Pain management in adults with sickle cell disease in a medical center emergency department.

Guidelines for pain management in adult sickle cell patients with vaso-occlusive crises suggest prompt, frequent administration of parenteral opioids. Neither the ability to implement these guidelines in a busy urban emergency department nor opioid dose requirements in uncomplicated vaso-occlusive crisis have been previously documented. Thus, a retrospective review of vaso-occlusive crisis treated in an urban medical center emergency department in 2005 was performed to define opioid requirements and barriers to guideline implementation. Fifty-seven visits by 19 patients were evaluable. Opioid treatment was not initiated for more than 2 hours during 30% of visits; the interval between the first and second opioid doses exceeded 1 hour in 26% of visits and increased with subsequent doses; and total treatment time was less than 1 hour during 21% of visits (median, 2.2 hours). Opioid doses (as intravenous morphine equivalents) ranged from 4 to 26.7 mg (0.05-0.50 mg/kg) and exceeded 10 mg during 40 visits (70%) and in 10 patients (53%). Hospitalization occurred on 25 occasions with 48% of patients admitted after 3 or fewer opioid doses and 50% of patients admitted after less than 3 hours of treatment. Moreover, return emergency department visits occurred within 3 days after 9 of 32 home discharges (28%) with treatment times uniformly less than 3 hours during the preceding visit. It is concluded that: (1) opioid dose requirements vary widely, often exceeding guideline recommendations; and (2) treatment time and timely opioid administration are often compromised, resulting in delayed pain control and premature decisions on disposition with early return visits and possibly avoidable hospital admissions.