The non-pharmacologic approaches involve offering emotional and psychological counseling to the patient.

The non-pharmacologic approaches involve offering emotional and psychological counseling to the patient.

 NHS is coming up with strategies that will ensure sickle-cell patients are well-taken care. They are advocating for early diagnosis of the condition to reduce the cost of treatment and the rate of hospitalization. They will also help in reducing the psychological impacts of the pain on patients. Most patients have particular psychological responses to both acute and chronic pain episodes.  The responses or effects include low mood, stress, and poor coping strategies such as alcohol abuse and negative thinking. Most patients adapt these responses at an early age, and it becomes difficult to change during old age. However, psychological therapies can be used to reduce the psychological pressures experienced by these patients.

Socioeconomic factors have an impact on clinical patient outcomes. The deprivation of these factors has adverse effects on the quality of life of sickle-cell anemia patients. For instance, patients who do not have insurance covers avoid hospitals due to financial problems.  To reduce such cases, the UK NHS is offering universal medical care. Evaluation of rates of hospitalization by     NHS revealed that patients living in areas that are socially or economically deprived have a higher risk of admission and readmission. High mortality rates were also reported among patients from families that are socially and financially unstable.

The treatment of SCD requires the collaboration of multi-disciplinary teams to offer quality care to the patients. Various professionals, such as social workers, hematologists, pediatricians, registered nurses, nephrologists, and clinical psychologists, participate in the treatment of SCD. NICE advocates that all medical specialists who handle people with an acute painful crisis should have access to local protocols on treatment and management procedures.  The NHS requires that all professionals in the team should actively participate in the management and treatment of sickle-cell disease.  The physicians have a role in monitoring the patients and encourage them to take their medications.   NICE and Clinical Commissioning Groups (CCGs) help the professionals to monitor patients who are taking strong opioids. They should be observed every hour for six hours after the first administration of the opioid. The monitoring is essential to assess if there are any adverse medical events. However, studies conducted by (martin) show that nurses and physicians have difficulties in deciding the most effective to use when managing a painful crisis. The management and treatment methods have varying impacts on different patients. Therefore, a literature review will be conducted to identify approaches that can be used to manage acute and chronic pain episodes.

 Method

A systematic review was conducted to look for articles that met the PRISMA guidelines.  The research was carried out on MEDLINE, Embase, PubMed, CENTRAL, LILAC, Web of Science, and CINAHL.   The databases are reliable in providing recent and updated information on nursing. A comprehensive search strategy was applied to these databases using Boolean operators, and MeSH terms were used to control the search.  Some of the search terms used included acute pain, pain management, sickle cell disease, peer-reviewed journals, and pharmacological treatment. All studies that were not peer-reviewed, and those that were written in any other language except English were excluded.  To get more results, Google Scholar was also used. The NICE website was also useful during our search. We also searched the references of reviews and studies that were retrieved in the past.

The search produced 848 articles in which 185 were removed because they were duplicates. The titles and abstracts (n=663) were screened to determine their eligibility. Six hundred twenty-one studies were excluded from the research because they were irrelevant. The Critical Appraisal Skill Programme was used to evaluate the remaining (n=42). Twenty-seven reviews were removed because they did not meet the selection or inclusion criteria. Three studies that were not yet classified were also excluded from the study.  Three other studies were ongoing, and they were excluded. After a comprehensive evaluation (n=9) were eligible for our research. However, we only include five studies in this review because four of them were published before 2000. We did not find any articles that soles focused on non-pharmacological interventions to treat a vaso-occlusive crisis.

The selection criteria were randomized control trials, double-blind trials of pharmacological remedies that were compared to an active comparator, or a placebo for treatment (Not Prevention) of vaso-occlusive crisis in adults who have sickle-cell disease. The articles had to be published from 2000 to the current year. Three themes were produced from the search strategy: (i) Non-steroidal anti-inflammatory drugs compared with placebo, (ii) Opioids compared with placebo, (iii) Opioids compared with an active comparator.

1. Non-steroidal anti-inflammatory drugs (NSAID) versus placebo

One article (Bartolucci 2009) compared non-steroidal anti-inflammatory drugs with placebo.  The report focused on the intensity of relieving enjoyed by patients for using the Ketoprofen group of non-steroid pain relievers.  It also analyzed how long it took for the patients to be relieved and if they experienced any adverse medical events.  Thirty-three participants were used for the investigation.  Mild adverse events were experienced by 16 of the patients who used the Ketoprofen and Ketorolac group of non-steroids.  Besides, 19 patients also had mild adverse events after using the placebo.  However, 1 participant experienced severe adverse medical events after using the Ketoprofen group. Two participants also had extreme adverse events after using the placebo.

