ED Pathway for Evaluation/Treatment of Children with Sickle Cell Disease and Pain
  • Severe or Atypical HA
  • Altered Mental Status
  • Focal Neurologic Findings
  • New Seizure
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MD/CRNP/RN Rapid Assessment
MILD / MODERATE PAIN
MODERATE / SEVERE PAIN
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Minimal Pain Management at home
Aggressive Pain Management at home
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Oxycodone 
< 6 yrs0.15 mg/kg up to 2.5 mg
6-12 yrs0.2 mg/kg up to 5 mg
> 12 yr0.2 mg/kg up to 10 mg
AND
Ibuprofen10 mg/kg
 (If no NSAIDS in preceding 6 hrs)

Reassess

  • 30-60 minutes after po dose
  • If pain adequately controlled, discharge at 1 hour
  • If pain not adequately controlled, proceed
    to IV analgesia
IV/IN Analgesia
Fentanyl2 mcg/kg administered with MAD
 Consider as bridge if severe pain to ease IV access
 Does not replace need for IV morphine
Morphine 0.1-0.15 mg/kg/dose IV(max 7 mg/dose) 
 Order 1st prn dose (50% of initial dose at the same time)
OR
Hydromorphone0.015-0.02 mg/kg/dose IV(max 2 mg/dose) 
 Order 1st prn dose (50% of initial dose at the same time)
AND
Ketorolac 0.5 mg/kg/dose IV(max 30 mg/dose) 
 (if no NSAIDS in preceding 6 hours)
ReassessEvery 20-30 minutes
 Document pain score using age-appropriate scale
 Monitor for side effects and complications

Titration of Opioid Therapy

Administer 25-50% of initial Morphine or Hydromorphone loading dose every 20-30 minutes as patient tolerates until pain adequately controlled

After 3rd PRN morphine or hydromorphone dose

Pain not adequately controlled – Admit to Hematology Service
Pain adequately controlled, or consider transition to PO, possible discharge

Hematology Consultation
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Home
  • Patients with the following:
  • Pain relief continues for a minimum of 60 minutes following oral analgesia
  • Pain is relieved after 1 or 2 doses of IV analgesia
  • Relief is maintained on oral analgesic therapy
  • Absence of other complications of sickle cell disease
  • Pain Management Algorithm
  • Discharge Plan
HACU Admission
  • Patients with the following:
  • ≥ 6 months of age
  • Non-toxic
  • Uncomplicated vaso-occlusive pain event requiring multiple IV doses of analgesics
Inpatient Admission Criteria
  • Patients with the following:
  • < 6 months of age
  • Focal neurologic findings
  • Acute chest syndrome
  • Splenic sequestration
  • Fever
  • Reticulocyte count < 1 % (unless Hgb > 10 g/dL)
  • Severe anemia (Hgb < 5 g/dL)
Posted: July, 2010
Revised: October 2011, October 2014
Authors: A. Ellison, MD, Lisa Payne, RN, C. Norris, MD, K. Smith-Whitley, MD, C. Jacobstein, MD, J. Lavelle, MD
 
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