ADULT (>16) ACUTE SICKLE PAIN GUIDELINE

Transcription

1 ADULT (>16) ACUTE SICKLE PAIN GUIDELINE ID Author s Name Dr Anna Wood Author s Job Title Consultant Haematologist Division Consultant Haematologist Department Haematology Version number 3 Ratifying Committee Integrated Standards Executive Ratified date April 2013 Review date March 2015 Upload Date 5 June 2013 Name of manager responsible for review Dr Anna Wood Job title of manager responsible for review Consultant Haematologist address for this manager anna.wood@whht.nhs.uk Source of evidence NICE Clinical Guideline CG143 Sickle cell acute painful episode; management of an acute painful sickle cell episode in hospital June 2012 Standards for the clinical care of adults with sickle cell disease in the UK, (2008) Guidelines for the management of acute painful crisis in sickle cell disease, B.J. Haem (2003): 120(5) Rees, D.C., Olujohungbe A.D. Level of evidence indicated B Referenced Yes Key words Adult Sickle Cell; Pain The Trust is committed to promoting an environment that values diversity. All staff are responsible for ensuring that all patients and their carers are treated equally and fairly and not discriminated against on the grounds of race, sex, disability, religion, age, sexual orientation or any other unjustifiable reason in the application of this policy, and recognising the need to work in partnership with and seek guidance from other agencies and services to ensure that special needs are met. Page 1 of 8

2 Contents Page Introduction 3 1. Routine Investigations 3 2. Additional Investigations 3 3 Pulse oximetry 3 4. Pain Management Fluids 4 6. Oxygen 5 7. Antibiotics 5 8. Other Drugs Management on PCA 7-8 Page 2 of 8

3 Introduction Patients with Sickle Cell Disease presenting to Casualty should be fast tracked and treated as an acute medical emergency. Pain relief should be administered within 30 minutes of presentation. If patient is admitted to AAU, haematologists should be informed by the medical team, particularly if a patient has chest or abdominal signs, neurological signs, priapism or shock. Sickle cell patients should be allocated as category 1 Haematology. 1. Routine Investigations Should include: FBC, reticulocytes and blood film Group & antibody screen (red cell genotype should be requested if patient new to us) Haemoglobin electrophoresis (only when a new sickle cell patient presents). Please do NOT request % HbS. Baseline chemistry including liver function Note: Patients on Desferrioxamine (DFO), admitted with diarrhoea/abdominal pain, should have blood (clotted sample) and stool screened for Yersinia and the DFO stopped. If indicated Viral serology Blood cultures Urine dipstick + MSU Throat swab 2. Additional Investigations If there are chest, abdominal, or spinal signs: chest X-ray and oxygen saturation If there are abdominal signs: abdominal x-ray and amylase Appropriate microbiological specimens (sputum, stool, wound, etc.) Routine chest x rays are not necessary 3. Pulse Oximetry Record baseline pulse oximetry on air with other vital signs and then monitor and chart 2 hourly. If oxygen saturations <90% do arterial blood gases on air. 4. Pain Management Document pain level on scale 0 to 3. Ask the patient how much and what form of analgesia (especially opiates) they have taken in the previous 24 hours. Discuss their normal analgesia Page 3 of 8

4 5. Fluids requirements. If they are requesting different analgesia or at non standard doses (see below) please liaise with haematology team as soon as possible. Ask if the patient has a specific written management plan with them. a) If the patient is in severe pain (with a pain score of 3) Give a subcutaneous (S/C) dose of MORPHINE SULPHATE 5-20mg This will take minutes to have effect and may be repeated at 1 hour intervals if needed. If the patient requires admission and is requiring repeated opioid doses consider using a S/C Patient Controlled Analgesia (PCA) pump. For more details on PCA pump please refer to Management of Sickle Pain on the ward, found at the end of this document on pages 6-7 inclusive. Please note Pethidine is not routinely offered in oral or parenteral form to patients with sickle cell disease. In rare circumstances Pethidine may be required. However, very occasionally patients are truly allergic to morphine (< 10%) with bronchospasm or severe pruritis and they may be given IM Pethidine (75-100mg) initially Start oral Ibuprofen 400mg qds if no contraindications (such as renal impairment, gastric ulcers or cardiovascular conditions 1 ) or Diclofenac by suppository (maximum dose of 150mg in 24 hours) b) If the patient has moderate pain (with a pain score of 2) and can take oral medication: Give oral Ibuprofen 400mg qds and oral Dihyrocodeine 60mg qds c) If the patient has mild pain (with a pain score of 1) and can take oral medication: Give a simple analgesic such as oral Paracetamol 1g qds (if nil by mouth see page 8 below) or Oral Dihydrocodeine 30mg qds An intravenous line should be established whenever parenteral opiates have been given: Give 1 litre of Sodium Chloride 0.9% over 3 hours, then alternating litres of Sodium Chloride 0.9% and 5% Glucose + 20 mmols Potassium Chloride at a rate of a litre 8 hourly. Start a fluid balance chart. If this is not possible, consider nasogastric (NG) fluids unless there are abdominal signs or symptoms. Page 4 of 8

