Sickle Cell Crisis and pain management? - page 2

I work on a busy med-surg floor and recently have taken care of several patients aged 28-37 with sickle cell crisis. When I receive report from other nurses on these patients, it is always the same story - they say they are drug... Read More

  1. 0
    Quote from Bklyn_RN
    An inconvenient truth is that there are sicklers who have become addicted to highly addictive narcotics (read the drug info insert for dilaudid etc). Also a sickle cell crisis can be as painful as narcotic withdrawal symptoms. I do not know if they would intentionally dehydrate themselves. However as JCAHO mandates, patients reports of pain are to be given the highest priority. So as long as there was a valid order...
    I often wonder after getting Dilaudid 3mg IV Q2 hrs for x amount of days then suddenly being taken off it, how it affects you. We try and decrease the amounts to wean. I don't recall anyone going home on any kind of maintenance narcotics. After the crisis is over the pain should cease? Correct? It has to be difficult because it is withdrawing...

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  2. 5
    Please remember that in sickle cell disease, acute crises involve vaso-occlusive pain episodes often with tissue ischemia occurring.

    sickle cell disease pain management:
    evidenced-based clinical practice guidelines
    enhance health related quality of life

    the vaso-occlusive crisis, or sickle cell crisis, is initiated and sustained by interactions among sickle cells, endothelial cells and plasma constituents.1 vaso-occlusion is responsible for a wide variety of clinical complications of sickle cell disease, including pain syndromes, stroke, leg ulcers, spontaneous abortion and renal insufficiency.

    a vaso-occlusive crisis is initiated and sustained by the interaction among sickle cells, endothelial cells and plasma constituents. clinical complications include pain syndromes, stroke, leg ulcers, spontaneous abortion and renal insufficiency.

    acute pain in patients with sickle cell disease is caused by ischemic tissue injury resulting from the occlusion of microvascular beds by sickled erythrocytes during an acute crisis. chronic pain occurs because of the destruction of bones, joints and visceral organs as a result of recurrent crises. the effect of unpredictable recurrences of acute crises on chronic pain creates a unique pain syndrome.2,3

    acute bone pain from microvascular occlusion is a common reason for emergency department visits and hospitalizations in patients with sickle cell disease.4 obstruction of blood flow results in regional hypoxemia and acidosis, creating a recurrent pattern of further sickling, tissue injury and pain. the severe pain is believed to be caused by increased intramedullary pressure, especially within the juxta-articular areas of long bones, secondary to an acute inflammatory response to vascular necrosis of the bone marrow by sickled eythrocytes.5 the pain may also occur because of involvement of the periosteum or periarticular soft tissue of the joints.

    the approach to pain control must include measures to treat acute pain crises, prevent future vaso-occlusive crises and manage the long-term sequelae of chronic pain that can result from multiple recurrent bony infarction.

    The management of sickle cell disease
    tolerance, physical dependence, addiction, and pseudoaddiction
    a major barrier to effective management of
    sickle cell pain is a lack of understanding of
    opioid tolerance, physical dependence, and
    addiction. tolerance and physical dependence
    are expected pharmacologic consequences of
    long-term opioid use and should not be confused
    with addiction.

    tolerance is a physiologic response to the
    exogenous administration of opioids, and
    the first sign is decreased duration of medication
    action. when tolerance develops,
    larger doses or shorter intervals between
    doses may be needed to achieve the same
    analgesic effect.

    physical dependence also is a physiologic
    response to the exogenous administration
    of opioids. it requires no treatment unless
    withdrawal symptoms—such as dysphoria,
    nasal congestion, diarrhea, nausea, vomiting,
    sweating, and seizures—occur or are
    anticipated. the risk varies among individuals,
    but when opioids are given for more
    than 5 to 7 days, doses definitely should
    be tapered to avoid physiologic symptoms
    of withdrawal.
    genetic, psychologic, and social roots. the
    use of opioids for acute pain relief is not
    addiction, regardless of the dose or duration
    of time opioids are taken. patients
    with scd do not appear to be more likely
    than others to develop addiction. the
    denial of opioids to patients with scd
    due to fear of addiction is unwarranted
    and can lead to inadequate treatment,

    pseudoaddiction (16) applies to patients
    who receive inadequate doses of opioids
    whose doses are not tapered, and therefore
    they develop characteristics that resemble
    opioid addiction.
    understandably, some patients whose pain is
    managed poorly will try to persuade medical
    staff to give them more analgesic, engage in
    clock-watching, and request specific medications
    or dosages. staff often regard this as
    manipulative or demanding behavior. patients
    with scd often are quite knowledgeable
    about the medications they take for their condition
    and the doses that have worked in the
    past. requests for these specific medications
    and doses should not be interpreted as indications
    of drug-seeking behavior. in addition,
    patients who have had frequent painful
    episodes often behave in ways learned from
    prior experiences. a patient, for example, who
    believes that a medication will not be given
    unless he or she appears to be in severe pain
    may lie quietly when alone but begin to
    writhe and moan when a nurse or physician
    enters the room. pseudoaddiction or clockwatching
    behavior usually can be resolved by
    effective communication with the patient to
    ensure accurate assessment and by adequate
    opioid doses.
    as in the general population, some persons
    with scd will use illicit drugs, such as
    cocaine. patients who have problems with
    substance abuse require individual treatment
    to provide competent and humane management
    of their pain.

    Last edit by NRSKarenRN on Jun 21, '14
    SharonH, RN, Bklyn_RN, PurpleLVN, and 2 others like this.

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