900% Greater Odds of Going Home – Nasal Fentanyl for Pediatric Sickle Cell Crisis

Written by Amanda Mathews

Spoon Feed
In this large, multi-center retrospective study of academic pediatric emergency departments across the US and Canada, researchers found that children presenting with sickle cell disease vaso-occlusive events had nine times (900%) greater adjusted odds of discharge home if given intranasal fentanyl (INF).

Why wait when you can go IN?
This retrospective study was conducted across 20 academic pediatric emergency departments in the US and Canada. Patients aged 3-21 who were treated for sickle cell pain were included even if they had a fever upon presentation. Patients diagnosed with acute chest syndrome were excluded. 400 patients were ultimately included, and the primary outcome of interest was discharge home from the ED.

Children who received INF received higher overall total parenteral opioid morphine equivalents; however, there was no difference in the mean total IV opioid morphine equivalents administered to those who received INF and those who did not (0.2 mg/kg in both groups). Children who received INF were more likely to receive their first parenteral opioid within 30 minutes of presentation and within 60 minutes of presentation compared to children who did not.

Children who received INF had a nearly nine-fold greater adjusted odds of discharge from the ED. There was also three-fold greater adjusted odds of discharge for children who received oral opioids.  Median length of stay was three hours in both groups. Additionally, children who presented with lower initial pain scores, who had larger reduction in their pain scores during their ED visits, and those who received a lower overall morphine equivalent dosage of opioids had higher odds of discharge home.

How will this change my practice?
I will be advocating for the use of intranasal fentanyl as a first line analgesia agent for pediatric patients presenting with sickle cell pain crisis in my institution. Not only does this paper make the case that this improves dispositions to home, but it’s also the right thing to do for a population of patients who are experiencing significant pain.

A note from the lead author Chris Rees:
“The magnitude of the benefit of intranasal fentanyl on discharge to home, even when controlling for pain scores and other potentially contributory factors, was astounding. In medicine, we are often impressed by 50% to 60% improvements, but here we saw more than a 900% greater likelihood of being discharged to home with intranasal fentanyl.”

An additional note from senior author Claudia Morris:
“One caution for physicians and nurses. INF was meant as a bridge to IV medications and was not meant to replace IV analgesics in moderate-to-severe sickle cell pain.  Since INF is short acting, the clinical team should utilize INF to provide rapid pain relief but follow it up with IV opioids to avoid a rapid return of pain when it wears off.”

Editor’s note: Many thanks to Dr. Jason Woods for pointing out this important article and connecting us with the authors for these quotes! ~Clay Smith

Editor’s note 2: Within sites that routinely give INF, children who received it were 4,000% more likely to be discharged home from the ED.

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 Apr;98(4):620-627. doi: 10.1002/ajh.26837. Epub 2023 Feb 6.

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