management of painful crises

Last edited 08/2020 and last reviewed 10/2021

Majority of painful episodes are managed at home.

Hospital admission should be considered when oral analgesia is insufficient or due to the presence of symptoms suggesting a serious complication (1).

Patients presenting with acute painful crises should be rapidly assessed and should receive effective analgesia immediately (2):

  • an appropriately potent analgesic must be administered within 30 minutes (should include time spent in triage) from arrival (1)
  • adequate pain control should be achieved within 1 hour
  • long acting oral or parenteral analgesia should be used for maintenance of analgesia with provision for bolus analgesia if breakthrough pains occurs

A standard pain assessment tool should be used for regular and continuous evaluation of pain during an acute episode

  • pain , respiratory rate and sedation should be evaluated every 20 min until pain is controlled (1)

The choice of analgesic depends on patient's analgesics history. Some patients will carry cards with details of their ideal analgesic regimen although sometimes patients will be seen for the first time and an empirical approach might be necessary:

  • a combination of NSAID's (unless contraindicated) and weak opioids can be used in patients with moderate pain but opiates are the mainstay of severe pain treatment (2)
  • non pharmacological and psychological methods of pain management should be encouraged (2)

Once the pain is controlled medical assessment should focus on detection of major complications which require specific therapy e.g. - acute chest syndrome, infection, abdominal crisis, neurological events - stroke or transient ischaemic attack, haemorrhage, seizures, priapism

Notes:

  • NICE suggest (3):

    • treat an acute painful sickle cell episode as an acute medical emergency. Follow locally agreed protocols for managing acute painful sickle cell episodes and/or acute medical emergencies that are consistent with this guideline

      • offer analgesia within 30 minutes of presentation to all patients presenting at hospital with an acute painful sickle cell episode

        Clinically assess all patients presenting at hospital with an acute painful sickle cell episode, including monitoring of:

        • blood pressure
        • oxygen saturation on air (if oxygen saturation is 95% or below, offer oxygen therapy)
        • pulse rate
        • respiratory rate
        • temperature

          assess all patients with sickle cell disease who present with acute pain to determine whether their pain is being caused by an acute painful sickle cell episode or whether an alternative diagnosis is possible, particularly if pain is reported as atypical by the patient
          • offer a bolus dose of a strong opioid by a suitable administration route, in accordance with locally agreed protocols for managing acute painful sickle cell episodes, to:
            • all patients presenting with severe pain
            • all patients presenting with moderate pain who have already had some analgesia before presentation
          • consider a weak opioid as an alternative to a strong opioid for patients presenting with moderate pain who have not yet had any analgesia
          • offer all patients regular paracetamol and NSAIDs (non-steroidal antiinflammatory drugs) by a suitable administration route, in addition to an opioid, unless contraindicated

      • do not offer pethidine for treating pain in an acute painful sickle cell episode
      • do not use corticosteroids in the management of an uncomplicated acute painful sickle cell episode

Notes (4):

  • a systematic review states that:
    • amount and quality of evidence around the use of any pharmacological treatment for painful sickle cell vaso-occlusive crises (VOC) is very low
    • treatment is based on clinical experience and advice from respected authorities
    • authors can make no judgement about which pharmacological treatment is more effective than any other to reduce the painful crisis

Reference: