdermal routes. The advent of newer anesthetic agents has led to a decline in the use of ketamine as an anesthetic, but its utility in short-term sedation and analgesia has expanded. Its value for chronic pain management in children with cancer is being increasingly recognized but requires more evidence. The use of topical ketamine is largely in investigational stages. Medical use of ketamine is, to a great extent, free from significant long-term neurological side effects. The objective of this review is to provide a brief account of the pharmacology of ketamine and primarily focus on the clinical applications of ketamine in pediatric oncology.
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Affiliation(s)
- Satya Prakash
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Aditya Kumar Gupta
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Jagdish Prasad Meena
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rachna Seth
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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Alenzi E. The Effectiveness of Ketamine Compared to Opioid Analgesics for Management of Acute Pain in Children in the Emergency Department: Systematic Review. Health (London) 2021. [DOI: 10.4236/health.2021.1311098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Creary SE, Chisolm DJ, Wrona SK, Cooper JN. Opioid Prescription Filling Trends Among Children with Sickle Cell Disease After the Release of State-Issued Guidelines on Pain Management. PAIN MEDICINE 2020; 21:2583-2592. [PMID: 32142138 DOI: 10.1093/pm/pnaa002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To assess the impact of Ohio's 2012, 2013, and 2016 opioid prescribing guidelines on opioid and nonsteroidal anti-inflammatory drug (NSAID) prescription filling and health care utilization for pain among children with sickle cell disease (SCD). DESIGN Quasi-experimental retrospective cohort study. SETTING Ohio Medicaid claims data from August 2011 to August 2016. SUBJECTS Medicaid beneficiaries under age 19 years with SCD. METHODS Interrupted time series analyses comparing population-level rates of opioids and NSAID prescriptions filled, standardized amounts of opioids dispensed, and acute health care utilization for pain before and after release of each guideline. RESULTS In our cohort of 1,505 children with SCD, there was a temporary but significant decrease in the opioid filling rate (-2.96 prescriptions per 100 children, P = 0.01) and in the amount of opioids dispensed (-31.39 milligram morphine equivalents per filled prescription, P < 0.001) after the 2013 guideline but a temporary but significant increase in the opioid filling rate (7.44 prescriptions per 100 children, P < 0.001) and in the amount of opioids dispensed (72.73 mg morphine equivalents per filled prescription, P < 0.001) after the 2016 guideline. The NSAID filling rate did not significantly change after any of the guidelines. Acute health care utilization rates for pain after the 2016 guideline were similar to those before the 2013 guideline (rate ratio = 1.04, P = 0.63). CONCLUSIONS Our results suggest that Ohio's 2013 and 2016 guidelines were associated with significant but nonsustained changes in opioid prescription filling among children with SCD. Additional studies are needed to confirm that opioid guidelines have a sustained impact on excessive opioid prescribing, filling, and misuse.
