Emergency Department and Inpatient Clinical Pathway for the Evaluation/Treatment of Children with Sickle Cell Disease and Pain
- Related Pathway
40 mins
60 mins
90 mins
120 mins
150 mins
180 mins
- Consider Stroke Protocol
- Severe or atypical headache
- Altered mental status
- Focal neurologic findings
- New seizure
- Consult Hematology, Neurology
Contact T7 Attending/APP for Medication Orders
- Offer IN fentanyl immediately
- Order pain medications
- IV access if moderate/severe pain
- CBC, differential
- Reticulocyte count
- History and Physical
- Child Life, Acupuncture Consult
- Consider ThermaCare Wrap
- Admit to central monitoring system
Initial Bundle
IV ketorolac and
Morphine 0.1 mg/kg or hydromorphone 0.01 mg/kg
Morphine 0.1 mg/kg or hydromorphone 0.01 mg/kg
- Consider IN fentanyl
- Ibuprofen and
- Morphine IR or oxycodone
Reassess pain 20–30 min
Reassess 60 mins
Reassess pain 20–30 min
IV Opioid #2
Give 50% initial dose if no significant improvement
Persistent pain
Consider IVpain medications
Child comfortable
Reassess pain 20–30 min
IV Opioid #3
Give 50% initial dose if no significant improvement
Reassessing Pain
- Reported pain remains the gold standard for pain assessment
- Wake the child to reassess pain
- Pain Assessment and Management
Determine disposition, Hematology Consult
Persistent, significant pain
Child comfortable
Plan for Admission
Persistent pain
PO Opioid
Oxycodone or morphine IR
IV Opioid #4
- Repeat morphine 0.1 mg/kg or hydromorphone 0.01 mg/kg
- Start q3hr scheduled opioid
- Schedule ketorolac q6 hrs
- Hourly pain assessment
- Continue non-pharmacologic interventions
- Continue scheduled opioid q3hr and ketorolac
Reassess 1 hr
Child comfortable
Discharge criteria
Discharge
- Pain relief
- After 1–3 doses of IV analgesia
- Continues 60 mins after PO opioid
- No complications of sickle cell disease
- Medications
- Morphine IR or oxycodone 3-day supply
- Ibuprofen/acetaminophen for 5–7 days total
- Advise child/family timing of the next dose
- Continue non-pharmacologic interventions
Evidence
- American Society of Hematology 2020 Guidelines for Sickle Cell Disease: Management of Acute and Chronic Pain
- Effect of Poloxamer 188 vs Placebo on Painful Vaso-Occlusive Episodes in Children and Adults With Sickle Cell Disease
- Evaluation of Vaso-occlusive Crisis Management With Patient-Controlled Analgesia in Children With Sickle Cell Disease Requiring Hospitalization
- Patient Controlled Analgesia for Vaso-Occlusive Episodes in Children: A Retrospective Study
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