Sickle Cell Crisis

Card A — Ketamine + Dexmedetomidine (Precedex) for Acute Sickle Cell Pain

Opioid-sparing analgesia for moderate to severe vaso-occlusive pain not controlled with standard therapy. Intended for step-down or ICU monitoring. Follow local protocols and pharmacy guidance.

No intubation required at analgesic doses

Quick start (no bolus)

Drug	Starting infusion	Titration	Typical max (analgesic range)	Notes
Ketamine	0.1 to 0.3 mg per kg per hour	Increase by 0.05 to 0.1 mg per kg per hour every 30 to 60 minutes	0.5 mg per kg per hour	Optional slow bolus 0.1 to 0.3 mg per kg over at least 10 minutes if protocol allows
Dexmedetomidine	0.2 to 0.4 microgram per kg per hour	Increase by 0.1 to 0.2 microgram per kg per hour every 20 to 30 minutes	0.7 to 1.0 microgram per kg per hour per local policy	No loading dose; avoid rapid bolus to reduce bradycardia and hypotension

Monitoring and targets

• Continuous pulse oximetry; noninvasive blood pressure every 15 minutes during titration, then every hour
• Cardiac monitoring during initiation and dose changes
• Assess pain and sedation at least hourly

Target RASS	Meaning
0 to minus 2	0 = alert and calm; minus 1 = drowsy but sustained eye contact; minus 2 = light sedation, briefly awakens to voice

Expected effects and airway considerations

• Both agents preserve spontaneous ventilation at analgesic doses
• Dexmedetomidine may cause bradycardia or hypotension
• Ketamine may cause mild increase in heart rate and blood pressure; dissociation possible

Adjuncts to continue

• Acetaminophen scheduled if not contraindicated
• NSAID if no acute kidney injury or bleeding risk
• Rescue opioid for breakthrough pain
• Bowel regimen, antiemetic, incentive spirometry, hydration and trigger management

Cautions

• Dexmedetomidine: caution in significant bradycardia or higher-degree heart block without pacer
• Ketamine: caution in uncontrolled hypertension, active ischemia, or acute psychosis; consider lower start in severe hepatic impairment

Disclaimer: Adult reference; verify doses and maximums with local policies and pharmacy.

Card B — Complete Analgesia Options for Acute Sickle Cell Crisis

Multimodal approach: treat pain aggressively while preserving breathing, prevent acute chest syndrome, and address triggers. Use clinical judgment and local order sets.

Pharmacologic and non-pharmacologic

Opioids (first line for moderate to severe pain)

Agent	Typical IV bolus for titration	Common PCA settings (opioid naive)	Notes
Morphine	2 to 4 mg IV every 10 to 15 minutes as needed	Demand 1 to 2 mg; lockout 6 to 10 minutes; no basal initially	Reduce dose in renal impairment; histamine release may cause pruritus
Hydromorphone	0.2 to 0.4 mg IV every 10 to 15 minutes as needed	Demand 0.1 to 0.3 mg; lockout 6 to 10 minutes; no basal initially	Often preferred when renal dysfunction or morphine intolerance
Fentanyl	25 to 50 microgram IV every 5 to 10 minutes as needed	Demand 10 to 25 microgram; lockout 6 to 10 minutes	Short acting; hemodynamically stable option if hypotension limits others

Mini PCA setup cheat sheet

Patient profile	Suggested starting PCA (choose one agent)	Basal infusion	Safety notes
Opioid naive, normal kidney function	Morphine demand 1 to 2 mg, lockout 6 to 10 minutes or Hydromorphone demand 0.1 to 0.2 mg, lockout 6 to 10 minutes or Fentanyl demand 10 to 25 microgram, lockout 6 to 10 minutes	None at start	Assess pain and sedation every 1 hour during first 4 to 6 hours
Opioid tolerant (taking daily opioids before admission)	Use higher end of demand ranges above; consider shorter lockout (6 minutes) Example: Hydromorphone demand 0.2 to 0.3 mg	Consider low basal only if clearly tolerant and monitored: Morphine 0.5 to 1 mg per hour, or Hydromorphone 0.1 to 0.3 mg per hour, or Fentanyl 25 to 50 microgram per hour	Confirm tolerance; continuous pulse oximetry recommended
Renal impairment or high risk for oversedation (elderly, low BMI, OSA)	Prefer Hydromorphone or Fentanyl over Morphine; use lower demand dose: Hydromorphone 0.05 to 0.1 mg; lockout 8 to 10 minutes	None at start	Avoid basal early; reassess frequently; consider capnography if available
Persistent severe pain despite above	Keep PCA for rescue	None or minimal basal unless clearly tolerant	Add multimodal infusions (Ketamine or Dexmedetomidine) per Card A

