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enefits of nalbuphine (adult dosage, 0.3 mg/kg up to 20 mg, with maxi-
mum dose 160 mg/day) include an excellent adverse effect profile.
Nalbuphine is associated with relatively less nausea, sedation, and respiratory
depression compared with pure opioid agonists. A retrospective analysis
of children receiving nalbuphine for VOC found this agonist–antagonist
at least as effective as morphine, with some endpoints (e.g. development of
acute chest syndrome) favoring nalbuphine. 33 The authors concluded that
prospective study is necessary to delineate any advantages of nalbuphine. 33
More study is required before widespread adoption of nalbuphine, since
the agent’s antagonist properties have disadvantages. The most important
issue with nalbuphine is its ceiling dose of 20 mg every 3 h, which is
necessitated by the agent’s antagonist activity. Therefore, if pain is not
controlled after titration to 20 mg every 3 h, nalbuphine should be stopped
and the patient should be given a pure opioid agonist. Also, nalbuphine’s
antagonist properties preclude its use in patients who have frequent or
regular need for pure-agonist opioids (owing to the risk of acute withdrawal
symptoms). 13,14,28
Transdermal fentanyl (25–50 μg/h) has been administered to children in
an open-label trial assessing its use as adjunctive therapy to morphine PCA. 34
The trial’s authors concluded that further study is necessary to elucidate the
pharmacology of transdermal fentanyl in children. While acute care recommendation
of this approach must await further data, the finding of subjective
improvement in pain relief in 70% of patients indicates promise for transdermal
fentanyl. At this time, the role of transdermal fentanyl appears
limited to chronic-care use. 12
Opioids comprise the mainstay of therapy of VOC in pregnancy, although
acetaminophen may also be useful in gravida with mild pain. 35
PATIENT-CONTROLLED ANALGESIA
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The PCA technology is of high potential utility in the ED management of
VOC. Pumps can be set for basal (i.e. constant) infusion rate and bolus doses;
a “lockout” interval after each bolus dose prevents stacking of analgesic doses
and reduces chances of toxicity. The PCA is a valuable tool for ED clinicians,