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Affiliation(s)
- Susan E Creary
- Division of Pediatric Hematology/Oncology/BMT, Center for Innovation in Pediatric Practice, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Deena J Chisolm
- Center for Innovation in Pediatric Practice, Abigail Wexner Research Institute at Nationwide Children's Hospital Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Sharon K Wrona
- Department of Anesthesiology & Pain Medicine/Comprehensive Pain and Palliative Care Services Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
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Brandehoff N, Benjamin JM, Balde C, Chippaux JP. Ketamine for pain control of snake envenomation in Guinea: A case series. Toxicon 2020; 187:82-85. [PMID: 32891662 DOI: 10.1016/j.toxicon.2020.08.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/11/2020] [Accepted: 08/26/2020] [Indexed: 11/18/2022]
Abstract
Snakebite envenomation is a global health crisis and is classified as a Category A neglected tropical disease by the World Health Organization (WHO). Snakebite envenomations account for a significant amount of morbidity and morbidity in tropical and subtropical regions. Recently, publications have illustrated the potential for snake envenomations causing post-traumatic stress disorder (PTSD) in a significant number of patients. Ketamine is on the WHO's list of essential medications and is used for a variety of pharmacologic applications including anesthesia and acute pain management. To date it has not been assessed for pain control in snakebite envenomations. Twelve patients who presented with severe pain secondary to Bitis, Causus, and Atractaspis envenomations were treated with low-dose intravenous ketamine. The patients included 7 males and 5 females with a median age of 37.5 (range 14-64) and a median presentation time of 5.75 h (range 5 min-96 h) after the initial bite occurred. Ten envenomations were presumed to have been caused by Bitis species resulting in extensive swelling and blistering of the affected extremities. One envenomation was presumedC. maculatus causing local swelling and pain. One envenomation was a presumed Atractaspis species causing significant local pain with minimal swelling. All patients expressed having significant pain but could not express the degree of their pain using an analogue pain scale. An initial median dose of 5 mg of ketamine (range 2.5-15 mg) was administered intravenously for pain control. Every patient expressed decreased pain and felt more comfortable within 1 min after administration of ketamine. Nine of the twelve patients only required a single dose. There were no adverse side effects. Ketamine appears to be an effective means of pain control for those suffering from painful envenomations. With minimal risk of significant side effects at acute pain management doses and the average cost per effective dose averaging between US$0.03-0.06, this may provide a cheap, safe, and effective solution for Sub-saharan Africa and other resource-limited settings. Controlled studies need to be done to critically assess our observations.
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Affiliation(s)
- Nicklaus Brandehoff
- Asclepius Snakebite Foundation, 217 Howard St, Walla Walla, WA, 99362, USA; University of Colorado School of Medicine, 13001 E 17th Pl, Aurora, CO, 80045, USA; Rocky Mountain Poison and Drug Safety, 1391 Speer Blvd, Denver, CO, 80204, USA.
| | - Jordan Max Benjamin
- Asclepius Snakebite Foundation, 217 Howard St, Walla Walla, WA, 99362, USA; Whitman College, 345 Boyer Ave, Walla Walla, WA, 99362, USA
| | - Cellou Balde
- Asclepius Snakebite Foundation, 217 Howard St, Walla Walla, WA, 99362, USA; Institut de Recherche en Biologie Appliqueé de Guinée (IRBAG), Conakry, Guinea
| | - Jean-Philippe Chippaux
- Asclepius Snakebite Foundation, 217 Howard St, Walla Walla, WA, 99362, USA; Institute of Research for Development, Paris, France
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Fiocchi J, Urits I, Orhurhu V, Orhurhu MS, Giacomazzi S, Hoyt B, Kaye AD, Kaye RJ, Viswanath O. A Comprehensive Review of the Treatment and Management of Pain in Sickle Cell Disease. Curr Pain Headache Rep 2020; 24:17. [PMID: 32200490 DOI: 10.1007/s11916-020-00854-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW Sickle cell disease (SCD) is a hematological disorder which leads to serious complications in multiple organ systems. While significant research has addressed many of the effects of acute pain episodes and end-organ damage connected to this disease, little has approached the chronic pain state associated with this condition. RECENT FINDINGS Associated chronic pain represents a significant detractor from the quality of life experienced by these patients, affecting over half of those with SCD on more days than not. Current treatment typically is centered upon preventing and responding to acute vasoocclusive crises, presumably because this is the most common reason for hospitalization in these patients. The lack of management of chronic pain symptoms leaves many with SCD in a state of suffering. In this review, the treatment methodologies of SCD patients are examined including alternative treatments, both pharmaceutical and non-pharmaceutical, as well as procedural approaches specifically aimed at reducing chronic pain in these patients.
