394 - Intranasal fentanyl (INF) use as first-line therapy for sickle cell Vaso-occlusive crisis in the pediatric emergency department- A systematic review

Poster Number: 394
Publication Number: 394.406

Tayyaba Ali, State University of New York Downstate Medical Center College of Medicine, Brooklyn, NY, United States; Junaid Razzak, Weill Cornell Medicine, New York, NY, United States

Background: Vaso-occlusive crisis (VOC) accounts for approximately 70% of pediatric emergency department (PED) visits for Sickle cell disease (SCD). Delays in pain relief and significant morbidity have been associated with inadequate and delayed analgesics administration. The National Heart, Lung, and Blood Institute (NHLBI) 2014 guidelines advocate for rapid diagnosis and treatment of VOC in the acute care setting, recommending rapid initiation of analgesia within 30 minutes (min) of triage. Fentanyl is a synthetic highly potent narcotic analgesic with an onset of action of 5-10 min and a peak effect in 30 min. Current literature suggests that INF is a safe and effective method of pain management in the PED yet no study has been conducted to comprehensively evaluate the role of INF for VOC.

Objective: We present a systematic review aimed at assessing the outcomes, safety, and efficacy following the administration of INF as a first-line therapy for the sickle cell Vasoocclusive crisis in the PED.

Design/Methods: We screened a total of 466 records identified from 4 databases (PubMed, Embase, Cochrane, and ClinicalTrials.gov), using the search terms "intranasal fentanyl," "sickle cell crisis," "emergency medicine," and "vaso-occlusive crisis," from the date of inception to November 2022. After excluding review, duplicate, and nonrelevant articles. we included 5 studies reporting outcomes of INF use as a first-line therapy in PED, including pain scores, mean time from triage to first INF administration, and adverse events.

Results: Fein et al. noticed a significant decrease in median pain score at 20 min among subjects who received INF compared to placebo (2 [interquartile range, (IQR) 0.5–4] vs. 1 [IQR 0–2], P = 0.048), but not at 10 or 30 min (Table 2). INF has proved to be the quickest possible way to administer analgesia in the PED, meeting NHLBI guidelines (Figure. 1). In addition, 4% of subjects needed additional doses of Morphine in the INF group as compared to 20% in the placebo group within 30 min. Paquin et al. showed 4 of 44 subjects (9%) received IV insertions in a post-INF period compared to 17 of 52 subjects (33%) before implementing INF use. Capitation of INF dose to the maximum of 100 𝜇g limited the results of studies included in the review. Therefore, subjects with higher weights received sub-therapeutic doses. We found no statistically significant difference in hospitalization or PED return rates.

Conclusion(s):

INF is an ideal medication to supplement the current standard of care by serving as a bridge until intravenous access can be obtained and further parenteral analgesics can be administered.