Sickle Cell Disease with Pain Clinical Pathway – Emergency Department and Inpatient – Moderate/Severe Pain Medication Dosing

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

Moderate/Severe Pain Medication Dosing

  • Refer to individualized pain plan if available
  • Children on chronic opioid therapy may require higher opioid dosing than recommended below. Use individual clinical decision making based on pain assessment
  • ED management
    • Optimal IV pain treatment includes initial bundle: ketorolac + opioid within 60 mins of ED arrival
    • Reassess pain 20–30 mins after giving the IV bundle
    • Give 2nd opioid dose (50% of the initial dose) if pain persists after 20–30 mins
    • Give 3rd opioid dose (50% of the initial dose) if pain persists after 20–30 mins
  • Admission required
    • Repeat initial dose of the IV opioid
    • Start scheduled IV opioid every 3 hrs
    • Continue ketorolac IV every 6 hrs
    • ED consults Child Life to provide non-pharmacologic pain treatment e.g., music, guided imagery, movies/video games, etc
    • ED consults Integrative Medicine to offer acupuncture
  • Inpatient service
Medication Route Administration Dose/Indication Comment
Ketorolac IV IVP 2–3 min
  • 0.5 mg/kg/dose
  • Max
    30 mg/dose
  • If child has significant dehydration/volume depletion, speak with Attending about NS bolus before administration
  • Avoid after 1st trimester
  • If completed a 5-day ketorolac course within 7 days, do not continue ketorolac
Fentanyl IN
  • ED Only
    • With atomizer
    • Use 1 mL syringe, add 0.1 mL extra to prime, administer half of volume into each nostril
  • 2 mcg/kg
  • Max
    100 mcg/dose
  • Max Volume
    1 mL per nare
  • Does not replace need for IV opioid unless child has mild/moderate pain and PO treatment is considered
  • Bridge for IV placement
  • Onset 5–10 min
Morphine IV Slow IVP over 5 mins by RN or MD — ED Only
  • 0.1–0.15 mg/kg/dose
  • Max
    6 mg/dose
  • Children on chronic opioid therapy may require higher opioid dosing than recommended below
  • Use individual clinical decision making based on pain assessment
  • Hydromorphone 5–7 times more potent than morphine
Hydromorphone IV Slow IVP, 2 or 3 min by RN with MD available — ED Only
  • 0.01–0.015 mg/kg/dose
  • Max
    1 mg/dose

Adjunctive Medications While on Opioids

Medication Route Dose/Indication Comment
Diphenhydramine PO
  • PRN for itching:
    • 1 mg/kg/dose
    • Max
      50 mg/dose
  • IV use is discouraged due to abuse potential
  • If IV necessary, infuse over 10–15 min
Cetirizine PO
  • PRN for itching
  • ≥ 2–5 yrs: 5 mg once daily
  • ≥ 6 yrs: 10 mg once daily
  
Hydroxyzine PO
  • IP Only
    • PRN for itching:
      • 2 mg/kg/day
      • Max
        25 mg/dose in 3–4 divided doses
  
Polyethylene Glycol (PEG) PO
  • Daily for constipation prevention:
    • PEG ≥ 20 kg: 17 g
  
Senna PO
  • Daily for constipation:
    • Syrup
      • 5–15 mL (8.8–26.4 mg) at bedtime
      • < 12 yrs: Max 7.5 mL (13.2 mg) BID
      • ≥ 12 yrs: Max 15 mL (26.4 mg) BID
    • Tablet
      • 1–2 tablets (8.6–17.2 mg) at bedtime
      • < 12 yrs: Max 2 tablets (17.2 mg)
      • ≥ 12 yrs: Max 4 tablets (34.4 mg) BID
  
Ondansetron PO/IV
  • q8hr PRN nausea:
    • 0.1–0.15 mg/kg dose
    • Max
      8 mg
  
Naloxone IV
  • PRN respiratory depression:
    • 0.001–0.01 mg/kg
 May repeat q2–3min as needed based on response