Intranasal Fentanyl for Sickle Cell Vaso-Occlusive Pain

Case

A 15-year-old female with sickle cell disease (SCD) presents to your emergency department (ED) with a vaso-occlusive pain episode (VOE) of her legs and back. She has a history of similar episodes. There are no other concerning aspects to her examination. Routine bloodwork was ordered in triage. While waiting for results you wonder if a dose of intranasal (IN) fentanyl could address her pain until intravenous (IV) access can be obtained?

Background

Timely and effective pain control is important for all patients including children. The Pediatric Pain Management Standard¹ for children was published this year to provide guidance to health organizations on how to deliver equitable and quality pain management across hospital settings.

Children with SCD often present to the ED in pain due to VOE. The National Heart, Lung, and Blood Institute released an expert panel report in 2014 with evidence-based guidelines for management of SCD recommending timely administration of parenteral opioids for VOE.2 However, multiple barriers including ED crowding, boarding, and staffing shortages 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.3,⁴

Clinical Question

In children with SCD with VOE, how does IN fentanyl 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. Am J Hematol. 2023;98(4):620-27

Population: Children aged three to 21 years, with SCD (Hemoglobin SS disease or hemoglobin S-beta thalassemia) who presented to the ED with VOE

Excluded: Children with upper respiratory infection, concern for stroke, altered mental status, or head injury, acute chest

Intervention: IN fentanyl (50 mcg/mL) delivered via atomizer with maximum of 100 mcg

Comparison: No IN fentanyl 

Outcomes:

Primary Outcome: Discharge home from the ED

Secondary Outcomes: Dose and route of opioids administered, 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 EDs in the United States and Canada

Authors’ Conclusions

“Children with sickle cell disease who received intranasal fentanyl for vaso-occlusive pain episodes had greater odds of being discharged from the emergency department than those who did not receive it.”