5 6. Oxygen This is of doubtful use if the patient has only limb pain but may be prescribed and given if the patient requests it. Patients should be monitored by pulse oximetry with regular readings on air. Offer oxygen if oxygen saturation < 95% on air. Check arterial gases if O 2 saturation< 90%. If the arterial po 2 on air is: <10.7kPa (80 mm Hg) - use a 35% mask but, if po 2 <9.5kPa (70 mm Hg), Haematologist needs to be involved in view of the possibility of acute chest syndrome. Remember that excess opioid analgesia can cause respiratory suppression. (Naloxone is occasionally required 2.) 7. Antibiotics Patients admitted with sickle crises are often pyrexial. If temperature <38 C and infection not clinically suspected continue prophylactic Penicillin (or Erythromycin if Penicillin sensitive). If the patient is pyrexial 38 C, start iv antibiotics, the choice of agents to be determined by the likely focus of infection, and discontinue Penicillin V if relevant. More common causes of high fever in SCD include: Pneumococcal sepsis Gram negative sepsis Lower respiratory tract infection Urinary tract infection Osteomyelitis Antibiotics for patients with chest signs should be discussed with Haematologist on call who may wish to discuss this further with the Microbiologist on call if severe infection suspected. Note: If patients on DFO have diarrhoea, the DFO should be stopped and Ciprofloxacin started immediately but stopped if diagnosis of Yersinia has been excluded. Ciprofloxacin should be avoided where possible in adolescents in line with national guidance (see BNF). 8. Other Drugs Please write up for: Folic acid 5mg orally od Patients admitted on Morphine sulphate regimes may experience a variety of side effects. The following are suggested: Constipation: Docusate sodium 200mg bd regularly Senna 2-4 tablets od prn Pruritis: Chlorphenamine 4mg po, 10mg im 8 hourly or Hydroxyzine 25mg po 12 hourly Page 5 of 8

6 Nausea/Vomiting Cyclizine 50mg im/po/iv 8 hourly or Metoclopramide 10mg, po, im, iv 8 hourly Note: Avoid Metoclopramide in patients <20 years in line with national guidance (see BNF) 9. NEVER aspirate an affected joint without prior discussion with the Haematologist. 10. Stop oral intake if the abdomen is silent. Page 6 of 8

7 MANAGEMENT OF SICKLE PAIN ON PCA Patient controlled analgesia (PCA) Morphine Sulphate PCA Via Graseby 3300 pump Subcutaneous route of administration To set up pumps contact 9am-5pm pain control nurses via bleep (WGH 1120) 5pm-9am weekdays, weekends and Bank Holidays Anaesthetist on call (Bleep 1125 or 1102) Any other member of staff trained and deemed competent by Acute Pain Team to set/instigate pumps for PCA facility How to set up pumps Pumps should be initially set up using following schedule This should be reviewed every 24 hours and dosages adjusted if necessary Obtain Graseby 3300 pump and anti-syphon and anti reflux giving set (located in recovery) Obtain pre-filled syringe 50mg Morphine sulphate in 50ml Sodium Chloride 0.9%. Surgical wards keep these syringes, Medical wards will have to obtain them from pharmacy Connect and prime giving set. Programme pump (see page 7). Ensure the patient knows how to bolus their dose as necessary via the pump, it must be the patient only that give the bolus dose. Write prescription for PCA pump on prn side of drug chart Prescribe anti-emetic either: Cyclizine 50mg im/po 8 hourly or Metoclopramide 10mg po/im/iv 8 hourly Note: Avoid Metoclopramide in patients <20 years in line with national guidance (see BNF) Prescribe Naloxone 400 micrograms iv on prn side of drug chart to reverse opiate induced respiratory suppression to keep respiratory rate >8rpm. Make up 400 micrograms to a total of 8mls 0.9% Sodium Chloride. Give in 2ml boluses and review response. Repeat as necessary every 5 mins as indicated to keep respiratory rate >8rpm and action any deterioration. Call for medical help. Nursing staff to monitor following observations hourly for first 4 hours then every 2 hours: Respiratory rate Sedation score Oxygen saturation on air Pain score Nausea and vomiting score Record PCA values on green PCA chart If respiratory rate falls to <8rpm or sedation score 3 irrespective of respiratory rate, STOP the Morphine Sulphate pump and inform the doctor. Page 7 of 8

8 MORPHINE PATIENT-CONTROLLED ANALGESIA (PCA) Set up values for Graseby 3300 pump Concentration MORPHINE (mg/ml) PCA Bolus dose (mg) PCA Bolus delivery time Lockout time (mins) SET UP VALUES 1mg/ml 2 mg = 2ml Stat 5 mins IV Paracetamol When paracetamol is administered intravenously the dose must be weight related for adult patients if below 50kg. Administer, 15mg/kg every 4-6hrs (BNF) References:- 1. British National Formulary: Latest publication. 2. West Hertfordshire Hospitals NHS Trust Guideline for Administration of Naloxone for Adult Patients Receiving Patient Controlled Analgesia & Opioid Epidural Analgesia. Page 8 of 8