Vasoocclusive Pain Crisis

The mainstay of treatment for vasoocclusive crisis includes hydration and analgesia

(Table 68-4). Pain may involve the extremities, back, chest, and abdomen. Patients with mild pain crisis may be treated as outpatients with rest, warm compresses to the affected (painful) area, increased fluid intake, and oral analgesia. Moderate to severe crises should be hospitalized. Infection should be ruled out because it may trigger a pain crisis, and any patient presenting with fever or critical illness should be started on empirical broad-spectrum antibiotics. Patients who are anemic should be transfused to their baseline. IV or oral fluids at 1.5 times maintenance is recommended. Close monitoring of the patient's fluid status is important to avoid overhydration, which can lead to ACS, volume overload, or heart failure.5,9

Aggressive pain management is required in patients presenting in pain crisis. Assess pain on a regular basis (every 2-4 hours) and individualize management to the patient. The use of pain scales may help with quantifying the pain rating. Obtain a good medication history of what has worked well for the patient in the past. Use acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) for treatment of mild to moderate pain. Patients with bone or joint pain, who require IV medications may be helped by the use of ketorolac, an injectable NSAID. Because of the concern for side effects, including GI bleeding, ketorolac should be used only for a maximum of 5 consecutive days. Monitor for the total amount of acetaminophen given daily, because many products contain acetaminophen. Maximum daily dose of acetaminophen for adults is 4 g/day, and for children, five doses over a 24-hour period.44 Add an opioid if pain persists or if pain is moderate to severe in nature. Combining an opioid with an NSAID can enhance the analgesic effects without increasing adverse effects.45-47

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