Mar 25, '10 by NRSKarenRN
please remember that in sickle cell disease, acute crises involve vaso-occlusive pain episodes often with tissue ischemia occuring.
sickle cell disease pain management: evidenced-based clinical practice guidelines
th e ma n a g e m e n t
[color=#315a66]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.
[color=#315a66]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.
[color=#315a66]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
[color=#315a66]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.
[color=#315a66]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.
o f si c k l e ce l l di s e a s e
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. http://www.nhlbi.nih.gov/health/prof/blood/sickle/sc_mngt.pdf
Last edit by NRSKarenRN on Feb 3, '11