Utilization of Patient-Controlled Analgesia Reduces Length of Stay of Sickle Cell Crisis Hospitalizations

Objective: Red blood cell exchange (RBCE) is the standard of care for patients with sickle cell disease (SCD) who present with severe vaso-occlusive crisis (VOC). However, subsets of these critically ill patients have progressive multiorgan failure (MOF) despite RBCE therapy. The purpose of this case series is to describe the use of plasma exchange (PLEX) for the treatment of SCD-related MOF that is refractory to RBCE. Methods: A retrospective case review of patients with severe MOF from sickle cell crisis unresponsive to RBCE who underwent PLEX in a 14-bed adult medical intensive care unit (ICU) at a tertiary care university hospital over a 4-year time period. Key laboratory data including complete blood count, indices of hemolysis, and markers of organ failure were recorded before and after both RBCE and PLEX. Results: Our primary objective is to evaluate the effectiveness of PLEX, in addition to RBCE, on organ dysfunction, laboratory indices, and mortality. Of the 7 patients, 6 survived. Of the patients who survived, all remained hemodynamically stable during PLEX sessions and showed both clinical and laboratory evidences of improvement in hemolysis and organ function. Average time from completion of first PLEX treatment to initial laboratory signs of organ failure reversal for patients who survived was 15.6 hours, the average length of stay in the ICU was 5.6 days, and the average total length of stay in the hospital was 14 days. Conclusions: Plasma exchange, in addition to RBCE, may be a novel synergistic treatment option to decrease risk of mortality in patients with refractory VOC and MOF.

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Intermittent Injection vs. Patient-Controlled Analgesia for Sickle Cell Crisis Pain

Survey of Anesthesiology ◽

10.1097/00132586-199204000-00035 ◽

1992 ◽

Vol 36 (2) ◽

pp. 86

Author(s):

E. R. GONZALEZ ◽

N. BAHAL

Keyword(s):

Sickle Cell ◽

Patient Controlled Analgesia ◽

Sickle Cell Crisis

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Patient-Controlled Analgesia for Management of Pain Associated With Acute Sickle Cell Crisis

Southern Medical Journal ◽

10.1097/00007611-199302000-00031 ◽

1993 ◽

Vol 86 (2) ◽

pp. 254

Author(s):

William E. Ackerman

Keyword(s):

Sickle Cell ◽

Patient Controlled Analgesia ◽

Sickle Cell Crisis

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Effect of Marijuana Smoking Among Adult Sickle Cell Patients on Trends in Sickle Cell Crisis Hospitalizations and Acute Chest Syndrome: A Nationwide Inpatient Assessment

Blood ◽

10.1182/blood-2019-122179 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 4850-4850

Author(s):

Shashank Sama ◽

Varun Tandon ◽

Nikhila Kethireddy ◽

Prajwal Boddu

Keyword(s):

Relative Risk ◽

Length Of Stay ◽

Cell Population ◽

Sickle Cell ◽

Pain Control ◽

Marijuana Use ◽

The United States ◽

Acute Chest Syndrome ◽

Sickle Cell Crisis ◽

Total Charges

PURPOSE Pain for sickle cell patients occurs on a daily basis, but this becomes magnified during a sickle cell crisis (SCC). The mainstay of treatment during hospitalization is intravenous fluids and opiates however this can be a nidus for an opiate addiction long term, especially in the ongoing opiate epidemic. Marijuana has been used in a variety of chronic pain disorders including those from cancer. It is known that within the sickle cell population, smoking tobacco increases the risk of acute chest syndrome. Marijuana use or its derivatives used to treat pain has not been studied on a large scale within the sickle cell population. We propose the question of whether marijuana use affects SCC admissions as well as acute chest syndrome (ACS). METHODS The National Inpatient Sample (NIS) dataset was queried from 2005 to 2014 to identify the primary diagnosis of SCC with the International Classification of Disease (ICD) Code 282.42, 282.62, 282.64 and 282.69, as has been done in the literature. We then identified those with marijuana use, excluding those used in the past and not currently with the ICD code 304.30, 304.31 and 304.32. Additionally we identified those with ACS with the ICD code of 517.3. We then used multivariate analysis along with Chi-square for non-continuous variables using the statistical software SAS. RESULTS Between the years of 2005 and the 2014, there were a total of 798,313 hospitalizations for sickle cell crisis in the United States. Around 0.08 % of these patients had marijuana use. When stratified by race marijuana use was predominantly documented among African Americans (95.2%) followed by Hispanics (3.8%). Length of stay was statistically the same among marijuana users at 4.65 vs 5.28 days without use (p = 0.11) when compared to non-users. Total charges at the end of hospitalization were also the same at $23134.2 vs $24662.7 (p=0.60) with marijuana users and non-users respectively. Marijuana patients did that lower proportions of ACS at 5.46% vs 8.48% without (p= 0.004) and a relative risk of 0.64. Proportion of death was the same with marijuana users of 0% and non-users 0.28% (p=0.16). The age at admission was higher at 30.77 when compared to 27.25 among non-users (p=0.0009). CONCLUSIONS: Marijuana use was associated with lower instances of ACS with a relative risk of 0.64. Additionally patients presented on average 3 years later than non-users. The fact that mortality, length of stay and total charges were the same amongst the two groups may indicate that during a crisis, the disease process is the same, however outside of having a crisis, marijuana use may help with pain control given later presentation. CLINICAL IMPLICATIONS: Further research should be done to look at marijuana use as an alternative to pain control for sickle cell patients in the community setting. Disclosures No relevant conflicts of interest to declare.

