More Rapid Delivery of Parenteral Analgesia By Adding Intranasal Fentanyl to the Management of Sickle Cell Disease Vaso-Occlusive Pain Episodes at a Pediatric Emergency Department
Authors: Akinsola Bolanle T , Hagbom Robert , Zmitrovich April , Kavanagh Patricia , Ashkouti Ashley , Fletcher Amy , Vinson Natalie , Simon Harold , Fleming Alesia , Jain Shabnam , Adisa Olufolake , Dampier Carlton , Morris Claudia R. 
Published: October 2019

Abstract

Background: Vaso-occlusive episodes (VOE) are the leading cause of hospitalizations & emergency department (ED) visits in sickle cell disease (SCD), & are associated with increased mortality. Intranasal fentanyl (INF) provides rapid & powerful parenteral analgesia, with an onset of action of 5-10 minutes, & peak effect in 30 minutes. INF is a safe & effective method of pain management for children in the ED & other settings, yet it is underutilized in SCD.
Objective: To study the impact of the addition of INF to standard ED management for SCD VOE on time to parenteral opioid, pain scores, ED length of stay (LOS) & admission rate.
Methods: This quality improvement initiative was conducted at a tertiary pediatric ED at Children's Healthcare of Atlanta from November 2013-May 2014. Patients with all genotypes of SCD ages ≥2 years old who presented with VOE & pain score >6/10 were offered INF within 15 minutes of triage. 2 INF doses (1.5mcg/kg/dose; max 100mcg/dose) were given 5 minutes apart. Patients then continued on institutional standard protocol treatment for VOE (±PO hydrocodone, ±IV ketorolac, & ± IV morphine or IV hydromorphone). Pain scores were documented at frequent intervals by nursing staff. Patient/parent satisfaction data were obtained using a satisfaction questionnaire. Outcomes included: Time from arrival to 1st parenteral opioid, pain scores, ED LOS (time from arrival to disposition), admission rates & patient/parent satisfaction. We compared patients in this study to those who did not receive INF during the study period (n=48) & historical controls from Jan-Dec 2012 (n=231) for the 1st three outcomes.
Results: 248 visits for VOE met inclusion criteria, of whom 228 received parenteral opioids (92%) & 180/228 (79 %) received INF. Mean age was 11.7±4.5 years. The majority were female (56%), 65% HbSS, 14% HbSC & 21% had other genotype. 48 patients did not receive INF; 36 were not offered INF without explanation for protocol deviation &12 patients refused. They had similar gender & Hb genotype, but were older than INF+ patients (13.5±4.0 years, p=0.01). The mean time from arrival to 1st parenteral opioid decreased significantly in the INF+ group compared to historical controls, and was remarkably shorter than those not treated with INF. There was minimal difference in LOS between INF+ group & historical controls, but LOS was shorter in the group that did not receive INF. Admission rates were significantly higher in those who did not receive INF when compared to those treated with INF & historical controls.
(See Table 1)
Table 1 INF+(n =180) INF-(n =48) Historical Data (n=231) P-value Time to 1st Parenteral Opioid (minutes) 29 ±15 77 ±44 35±18 p < 0.0001 LOS (minutes) 215± 86 197± 67 231±95 p = 0.028 Admission Rate (%) 48% 71% 45% p = 0.004
Mean baseline pain score was 8.5±1.5, 1st reassessment pain score after INF was 7.8±2.4 & last ED pain score prior to disposition was 5.5±3.4. Pain scores were similar in all groups. 98 families completed the patient satisfaction questionnaire, 79 (81%) of whom received INF. 65% of patients who received INF were satisfied & would like to receive the treatment again in the ED.
Conclusions: The addition of INF to the management of SCD VOE significantly improved time to receipt of 1st parenteral analgesia & was well tolerated. Admission rates were significantly higher in patients who did not receive INF during our study period. The associated delay in time to receipt of 1st parenteral analgesia may have contributed to the increased admission rate. However, causality of INF on admission rates cannot be determined without further study. INF did not impact ED LOS compared to historical controls, however rapid admission turn-around time likely decreased LOS in the INF- group. INF is a safe & effective strategy to provide rapid pain relief in children with SCD & VOE.

Disclosures
Off Label Use: Intranasal Fentanyl (INF). Widely accepted as off label use in pediatric ED's and a variety of other clinical settings for the management of pain. It is a synthetic narcotic analgesic with a rapid onset and short duration of action. Current evidence suggests that INF is a safe and effective method of pain management for children in a variety of clinical settings..