Sickle cell patients need better pain relief

Of 21,112 sickle cell disease patients in eight states who were hospitalized or treated and released from hospital emergency departments in 2005 and 2006, 40% returned to the ED for treatment of pain or were rehospitalized within 30 days.1

"The most important aspect for emergency department nurses would be to recognize that patients with sickle cell disease frequently receive care at more than one institution and receive care at hospitals and EDs repeatedly," says Claudia Steiner, MD, MPH, one of the study's authors and a senior research physician at Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project.

Ask the patient when they were last seen by their primary care physician, if they have a primary care physician, and where and when the patient was last treated in the hospital or ED. "This will help to establish how severe the patient's sickle cell disease is, as well as understand how coordinated or uncoordinated the patient's care is," says Steiner.

Many sickle cell patients do return to the ED shortly after being treated, reports Jim Phillips, MD, associate professor of emergency medicine at University of Mississippi Medical Center (UMMC) in Jackson. "The reasons for this are largely based on opinion," he says. "A minority of patients experience opiate addiction. Other groups of patients simply experience pain that may last for days at a time."

Unique needs

Sickle cell pain patients experience this chronic condition "in a very individual and unique way," says Jeremy Johnson, RN, PhD(c), CEN, CCRN, an ED nurse at UMMC. "The medical literature is sparse, when it comes to a definitive tool that can be used to treat all patients in crisis."

Johnson says that "the first and foremost mistake" an ED nurse can make, though, is to underestimate the quality and severity of the patient's pain. Nwachi Nwakanma, RN, a sickle cell nurse at Grady Health System in Atlanta, says, "It is not just giving the pain medicine. Showing some compassion goes a long way."

A small population of these patients visit UMMC's ED several times a week or month. "Every ED nurse is familiar with these patients," says Johnson. "It is easy to become complacent when treating patients with sickle cell disease."

Although a small minority of patients in sickle cell pain crisis are 'frequent flyers,' they make up a majority of ED visits, says Robert Cox, MD, PhD, professor and associate chair of emergency medicine at UMMC. "This makes management a particularly difficult task," he says.

Cox says that factors such as opiate-induced hyperanalgesia, opiate withdrawal, and drug-seeking behavior come into play for a small number of patients. "Unfortunately, the ED management of sickle cell pain crisis can lead to the development of opiate dependence," says Cox. This dependence is especially prevalent if the patient is visiting multiple EDs within a local area, he adds.

"Opiates have been the mainstay of treatment, but higher doses are often needed, due to tolerance by some patients," says Cox. (See clinical tip, below, on hydration, and related story on assessment of sickle cell patients, below.)

Reference

  1. Brousseau DC, Owens PL, Mosso AL, et al. Acute care utilization and rehospitalization for sickle cell disease. JAMA 2010;303:1288-1294.

Clinical Tip

Sickle cell crisis? Hydrate adequately

For an ED patient in sickle cell crisis, administration of hypotonic solutions such as one-half normal saline can be helpful, says Robert Cox, MD, PhD, professor and associate chair of emergency medicine at University of Mississippi Medical Center in Jackson.

"Oxygen therapy and oral fluid intake are often encouraged in patients, even if they are not hypoxic and/or clinically dehydrated," he adds.

Nwachi Nwakanma, RN, a sickle cell nurse at Grady Health System in Atlanta, says, "Our fluid of choice is D5W unless it's contraindicated for our patient. We also encourage oral hydration. It gets the patient out of trouble and keeps them from getting into crisis."


Medical emergencies possible with sickle cell

Don't assume anything

Even if you think pain control is the only reason a sickle cell patient is presenting to your ED, always perform a complete assessment, says Misty Heggemeier, RN, an ED nurse at St. John's Mercy Medical Center in St. Louis, MO. Heggemeier once cared for a man with a sickle cell crisis who had a cardiac event.

"The patient may be judged or assessed inaccurately due to frequent visits to the ER, often for the same complaint," says Heggemeier. "Staff may begin to assume the reason the patient is coming in and miss an actual emergent event."

Changes in vital signs, reported "new" pain, and findings such as weakness or chest pain should not be overlooked, warns Jeremy Johnson, RN, PhD(c), CEN, CCRN, an ED nurse at University of Mississippi Medical Center in Jackson. "It is important that the ED nurse maintain a higher index of suspicion for these patients, especially since they visit the ED so much," says Johnson.

Treatment for sickle cell pain crisis is typically aimed at resolving the pain and returning the patient to a baseline status, he notes. However, these patients should be treated with a high degree of clinical suspicion, Johnson says.

"This is especially important when the patient reports new clinical symptoms or different qualities of pain," says Johnson. "ED nurses often are able to spot these new symptoms in frequently visited patients and can intervene much earlier."