Sickle Cell Disease with Pain Clinical Pathway – Emergency Department and Inpatient – ED Team Assessment

Sickle Cell Disease with Pain Clinical Pathway – Emergency Department and Inpatient

ED Team Assessment

  • The initial team goal is to assess and treat pain rapidly. Offer intranasal fentanyl on arrival to room.
  • NSAIDS are a very effective component of initial therapy. Give initial bundle of NSAID + opioid.
  • Reassess pain 20–30 mins after IV administration and 60 mins after PO administration.
  • Provide additional doses of opioids for persistent pain in a timely way.
  • Consult Child Life and Integrative Medicine to provide non-pharmacologic adjuncts.
Pain Assessment
  • Reported level of pain is the gold standard
  • Assess, document pain
  • Home pain medications
  • Recent pain medication, dose, time of last dose
  • Allergies to any medication, use of PO Benadryl with morphine
  • Order pain medication immediately
    • Moderate/severe pain — IN fentanyl, IV Bundle: ketorolac + opioid
Monitoring Admit to central monitoring system for children receiving IV opioids
Vascular Access, Laboratory Studies
  • Place IV, ultrasound-guided as needed
  • For moderate/severe pain:
    • Send CBC, differential, reticulocyte count
  • For mild pain:
    • Labs only as clinically indicated
Additional Diagnostic Testing
  • Type and Screen
    • Pale, persistent tachycardia
    • Suspected splenic sequestration
    • Acute chest syndrome
    • Focal neurologic findings
    • Hgb < 5 g/dL or Hgb drop > 2 g/dL from baseline Hgb
    • Reticulocyte count < 1% (unless hemoglobin > 10 g/dL)
  • Chest Radiograph
    • New hypoxia
    • Chest pain
    • Clinical suspicion for pneumonia/acute chest syndrome
  • HCG
    • All post-menarchal females and all females > 12 yrs
IVF
  • As clinically indicated for:
    • Clinical dehydration/intravascular volume depletion
  • Note: IVF offers no therapeutic effect for children with VOE