Background:Vaso-occlusive crisis is the most common complication of sickle cell disease (SCD) and manifests as acute severe pain.1 There are no international evidence-based guidelines for the pain treatment of these episodes.2 We present a case of complicated SCD, which was a challenge for anaesthesiologists, haematologists and intensivists. Case Report:A 28-year-old black male patient with SCD associated to frequent hospitalizations was admitted in the emergency department with an acute SCD episode. He complained of excruciating pain of
sudden onset in the knee joints, upper limbs, chest and lumbar region. Pain was initially treated with intravenous morphine infusion, meperidine, paracetamol and non-steroidal anti-inflammatory drugs (NSAID) without satisfactory relief. After Acute Pain Unit team evaluation, the chosen strategy was morphine patient
controlled analgesia (PCA) supplemented with sublingual fentanyl. After 5 days, the patient had an acute chest syndrome and started experiencing breakthrough pain. Because of frequent dose adjustments, excessive side effects and lack of information by the professionals how to manage a PCA, it was replaced
by transdermal fentanyl. After controlled pain, at the 10th day he was transferred to Intensive Care due to a stroke. Eleven days after, he was discharged with opioids.
Discussion:Although opioids and NSAID are mainstay treatment in this type of pain, they were not effective in this patient. Meperidine was initially the only opioid used with pain relief despite its nonrecommendation due its neurotoxicity. PCA was not used early due to patient monitoring needs and lack of information by the professionals. Fentanyl has been used successfully in the management of chronic pain in SCD.2 In this case, fentanyl patch was an effective choice and allowed patient stabilization. Learning points:SCD pain management have to start early since admission with a multidisciplinary team. Knowledge, communication and homogeneity are important to establish a patient-adjusted pain management plan. Anaesthesiology department must create protocols and teach other professionals about this subject.References: 1.National Heart, Lung, and Blood Institute. Evidence-Based Management of Sickle Cell Disease: Expert Panel Report, 2014.
2.Puri L., State of the Art Management of Acute Vaso-occlusive Pain in Sickle Cell Disease, Pediatr Drugs, 2017.

01 / Challenging and controversial vaso-occlusive pain management of complicated sickle cell disease