Opioid selection during sickle cell pain crisis and its impact on the development of acute chest syndrome
Opioid selection during sickle cell pain crisis and its impact on the development of acute chest syndrome
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DOI：
10.1002/pbc.20403
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发表时间：
2005-10-15
影响因子：
3.2
通讯作者：
Reed, GW
中科院分区：
文献类型：
--
作者：
Buchanan, ID;Woodward, M;Reed, GW
背景 镰状细胞病 (SCD) 的特点是反复发作、疼痛的血管闭塞发作 (VOC)，是 SCID 患者住院的最常见原因。麻醉剂，特别是吗啡，与液体水化一起是疼痛发作的标准治疗方法，但与通常称为急性胸部综合征（ACS）的急性肺部事件的发生有关。 ACS 的发展通常先发生急性感染、疼痛发作、肋骨梗塞、骨髓梗塞和脂肪栓塞。其病理生理学仍然是多因素的，并已成为早期死亡的最常见原因。既往 ACS 发作会增加反复发生急性肺部事件和随后的肺动脉高压的可能性。盐酸纳布啡 (Nubain) 是一种阿片类药物，具有吗啡的止痛功效，但尚未研究其与 ACS 发生的关系，也未对其与吗啡在镰状细胞群体疼痛控制方面的功效进行比较。程序。我们回顾性地回顾了 1999 年 1 月至 2002 年 12 月期间因血管闭塞危象入住亚特兰大三所儿童医院的 5 岁至 19 岁患者的医疗记录。使用计算机化搜索工具来识别使用国际疾病分类第九版 (ICD-9) 诊断代码 282.60 和 282.62 的患者。 ACS 的最终出院诊断被定义为入院后和出院前胸片上出现新的肺部浸润。我们计算出需要 160 名患者入院才能达到 85% 的功效才能检测到两个治疗组之间 ACS 发生率大约 20% 的差异。结果。总共有 37 次 (21%) ACS 发作。其中，吗啡组有 26 例（29%），努巴因组有 11 例（12%）（P < 0.01）。接受吗啡治疗的患者入院时白细胞计数更高（P < 0.05），并采用持续输注给药（49% vs. 3%），P < 0.001。他们的住院时间也比接受 Nubain 的患者更长（中位住院时间 3 天与吗啡 4 天），P < 0.001。结论。疼痛发作期间 ACS 的发生是多因素的，但阿片类药物的选择可能会增加这一发生率。服用 Nubain 的患者患 ACS 的可能性较小，而且住院时间也较短。这些结果因使用 PCA 持续镇痛输注而变得混乱。然而，Nubain 可能提供吗啡的替代品来治疗镰状细胞性疼痛发作。下一步最好进行比较这两种镇痛药的前瞻性临床试验。
Background The hallmark of sickle cell disease (SCD) is recurrent, painful vaso-occlusive episodes (VOC) and is the most common reason for hospitalization in SCID patients. Narcotics, particularly morphine, along with fluid hydration are standard treatments for painful episodes but have been associated with the development of acute pulmonary events commonly referred to as acute chest syndrome (ACS). The development of ACS is often preceded by acute infections, painful episodes, rib infarction, bone marrow infarction, and fat embolism. Its pathophysiology remains multifactorial and has become the most common reason for early mortality. Previous episodes of ACS increase the likelihood of repeated acute pulmonary events and subsequent pulmonary hypertension. Nalbuphine hydrochloride (Nubain) is an opioid with the pain relieving potency of morphine but has not been studied for its association in the development of ACS or compared with morphine in its efficacy of pain control in the sickle cell population. Procedure. We reviewed the medical records retrospectively of patients between the age of 5 and 19 years, admitted for vaso-occlusive crisis to the three children's hospitals in Atlanta between January 1999 and December 2002. A computerized search tool was used to identify patients using the International Classification of Diseases Ninth Revision (ICD-9) diagnosis code 282.60 and 282.62. The final discharge diagnosis of ACS was defined as a new pulmonary infiltrate on chest radiograph after admission and before discharge. We calculated the need for 160 patient admissions for 85% power to detect a difference of approximately 20% in incidence of ACS between the two treatment groups. Results. There were a total of 37 (21%) episodes of ACS. Of these, 26 (29%) were in the morphine group and 11 (12%) were in the Nubain group (P < 0.01). Patients receiving morphine were more likely to have higher white cell counts on admission (P < 0.05), and to use continuous infusion for medication administration (49% vs. 3%), P < 0.001. They also had longer hospital stays than patients who received Nubain (median stay 3 days vs. 4 days, morphine), P < 0.001. Conclusions. The development of ACS during painful episodes is multifactorial, but opioid selection may increase this rate. Patients on Nubain were less likely to develop ACS, and they had shorter hospital stays. These results were confounded by use of continuous analgesia infusion with PCA. However, Nubain may provide an alternative to morphine in the treatment of sickle cell pain episodes. A prospective clinical trial comparing these two analgesics would be a preferable next step.