Implementing Intranasal Fentanyl for Pain Management

Date: June 15, 2023 Reference: Rees CA et al. Intranasal fentanyl and discharge from the emergency department among children with sickle cell disease and vaso-occlusive pain: A multicenter pediatric emergency medicine perspective. American Journal of Hematology Jan 2023 Guest Skeptic: Dr. Amy Drendel is a pediatric emergency medicine physician and physician scientist at Children’s Wisconsin. She is a Professor of Pediatrics and Interim Chief of the Section of Pediatric Emergency Medicine at the Medical College of Wisconsin. Her research interests include optimizing pain treatment in children. She has been a principal investigator and co-investigator on multiple collaborative grants evaluating effectiveness of analgesic regimens for children. Dr. Amy Drendel Case: A 14-year-old male with sickle cell disease (SCD) presents to your emergency department (ED) with a vaso-occlusive pain episode (VOE) of his bilateral legs and back. He tells you that he has had similar pain from previous VOEs, but his sister is graduating from high school tomorrow, and he really hopes he can go home so he can attend her graduation. He denies any fever or difficulty breathing. On exam, he appears uncomfortable with tenderness to palpation of the bilateral shins and lower back. The rest of his exam is unremarkable. As you begin ordering bloodwork and a dose of intravenous (IV) morphine, his nurse says to you, “He looks very uncomfortable. Do you want to give him a dose of intranasal (IN) fentanyl while we’re waiting for an IV?” Background: Children feel pain but are often under-treated. There are many options available to treat pediatric pain both pharmacologically (analgesics, NSAIDS, nerve blocks, sub-dissociative dose ketamine, and opioids) and non-pharmacologically (distraction, music, and splinting). [1-6] Children with SCD presenting to the ED with VOE require timely and effective pain control. Opioids are the primary therapy. The National Heart, Lung, and Blood Institute (NHLBI) released an expert panel report in 2014 with evidence-based guidelines for management of sickle cell disease recommending timely administration of parenteral opioids for VOE. [7] However, multiple barriers including ED crowding, boarding, and staffing shortage contribute to delays in care. IN fentanyl has been safely used to treat pain in pediatric patients. It offers a way to deliver analgesia without IV access. We have covered the use of IN fentanyl in children before in SGEM #123 and SGEM #242. Clinical Question: How does intranasal fentanyl for the treatment of vaso-occlusive pain episodes in children with sickle cell disease impact disposition? Reference: Rees CA et al. Intranasal fentanyl and discharge from the emergency department among children with sickle cell disease and vaso-occlusive pain: A multicenter pediatric emergency medicine perspective. American Journal of Hematology Jan 2023 Population: Children aged 3-21 years old, with sickle cell disease (Hemoglobin SS disease or Hemoglobin Sβ Thalassemia) who presented with vaso-occlusive pain episodes to Excluded: Children with upper respiratory infection, concern for stroke or altered mental status, or head injury, acute chest Intervention: Intranasal fentanyl (50 mcg/mL) delivered via atomizer with maximum of 100 mcg Comparison: No intranasal fentanyl administration Outcome: Primary Outcome: Discharge home from the emergency department Secondary Outcomes: Dose and route of opioids administered, the time of opioid administration, non-steroidal anti-inflammatory drug administration, use of IV fluid, time of ED or triage arrival to first opioid administration, time of day patient presented to the ED Type of Study: Secondary analysis of a cross-sectional study from 20 academic pediatric emergency departments in the United States and Canada Authors’ Conclusions: “Children with sickle cell disease who received intranasal fentanyl for vaso...