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Affiliation(s)
- Jacob Fiocchi
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Ivan Urits
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
| | - Vwaire Orhurhu
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Mariam Salisu Orhurhu
- Department of Anesthesia, Critical Care, and Pain Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Stephen Giacomazzi
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Briggs Hoyt
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Rachel J Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ, USA.,Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA.,Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
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Neuropathic pain in individuals with sickle cell disease. Neurosci Lett 2020; 714:134445. [DOI: 10.1016/j.neulet.2019.134445] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 06/06/2019] [Accepted: 08/20/2019] [Indexed: 12/18/2022]
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Opioid treatment for acute and chronic pain in patients with sickle cell disease. Neurosci Lett 2020; 714:134534. [DOI: 10.1016/j.neulet.2019.134534] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 09/13/2019] [Accepted: 10/01/2019] [Indexed: 12/24/2022]
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Harvey M, Sleigh J, Voss L, Bickerdike M, Dimitrov I, Denny W. KEA-1010, a ketamine ester analogue, retains analgesic and sedative potency but is devoid of Psychomimetic effects. BMC Pharmacol Toxicol 2019; 20:85. [PMID: 31856925 PMCID: PMC6923863 DOI: 10.1186/s40360-019-0374-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 11/26/2019] [Indexed: 12/21/2022] Open
Abstract
Background Ketamine, a widely used anaesthetic and analgesic agent, is known to improve the analgesic efficacy of opioids and to attenuate central sensitisation and opioid-induced hyperalgesia. Clinical use is, however, curtailed by unwanted psychomimetic effects thought to be mediated by N-methyl-D-aspartate (NMDA) receptor antagonism. KEA-1010, a ketamine ester-analogue designed for rapid offset of hypnosis through hydrolysis mediated break-down, has been shown to result in short duration sedation yet prolonged attenuation of nociceptive responses in animal models. Here we report on behavioural effects following KEA-1010 administration to rodents. Methods KEA-1010 was compared with racemic ketamine in its ability to produce loss of righting reflex following intravenous injection in rats. Analgesic activity was assessed in thermal tail flick latency (TFL) and paw incision models when injected acutely and when co-administered with fentanyl. Tail flick analgesic assessment was further undertaken in morphine tolerant rats. Behavioural aberration was assessed following intravenous injection in rats undergoing TFL assessment and in auditory pre-pulse inhibition models. Results KEA-1010 demonstrated an ED50 similar to ketamine for loss of righting reflex following bolus intravenous injection (KEA-1010 11.4 mg/kg [95% CI 10.6 to 12.3]; ketamine (racemic) 9.6 mg/kg [95% CI 8.5–10.9]). Duration of hypnosis was four-fold shorter in KEA-1010 treated animals. KEA-1010 prolonged thermal tail flick responses comparably with ketamine when administered de novo, and augmented morphine-induced prolongation of tail flick when administered acutely. The analgesic effect of KEA-1010 on thermal tail flick was preserved in opioid tolerant rats. KEA-1010 resulted in increased paw-withdrawal thresholds in a rat paw incision model, similar in magnitude yet more persistent than that seen with fentanyl injection, and additive when co-administered with fentanyl. In contrast to ketamine, behavioural aberration following KEA-1010 injection was largely absent and no pre-pulse inhibition to acoustic startle was observed following KEA-1010 administration in rats. Conclusions KEA-1010 provides antinociceptive efficacy in acute thermal and mechanical pain models that augments standard opioid analgesia and is preserved in opioid tolerant rodents. The NMDA channel affinity and psychomimetic signature of the parent compound ketamine is largely absent for KEA-1010.
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Affiliation(s)
- Martyn Harvey
- Emergency Department, Waikato Hospital, Pembroke St, Hamilton, 3240, New Zealand.
