Jane Doe is a 23-year-old African American female presenting to the ED with complaints of Vaso occlusive painful crisis for 2 days, patient gave a medical history of Sickle Cell Anemia. Patient stated that she has been exercising and doing a lot of intense activities to loss weight and has not been drinking a lot of liquids.

Taneka Miller Posted Date:June 1, 2022 2:42 AMStatus:Published
Patient Case

Jane Doe is a 23-year-old African American female presenting to the ED with complaints of Vaso occlusive painful crisis for 2 days, patient gave a medical history of Sickle Cell Anemia. Patient stated that she has been exercising and doing a lot of intense activities to loss weight and has not been drinking a lot of liquids.

She reports severe lower back pain that radiates to both legs. Patient is on oxycodone 5mg, but states that she is not getting adequate pain relief, and the pain is now unbearable.

The patient is a smoker and has not been tsking daily supplements of folic acid as prescribed. IV fluids for fluid hydration commenced and she was initially given a dose of codeine but that was not effective. For adequate pain relief she was started on Morphine via PCA pump.

Factors influencing the Pharmacokinetics and Pharmacodynamics process.

An important step in the pharmacokinetics of opioids is their conversion into metabolites that could be active or inactive. Prodrugs are drugs that are not active themselves, but their metabolites are. Thus, codeine is a prodrug without an analgesic effect by itself, but its metabolite morphine is the active analgesic. The conversion into an active metabolite depends on the presence of the required enzyme and polymorphic variants of the enzyme, (Ballas 2007).

African Americans lack the enzyme CYP2D6 and, hence, will not achieve pain relief by using codeine alone. Moreover, the enzyme is polymorphic, and some variants are more efficient in the conversion into other active metabolite than others are. Morphine is unique in that it is active drug itself, and its metabolites morphine-6-gluconide (M6

G) and morphine-3-glucronide (M3G) are active. (Ballas 2007).

Morphine is a stop opioid agonist and is effective in treating chronic sickle cell pain, it is also known to be hydrophilic and thus is rapidly distributed to tissues and organs. When metabolized into M6G and M3G it is four times more potent and has longer half life than its parent drug. (Ballas 2007).

Plan of care

With the patient history of sickle cell Anemia, the focus is pain control where the joints and extremities can be extremely painful, giving the patient the analgesic prescribed via continuous infusion for the duration of the painful crisis, and ensure the patient is positioned carefully to help alleviate pain. (Uwazuoke & Ayuk, 2018), mentioned that treatment of chronic pain for a sickle cell patient reduces physiological distress, and enhances the patient confidence and resilience. Fluid promotion of electrolyte balance and prevention of complications resulting from abnormal or undesired fluid levels. Encourage the patient to take fluids while observing for signs of dehydration. Treating Vasoocclusive painful crises in people with sickle cell disease is complex and requires multiple interventions. Extra fluids are routinely given as adjunct treatment, regardless of the individual’s state of hydration with the aim of slowing or stopping the sickling process and thereby alleviating pain, (Okomo & Meremikwu, 2017). The patient also needs to education on avoiding physical exertion, and knowledge of the disease helps ensure compliance with treatment regime and adherence to preventive measure. (Maakaron & Bessa, 2021), stated that patients must be educated about the nature of their disease. They must be able to recognize the earliest signs of a Vaso-occlusive crisis and seek help, treat all febrile illness promptly, and identify environmental hazards that may precipitate a crisis. Reinforcement should occur incrementally during ongoing care.

References

Ballas.,S (2007). Current Issues in Sickle Cell pain and its Management. Hematology Am Soc Hematol Program (2007) (1): 97-105. https://doi.org/10.1182/asheducation-2007.1.97

Okomo., U & Meremikwu., M, 2017. Fluid replacement therapy for acute episodes of pain in people with sickle cell disease. Cochrane database system Review, 2017 (7), http://doi: 10.1002/14651858.CD005406.pub5

Maakaron., J & Bessa., E, 2021. What education should patients with sickle cell disease (SCD) receive?. Retrieved May 31, 2022 from https://www.medscape.com/answers/205926-15325/what-education-should-patients-with-sickle-cell-disease-scd-receive#:~:text=Patients%20must%20be%20educated%20about,that%20may%20precipitate%20a%20crisis.

Uwazuoke., S & Ayuk., A, 2018. Vaso-occlusive crisis in sickle cell disease: current paradigm on pain management. National Library of Medicine. 2018; 11: 31413150. http://doi: 10.2147/JPR.S185582

Read a selection of your colleagues responses and respond to at least two of your colleagues on two different days by suggesting additional patient factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients they described. In addition, suggest how the personalized plan of care might change if the age of the patient were different and/or if the patient had a comorbid condition, such as renal failure, heart failure, or liver failure.

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