The painful crisis is the commonest acute presentation of sickle cell disease (SCD), yet effective pain control in hospital is often delayed, inadequate and dependent on injected opiates. Intranasal diamorphine (IND) has been used in paediatric emergency departments for management of acute pain associated with fractures, but the analgesic effect is short lived. We evaluated its efficacy and safety when given in combination with intravenous or oral morphine for rapid analgesia for children presenting to our emergency department with painful crisis of SCD. In phase 1, nine patients received IND plus intravenous morphine. In phase 2, 13 received IND plus oral morphine. There was a rapid improvement in pain score; the proportions in severe pain at t = 0, 15, 30 and 120 minutes in phase 1 were 78%, 11%, 0% and 11%, respectively; in phase 2, 77%, 30%, 15% and 0%, respectively. There were no serious side effects and questionnaire scores indicated that children found IND effective and acceptable. IND can be recommended for acute control of sickle pain in children presenting to hospital.
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The painful crisis is the most frequent acute complication of sickle cell disease (SCD) in children and adults.1 Pain is often extremely severe, but resolves spontaneously after a variable period lasting hours to days. Mild episodes are generally managed at home with simple analgesia but severe episodes require strong opiates and may require closer monitoring in hospital. Good management incorporates immediate pain control in the emergency department. Despite being such a common emergency in areas of high prevalence, management is often unsatisfactory from the patient’s viewpoint.2 This increases anxiety and may exacerbate pain, as well as jeopardising the relationship between patient, family and carer.
Parenteral opiates are the mainstay of analgesia, but injections are uncomfortable for children, and venous access is often difficult because of peripheral venous damage from repeated cannulations. This approach may also lead to unnecessarily high doses of opiates during childhood and adolescence with potential complications later in adulthood. Previously, we used an intravenous morphine bolus followed by a patient-controlled analgesia (PCA) pump, but an audit showed delays of up to ⩾1 h in receiving the first dose, and in setting up the PCA.
Diamorphine is a potent opiate which is highly soluble, enabling its preparation at a high concentration. It is rapidly effective when given by the intranasal route in children with acute pain related to fracture, but the analgesic effect wears off after 20–30 minutes.3 4 There are no previous reports on the use of intranasal diamorphine (IND) for acute pain management in SCD.
The aims of this study were to assess its efficacy in acute painful sickle cell crises and to evaluate the safety profile, prior to incorporation into a sickle cell pain management protocol in our unit.
Children with SCD (HbSS, HbSC or HbS/beta thalassaemia), aged 1–16 years, presenting to the paediatric emergency department with acute painful crisis which had not responded to home analgesia (paracetamol, ibuprofen and codeine) were eligible. Exclusion criteria were age <1 year, shock, airway compromise, respiratory depression, and diminished level of consciousness. The aim of the trial was to recruit 10 patients into each of two consecutive phases:
Phase 1: IND 0.1 mg/kg given as a single dose immediately on arrival, followed if required by intravenous morphine bolus (100 mcg/kg) and infusion via PCA when venous access had been secured.
Phase 2: IND 0.1 mg/kg given simultaneously with oral morphine (Oromorph) 0.4 mg/kg immediately on arrival, followed by further oral morphine 0.4 mg/kg after 1 h if required.
Diamorphine was prepared and administered according to published guidelines.5
Evaluation of pain score and adverse effects was carried out at t = 0, 15, 30 and 120 minutes. The British Association of Emergency Medicine paediatric pain assessment tool was used.5 The final category was chosen by the nurse managing the child. After resolution of pain, children (or parents of young children) were asked to assess efficacy and acceptability of IND on a visual analogue scale graded from 0 to 10 (0 = very bad, 10 = very good). The study was approved by the institutional Ethics Committee.
Nine patients were recruited to phase 1 and 13 to phase 2. The mean age was 10 years (range 2–16). Pain scores are shown in fig 1. There was a rapid improvement in pain score; the proportion of children in severe pain at t = 0, 15, 30 and 120 minutes in phase 1 were 78%, 11%, 0% and 11%, respectively, while in phase 2 they were 77%, 30%, 15% and 0%, respectively. Pain severity scores appeared to improve more rapidly in phase 1 compared with phase 2, but numbers were too small to make a formal statistical comparison. There was a recurrence of severe pain in one child in phase 1, following cannulation difficulties prior to the administration of intravenous morphine. In phase 1, six patients were given additional morphine, two did not require any additional analgesia and were sent home from the emergency department, and two had oral morphine because of difficulty with cannulation. In phase 2, all children received oral morphine in addition to IND. There were no episodes of respiratory depression or sedation. Eight children in total reported minor side effects, consisting of nasal irritation, pruritus and nausea. In response to the question: “How well did the medication work for you?”, the mean score was 8.2 out of 10, and to the question “Was this type of medication acceptable to you?” the mean score was 8.5.
We have shown that IND can be safely combined with morphine to provide immediate and safe analgesia, and that initial pain management is adequate in most cases with oral morphine, without the need for intravenous opiates. We found that rapid and efficient administration of analgesia in the emergency department by the nursing staff relieved anxiety and stress and provided reassurance to both the child and their parents. IND together with oral morphine is now used routinely in our centre and a recent audit shows that it is usually given within 5 minutes of arrival, and enables the remainder of the crisis to be managed effectively during the transition from emergency department to the in-patient ward. This regime could be applied in other centres where diamorphine is licensed for clinical use in children.
We thank the staff in the Paediatric Emergency Department, the Paediatric Pain Team and Paediatric Pharmacy at The Royal London Hospital.
Competing interests None declared.
Ethics approval The study was approved by the institutional Ethics Committee.
Contributions PT designed the protocol, analysed the results and wrote the manuscript. IM, FD, JS and JC undertook the evaluation of intranasal diamorphine in the Paediatric Emergency Department at The Royal London Hospital.
Provenance and peer review Not commissioned; externally peer reviewed.
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