| | - Jamie Sleigh
- Anesthesia Department, Waikato Hospital, Pembroke St, Hamilton, 3240, New Zealand
| | - Logan Voss
- Anesthesia Department, Waikato Hospital, Pembroke St, Hamilton, 3240, New Zealand
| | - Mike Bickerdike
- Kea Therapeutics Ltd, Lumley Centre, 88 Shortland Street, Auckland, New Zealand
| | - Ivaylo Dimitrov
- Auckland Cancer Society Research Centre, University of Auckland, Park Rd, Auckland, New Zealand
| | - William Denny
- Auckland Cancer Society Research Centre, University of Auckland, Park Rd, Auckland, New Zealand
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Masaracchia MM, Sites BD, Lee J, Thomas JJ, Fernandez PG. Subanesthetic ketamine infusions for the management of pediatric pain in non-critical care settings: An observational analysis. Acta Anaesthesiol Scand 2019; 63:1225-1230. [PMID: 31313291 DOI: 10.1111/aas.13429] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/01/2019] [Accepted: 06/04/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Guidelines issued by the American Society of Regional Anesthesia and Pain Medicine suggest that ketamine infusions for acute pain management are advantageous as a primary treatment or as an opioid adjunct. Despite significant data regarding its use in adult patients, there remains a paucity of information related to its quality and side effect profile in pediatrics and how it can be effectively used. We aimed to summarize our practice of utilizing ketamine for pediatric pain management in non-critical care settings. METHODS Patients aged 0-21 years receiving low-dose ketamine infusions (≤0.3 mg/kg/hour) in inpatient care units over five years were retrospectively analyzed. Demographics, specific quality metrics, and side effects were quantified. RESULTS About 172 patients received 270 subhypnotic ketamine infusions. The median duration of the infusions was 63.8 hours and 0.2 mg/kg/hour for the highest dose. The primary indication for ketamine was chronic pain exacerbation (83.3%). Despite similar opioid consumption, there was a significant reduction in mean verbal pain scores before (8.9 ± 1.9, P < .001) and after ketamine (6.5 ± 2.7, P < .001) use. Although there were 52 incidences of some side effect (neurologic excitability [10.4%]; over-sedation [7.4%]; rapid response team alerts [1.1%]), none resulted in termination of the infusion or escalations in care. CONCLUSION Ketamine can effectively be used as part of a multimodal analgesic regimen in pediatric patients in non-critical care settings. Our five-year experience using low-dose ketamine infusions highlights an acceptable side effect profile, with no attributable escalations in care or serious adverse events.
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Affiliation(s)
- Melissa M. Masaracchia
- Department of Anesthesiology, Section of Pediatric Anesthesiology University of Colorado, Children’s Hospital Colorado Aurora Colorado
| | - Brian D. Sites
- Department of Anesthesiology Dartmouth‐Hitchcock Medical Center Lebanon New Hampshire
| | - Justin Lee
- University of Colorado School of Medicine Aurora Colorado
| | - James J. Thomas
- Department of Anesthesiology, Section of Pediatric Anesthesiology University of Colorado, Children’s Hospital Colorado Aurora Colorado
| | - Patrick G. Fernandez
- Department of Anesthesiology, Section of Pediatric Anesthesiology University of Colorado, Children’s Hospital Colorado Aurora Colorado
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Alshahrani MS, Asonto LP, El Tahan MM, Al Sulaibikh AH, Al Faraj SZ, Al Mulhim AA, Al Abbad MF, Al Nahhash SA, Aldarweesh MN, Mahmoud AM, Almaghraby N, Al Jumaan MA, Al Junaid TO, Al Hawaj FM, AlKenany S, ElSayed OF, Abdelwahab HM, Moussa MM, Alossaimi BK, Alotaibi SK, AlMutairi TM, AlSulaiman DA, Al Shahrani SD, Alfaraj D, Alhazzani W. Study protocol for a randomized, blinded, controlled trial of ketamine for acute painful crisis of sickle cell disease. Trials 2019; 20:286. [PMID: 31133061 PMCID: PMC6537144 DOI: 10.1186/s13063-019-3394-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 05/04/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sickle cell disease (SCD) is an inherited hematological disorder where the shape of red blood cells is altered, resulting in the destruction of red blood cells, anemia, and other complications. SCD is prevalent in the southern and eastern provinces of the Arabian peninsula. The most common complications for individuals with SCD are acute painful episodes that require several doses of intravenous opioids, making pain control for these individuals challenging. Instead of opioids, some studies have suggested that ketamine might be used for pain control in acute pain episodes of individuals with SCD. This study aims to evaluate whether the addition of ketamine to morphine can achieve better pain control, decreasing the number of repeated doses of opiates. We hypothesize that early administration of ketamine would lead to a more rapid improvement in pain score and lower opioid requirements. METHODS AND ANALYSIS This study will be a prospective, randomized, concealed, blinded, pragmatic parallel group, controlled trial enrolling adult patients with SCD and acute vaso-occlusive crisis pain. All patients will receive standard analgesic therapy during evaluation. Patients randomized to the treatment arm will receive low-dose ketamine (0.3 mg/kg in 0.9% sodium chloride, 100 ml bag) in addition to standard intravenous hydration, while those in the control group will receive a standard dose of morphine (0.1 mg/kg in 0.9% sodium chloride, 100 ml bag) in addition to the standard intravenous hydration. All healthcare providers will be blinded to the treatment arm. Data will be analyzed according to the intention-to-treat principle. The primary outcome is improvement in pain severity using the Numerical Pain Rating Score. TRIAL REGISTRATION Clinicaltrials.gov, NCT03431285 . Registered on 13 February 2018.