Always individualize based on age, kidney and liver function, and prior opioid exposure. Basal infusions increase risk of respiratory depression—use only with clear tolerance and close monitoring.

Non-opioid analgesics and adjuvants

Class	Agent	Adult dosing	Key cautions
Acetaminophen	PO or IV	650 to 1000 mg every 6 to 8 hours; max 3000 mg per day in most adults (up to 4000 mg per day if low risk and per policy)	Reduce max dose in liver disease or with alcohol use disorder
NSAID	Ketorolac IV	15 mg IV every 6 hours in older or renally at risk; 30 mg IV every 6 hours in low risk; limit 5 days	Avoid in acute kidney injury, bleeding risk, platelets low, peptic ulcer, or recent surgery
Gabapentinoid	Gabapentin	Start 100 to 300 mg by mouth three times daily; titrate as tolerated; adjust for kidney function	Sedation, dizziness; renal dose adjustment required
Gabapentinoid	Pregabalin	50 to 75 mg by mouth two or three times daily; adjust for kidney function	Sedation, edema; renal dose adjustment required
Antidepressant (chronic overlay)	Duloxetine	30 mg daily, then 60 mg daily if tolerated	Not for rapid acute relief; avoid in severe liver disease
Antidepressant (chronic overlay)	Amitriptyline	10 to 25 mg at bedtime	Anticholinergic effects; avoid in prolonged QT

Analgesic infusions beyond opioids

Agent	Starting infusion	Titration and typical max	Monitoring	Notes
Ketamine	0.1 to 0.3 mg per kg per hour	Titrate by 0.05 to 0.1 mg per kg per hour; typical max 0.5 mg per kg per hour	Cardiac and oximetry monitoring	Preserves breathing; may cause mild dissociation
Dexmedetomidine	0.2 to 0.4 microgram per kg per hour	Titrate by 0.1 to 0.2 microgram per kg per hour; typical max 0.7 to 1.0 microgram per kg per hour	Cardiac and blood pressure monitoring	No loading dose to reduce bradycardia and hypotension
Lidocaine IV	Optional bolus 1 mg per kg over 10 minutes, then 0.5 to 1.5 mg per kg per hour	Titrate within 0.5 to 2 mg per kg per hour per protocol	Continuous ECG and neurologic checks	Avoid in significant heart block without pacer, severe hepatic failure, or seizure disorder; use institutional protocols
Clonidine	0.1 mg by mouth every 8 to 12 hours	Patch 0.1 to 0.2 mg per day weekly if oral not feasible	Blood pressure and heart rate	Adjunct for analgesia and anxiety; caution hypotension and bradycardia

Non-pharmacologic and supportive measures

Measure	How it helps	Practical notes
Heat packs and gentle positioning	Muscle relaxation and local comfort	Protect skin; avoid burns; limit continuous heat time
Incentive spirometry and early mobilization	Prevents atelectasis and acute chest syndrome	Set hourly reminders; document volumes and effort
Hydration and trigger management	Addresses dehydration and acidosis that worsen vaso-occlusion	Avoid overhydration if cardiac or renal dysfunction present
Cognitive and behavioral strategies	Reduces anxiety and pain amplification	Brief coaching: breathing exercises, guided imagery, reassurance
Sleep hygiene and quiet environment	Improves rest and reduces sympathetic tone	Cluster care at night; dim lights; limit alarms if safe

Disease-modifying therapy such as hydroxyurea or transfusion strategies may reduce future crises but do not treat acute pain directly; manage triggers and complications in parallel.