The author also revealed that it took 51hours for the pain to reduce among the people who used the Ketoprofen group of non-steroids while it took 50 hours among those who used the placebo. The rescue morphine was added to the placebo and Ketoprofen to improve the quality of treatment received by patients. However, the article did assess the amount of time the patients spent in the hospital after using the placebo or the Ketoprofen group.

The article was useful in showing the significance of NSAIDs in the treatment of painful crises among sickle-cell patients. They act on nociceptors, which are areas where the impulses of pain originate.   They are useful in inhibiting prostaglandins, which may lead to detrimental medical events on the patients.  The side effects include acute renal failure, nephritic syndrome, and congestive heart failure. NSAIDs should be used by adults who are experiencing severe pain. Besides, I feel the use of NSAIDs to treat the vaso-occlusive crisis should be a matter of debate.  Although the article did not record the impacts of Ketorolac, the NSAID should not be used for more than five days in a month due to potential renal toxicity. In the proposed project, questionnaires will be used to examine the impacts of using NSAIDs versus placebo in treating a vaso-occlusive crisis. Open-ended questions will be used to give the patients to narrate their experiences without limitations. The results used will be useful in the implementation of a management plan for a vaso-occlusive crisis.

1. Opioids Compared with Placebo

One article (Arambasik2013) compared the use of opioid Ketamine combined with hydromorphone and the use of a placebo combined with hydromorphone to treat painful crises among sickle-cell patients. The study had 37 participants, with 13 females and 24 males. The article did not offer any useful information on the length of hospital admission, the percentage of pain relieved, and the time it took for pain resolution. However, it revealed that on arrival at a scale of ten, the pain score was 9.29 among the Ketamine plus hydromorphone group and 8.5 among the group that was using the placebo plus hydromorphone. The pain score decreased to 5.2 and 5.6, respectively, after the drugs were administered to the patients.

• Opioids versus Active comparator

One study that was conducted by Rehmani (2013) in which he compared the opioid morphine and the active comparator paracetamol. Fifty-four participants were used in the research, and the author reported the use of additional rescue morphine to treat patients who were experiencing severe pain.  Five cases of mild adverse events were reported among the participants who use morphine, while three cases were observed among those who used paracetamol. The mild side effects include vomiting and nausea. There were no serious adverse events found in both types of intervention. There was no data offered about the rate of hospitalization, and cases of withdrawals due to mild adverse events.

Theme (ii) and (iii) were effective in showing the efficiency of opioids in treating severe pain among sickle- cell patients.  Their complex and individual way of interacting with opioid receptors makes them more useful. Morphine is the commonest opioid used to treat vaso-occlusive crises and other forms of pain among patients in hospitals. It is a full receptor agonist that can be used to compare the relative potency of other drugs. It is highly soluble; hence it produces rapid and long-lasting analgesia. It primarily acts on the stomach, spinal cord, intestines, and brain and causes sedation, hence reduction of pain among the patients. However, it can be addictive; thus, using it for the long-term can lower its reliability over time. Morphine is absorbed via the gastro-intestinal tract and then metabolized into the kidneys and liver.  Besides, the induction of analgesia morphine and other opioids also increases the survival, growth, and cytoprotection of several body cells and organs.

Additionally, Ketamine is commonly used for analgesic responses in pre-operative departments. It is used in pain management among sickle-cell patients as a third-line adjuvant when the pain becomes resistant to particular opioids.  It is administered via several routes such as oral, subcutaneous, intravenous, and intranasal. It is useful when it is added in small-doses to ongoing opioid treatments to treat severe pain in sickle-cell patients. It is mainly combined with non-steroid anti-inflammatory drugs. It is also reliable in reducing the need to use opioids whose excessive use can lead to addictions.   However, there is limited evidence on the efficiency of Ketamine to reduce pain. Its safety is under investigation, and it is still unclear if its side effects are severe.   The experiences of patients who used either of the treatment methods to treat their vaso-occlusive crisis will be examined using questionnaires that will have open-ended questions. The questions will allow the patients to explain their experiences without limitations. We will seek consent from the patients and the clinical setting to ensure they are comfortable with the research being conducted. We will ensure that high confidentiality will be maintained during the study.