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Affiliation(s)
- Mohammed S Alshahrani
- Emergency and Critical Care Departments, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia.
| | - Laila Perlas Asonto
- Emergency and Critical Care Departments, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Mohamed M El Tahan
- Anesthesia Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, Kingdom of Saudi Arabia, Mansoura University, Mansoura, Egypt
| | - Amal H Al Sulaibikh
- Emergency Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Sukayna Z Al Faraj
- Emergency Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Abdullah A Al Mulhim
- Emergency Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Murad F Al Abbad
- Emergency Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Samar A Al Nahhash
- Emergency Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Moath N Aldarweesh
- Emergency Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Alaa M Mahmoud
- Emergency Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Nisreen Almaghraby
- Emergency Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Mohammed A Al Jumaan
- Emergency Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Thamir O Al Junaid
- Emergency Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Faisal M Al Hawaj
- Emergency Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Samar AlKenany
- Emergency Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Omaima F ElSayed
- Emergency Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Haitham M Abdelwahab
- Emergency Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Mohamed M Moussa
- Emergency Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Bader K Alossaimi
- Emergency Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Shaikah K Alotaibi
- Emergency Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Talal M AlMutairi
- Emergency Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Duaa A AlSulaiman
- Pharmacy Department, King Fahad Hospital of the University, AlKhobar, Kingdom of Saudi Arabia
| | - Saad D Al Shahrani
- Emergency Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Donia Alfaraj
- Emergency Department, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University-Dammam, AlKhobar, Kingdom of Saudi Arabia
| | - Waleed Alhazzani
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
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Barelli R, Morelli Sbarra G, Sbaraglia F, Zappia L, Rossi M. Prevention of post-operative hyperalgesia in a heroin-addicted patient on methadone maintenance. J Clin Pharm Ther 2019; 44:397-399. [PMID: 30636175 DOI: 10.1111/jcpt.12798] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 11/26/2018] [Accepted: 12/10/2018] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE The exponential increase in chronic opioid consumers resulted in more challenges regarding post-operative pain management. Considering the usual hyperalgesic response to pain and the increased opioid-tolerance, a multidrug approach should be desirable. CASE DESCRIPTION We described the strategy in pain management of a patient receiving methadone maintenance treatment, who underwent surgery associated with moderate post-operative pain. The combination of balanced general anaesthesia and intraoperative continuous low-dose infusion of ketamine assured an appropriate control of post-operative pain without increasing opioid consumption. Besides, it was not associated with psychomimetic effects. WHAT IS NEW AND CONCLUSION Ketamine can effectively reduce opioid requirements in chronic opioid users on methadone maintenance therapy and should therefore be considered promptly as part of a multimodal perioperative analgesia management in this category of patients.
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Affiliation(s)
- Roberta Barelli
- Institute of Anesthesia and Intensive Care, Fondazione Policlinico Universitario "A Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gloria Morelli Sbarra
- Institute of Anesthesia and Intensive Care, Fondazione Policlinico Universitario "A Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fabio Sbaraglia
- Institute of Anesthesia and Intensive Care, Fondazione Policlinico Universitario "A Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Zappia
- Institute of Anesthesia and Intensive Care, Fondazione Policlinico Universitario "A Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marco Rossi
- Institute of Anesthesia and Intensive Care, Fondazione Policlinico Universitario "A Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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