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CORRESPONDENCE
Neuropathic pain in sickle cell disease triggered byPain-EaseTM
SIR—We describe an episode of neuropathic pain in a
16-year-old male patient having sickle cell disease trig-
gered by the use of Pain-EaseTM (Gebauer 4444 East
153rd Street, Cleveland, OH 44128): a vapo-coolant
local anesthetic spray, used during intravenous cannu-
lation. The patient had been admitted with a severe
vaso-occlusive crisis causing a severe deep and aching
pain affecting his chest, knees, shoulders, and elbows.
He required intravenous opioids (hydromorphone) via
both infusion and patient-controlled analgesia (PCA).
Despite aggressive multimodal pharmacotherapy (con-
comitant use of acetaminophen, ketorolac, and cloni-
dine), with escalating doses of opioid, the pain was
poorly controlled with a numeric rating score of 9/10.
Medical management of his sickle cell disease was
ongoing with exchange transfusions and hydroxyurea
in use. After 2 days, we decided to commence an iv
ketamine infusion as an analgesic adjunct
(2 mcg�kg�1�min�1), and a new intravenous cannula
was sited. A 20G iv cannula was successfully inserted in
the right forearm. To facilitate placement, the forearm
skin was sprayed with Pain-EaseTM, a vapo-coolant
spray to reduce the pain of cannulation. Minutes after
siting the iv and starting the ketamine infusion, the
patient started to complain of a different pain in terms
of quality and intensity from the original vaso-occlusive
pain. It affected all four limbs and was burning in char-
acter. Allodynia was noted on clinical examination to
all affected limbs. The clinical descriptors and physical
examination corroborated with a neuropathic pain
problem, which the patient found more unpleasant
than the previous pain. The onset of these new pains
correlated temporally with the use of the local anes-
thetic spray. Upon further questioning, we elucidated
that the patient had had similar past experiences: once
during an extremely cold day in the winter and once
while swimming in cold water, which precipitated the
same pain symptoms.
There is emerging evidence that there is a neuropathic
pain component to sickle cell disease (1). Furthermore,
it has been previously reported that there is a link
between cold and neuropathic pain in sickle cell disease
(2,3). We believe that the use of Pain-EaseTM in this
instance precipitated this pain episode in this patient.
The pain did resolve with ongoing intravenous ketamine
therapy the next day, which is known to have an anti-
neuropathic pain action. Pain-EaseTM has a useful role
as an inexpensive local anesthetic agent in pediatric
practice, but we would urge practitioners to be mindful
of this potential issue of its use in such patients.
Learning points:
1 There is emerging evidence that there is a neuropathic
pain component to sickle cell disease–related pain.
2 Neuropathic pain in sickle cell disease is very unpleas-
ant and may be precipitated by cold.
3 When using topical local anesthetic vapo-coolant
sprays in such patients, there is the potential to trigger
a neuropathic pain episode, so we advise caution.
Disclosure/Acknowledgments
No ethical approval was required for this letter. Written
consent was obtained from the patient. No funding was
required. None of the authors declare any conflict of
interest.
Conflict of interest
No conflicts of interest declared.
Sachin Rastogi, Lorraine Bird & Cengiz KarsliDepartment of Anesthesia & Pain Medicine,
Hospital for Sick Children,Toronto, ON, Canada
Email: [email protected]
doi:10.1111/pan.12142
References
1 Ballas SK, Gupta K, Adam-Graves P. Sickle
cell pain: a critical reappraisal. Blood 2012;
120: 3647–3656.
2 Nolan VG, Zhang Y, Lash T et al. Associa-
tion between wind speed and the occurrence
of sickle cell acute painful episodes: results
of a case-crossover study. Br J Haematol
2008; 143: 433–438.
3 Molokie RE, Wang ZJ, Wilkie DJ. Pres-
ence of neuropathic pain as an underlying
mechanism for pain associated with
cold weather in patients with sickle cell
disease. Med Hypotheses 2011; 77:
491–493.
© 2013 Blackwell Publishing Ltd
Pediatric Anesthesia 23 (2013) 463–466
463
