Sickle cell

AnaCatRN · Apr 21, 2010

There is no way you would not get addicted to pain meds if you were constantly in pain. If I took narcotics everyday for a month, I would build up a tolerance I think. Its sad I agree, and yes they are dependent somewhat on pain meds.
But, we have had some patients come in claiming they are having a sickle cell crisis and labs are done which prove they are not in a crisis. The lying, making up fake names, telling nurses and dr's how to do their job, and deceitfulness is what is sickening. We do get a fair share who are in crisis, but they don't act that way...

Wow. I can't imagine being so bold as to lie about something like that. That's ridiculous. All sickle cell patients have at least some sickled cells in their blood. Don't the fakers know how easy that would be to check? Are they that shameless? Wow. All I can say is wow. Real sickle cell patients may have a tolerance or dependency, but if you asked them, they'd tell you they'd love to never need the stuff again.

NBMom1225 · Apr 21, 2010

We have several regular SCA pts on my floor, surgery/hem-onc. One of the physicians told me that the Benadryl works as an adjuvant to the Dilaudid or Demerol and allows for more effective pain relief. We routinely give Dilaudid 2-3mg q2-3h (or Demerol 50-75mg) with Benadryl 50mg q4-6h. This seems to work the best for our pts, most of whom are very polite and respectful, and they are very good about not demanding their pain meds before the next dose is due...sure, there are the occassional SCA pts who are a PITA, but the majority on this unit are actually some of my favorite pts.

Trauma Columnist · Apr 21, 2010

I take care of sickle cell pts on dialysis.

Opiates cause histamine release and benadryl relieves this.

A peripheral blood smear isn't going to show much except whether the pt has sickle cell disease or not. It does NOT indicate crisis.

SC pts get started on narcotics early in life, usually tylenol with codeine for pain. So...by the time they are adults, they are very narcotic-tolerant and may require high doses for adequate pain control.

Of course along with meds should come education:

1. Stay away from sick contacts.

2. Stay hydrated.

3. Try to reduce the amount of stress you are under.

4. Make sure you follow-up with your hematologist regularly.

5. Take meds as directed.

inteRN · Apr 21, 2010

I take care of sickle cell pts on dialysis.
Opiates cause histamine release and benadryl relieves this.
A peripheral blood smear isn't going to show much except whether the pt has sickle cell disease or not. It does NOT indicate crisis.
SC pts get started on narcotics early in life, usually tylenol with codeine for pain. So...by the time they are adults, they are very narcotic-tolerant and may require high doses for adequate pain control.
Of course along with meds should come education:
1. Stay away from sick contacts.
2. Stay hydrated.
3. Try to reduce the amount of stress you are under.
4. Make sure you follow-up with your hematologist regularly.
5. Take meds as directed.

My question is why is it only and every SC patient I have ever seen in the ER wants benedryl. Does it have to do with the actual SC causing this "itching"??

Every non sickle cell patient I have ever given an opiate to never has asked for benedryl...

wooh, BSN, RN · Apr 21, 2010

I've had plenty of non-SC patients want their benadryl. But benadryl is a standard part of the orders when I care for a SC patient. SC patients tend to have docs that actually care about controlling their pain, they standardize the care, and the patients get used to getting benadryl, and they know to ask for it.

The patients who know what to ask for are the frequent flyers. SC patients tend to be frequent fliers because they need their fluids and O2, which you can't do at home.

AnaCatRN · Apr 21, 2010

My question is why is it only and every SC patient I have ever seen in the ER wants benedryl. Does it have to do with the actual SC causing this "itching"??
Every non sickle cell patient I have ever given an opiate to never has asked for benedryl...

I don't think the SC causes the itching. I'm thinking it's because that is what they've been given before, not only for the itching, but for the added pain relief. Also, perhaps the continuous exposure to the narcs makes the itching more prevalent or intense. The more exposure you get to an allergen, the more severe the reaction. They know their disease. They know what works. Most other patients may not be chronic pain patients, so they haven't had that combination, and it wouldn't occur to them to ask for it. Pain medicine is not understood by everyone, and most chronic pain patients don't get adequate treatment at all. I'd bet that as more chronic pain patients (non-SCA) get better treatment, they'll start asking for the Benadryl, too.

wooh, BSN, RN · Apr 21, 2010

Pain medicine is not understood by everyone, and most chronic pain patients don't get adequate treatment at all.

SC tends to be one of the few diagnoses that are treated seriously for pain control. And I'd agree, they know what works. And they aren't going to give up something that treats their pain just because it itches a bit.

Trauma Columnist · Apr 21, 2010

Also - you need to look at the dosing of the opiates given for SC pts: most are very tolerant and need much bigger doses than someone who is opiate-naive.

With the higher doses of opiates, you have more histamine release so that is why it is routine to give benadryl with the opiates.

cadency · Apr 22, 2010

We have a sickle cell protocol at my facility. O2, q30min dilaudid x 4, q1h dilaudid x 2 (iirc) and then see where the pain is at. If their pain is still unmanagable at that point, it decides whether we admit them or not. With those orders are always PRN benadryl and phenegran. I always simply assumed that it was for itching and had a SC patient recently tell me that the dilaudid made him itchy and nauseous. Though, it can definitely appear as though some prefer the snowed effect. Didn't know about the rest - such as the possible adjunct effects! Good to know!

Good topic! Thanks for the discussion! :)

inteRN · Apr 22, 2010

Also - you need to look at the dosing of the opiates given for SC pts: most are very tolerant and need much bigger doses than someone who is opiate-naive.
With the higher doses of opiates, you have more histamine release so that is why it is routine to give benadryl with the opiates.

It's hard to take care of these pt's in the ER because we have minimal history to work with so I can see why the Dr's are reluctant to give super doses of narcs. That's why some of the dr's will run that smear test first to see if they are even SC. It's sad.

inteRN · Apr 22, 2010

We have a sickle cell protocol at my facility. O2, q30min dilaudid x 4, q1h dilaudid x 2 (iirc) and then see where the pain is at. If their pain is still unmanagable at that point, it decides whether we admit them or not. With those orders are always PRN benadryl and phenegran. I always simply assumed that it was for itching and had a SC patient recently tell me that the dilaudid made him itchy and nauseous. Though, it can definitely appear as though some prefer the snowed effect. Didn't know about the rest - such as the possible adjunct effects! Good to know!
Good topic! Thanks for the discussion! :)

I know it is a good topic! Thanks for the input! :)

Trauma Columnist · Apr 22, 2010

Although I work fulltime nephrology and prn ER, my nursing background is 10 years in an inner city level one trauma center. Its important to educate providers about the doses needed to control a SC pt's pain.

I am (unfortunately) very aware of the liability of giving large doses of narcotics so documentation is an absolute must.

Great discussion.