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Opioid Prescription Practices at Discharge and 30-Day Returns in Children with Sickle Cell Disease and Pain

Blood ◽

10.1182/blood.v126.23.3417.3417 ◽

2015 ◽

Vol 126 (23) ◽

pp. 3417-3417

Author(s):

Leslie M Okorji ◽

Devin S Muntz ◽

Robert I Liem

Keyword(s):

Logistic Regression ◽

Sickle Cell Disease ◽

Length Of Stay ◽

Sickle Cell ◽

Acute Pain ◽

Cell Disease ◽

Patient Controlled Analgesia ◽

Opioid Prescription ◽

Prescription Practices ◽

Multivariable Logistic Regression

Abstract Background: Acute pain episodes in children with sickle cell disease (SCD) represent a leading cause of readmissions. Lack of evidence-based guidelines contributes to variability in the management of children with SCD after hospitalization for acute pain. However, the impact of treatment variability on readmissions in this population has not been well studied. We examined prescription practices at time of discharge in children with SCD and acute pain to determine their impact on incidence of 30-day Emergency Department (ED) revisits and readmissions. We hypothesize that prescription of scheduled opioids after discharge for acute pain episodes is associated with lower 30-day ED revisits and readmissions when compared to the prescription of as needed or no opioids. Methods: We performed a single-institution, retrospective study of all patients with SCD aged 7 to 21 who were hospitalized or discharged from the ED with a diagnosis of acute pain episode from June 2009 to May 2014. Patients with ≥ 8 hospitalizations in a single year were excluded from the analysis. We reviewed demographic, treatment and discharge data from each encounter along with 30-day returns, defined as ED revisits and readmissions within 30 days of discharge. Between-groups comparisons for continuous variables were performed using the Mann-Whitney U test and categorical variables using the Chi-Square or Fisher's Exact test where appropriate. Independent predictors of 30-day returns were evaluated using multivariable logistic regression (IBM, SPSS v22). Results: We reviewed a total of 290 encounters (n=110, ED discharge; n=180, hospital discharge) in 97 patients (51% male, median 11.9 years old) during the 5-year period. Patients had hemoglobin SS or S/ß0 thalassemia in 209/290 (72%) encounters and were on hydroxyurea in 104/290 (36%). For hospitalizations (median length of stay 4 days), patients were treated with parenteral opioids in 159/180 (88%) encounters, most commonly by patient-controlled analgesia. Patients were prescribed opioids at the time of discharge in 259/290 (89%) encounters, more commonly at discharge from the hospital versus ED (96 vs. 79%, p < 0.01). The remaining patients were either prescribed non-steroidal anti-inflammatory drugs (NSAIDs) or a prescription was not given. Compared to as needed or no therapy, scheduled opioids were more frequently prescribed when discharged from the hospital versus ED (61 vs. 19%, p < 0.01). In total, 56/290 (19%) encounters resulted in 30-day ED revisits or readmissions after discharge from the hospital or ED. Compared to hospital discharges, discharge from the ED for acute pain was associated with a higher incidence of 30-day returns (OR = 2.7 [95% CI 1.5, 4.8], p < 0.01). Median number of days to return was also shorter for patients discharged from the ED versus hospital (4 vs. 11.5 days, p < 0.01). In general, we found no association between prescribed opioid frequency and incidence of 30-day returns. Prescription of scheduled opioids was similar between encounters that did or did not result in a 30-day ED revisit or readmission (46 vs. 48%, p = 0.8). Using multivariable logistic regression, we examined if other factors were associated with an increased incidence of 30-day returns. After discharge from the ED, the prescription of NSAIDs only, without opioids, was independently associated with a higher incidence of 30-day ED revisits but not readmissions. Neither 30-day ED revisits nor readmissions was affected by age, sex, genotype, or hydroxyurea use. After discharge from the hospital, none of these factors, including hospital length of stay or use of patient-controlled analgesia, were independently associated with 30-day ED revisits or readmissions. Conclusions: Variability exists in opioid prescription practices after discharge from the ED or hospital in children with SCD and acute pain episodes. Prescribed opioid frequency did not impact overall 30-day returns after discharge from the ED or hospital. After discharge from the ED, however, prescription of NSAIDs only, without opioids, was an independent predictor of higher 30-day ED revisits. Formalized studies to better understand factors that influence 30-day returns in children with SCD and acute pain are needed. Standardized approaches to outpatient opioid management after discharge and their impact on 30-day returns are also warranted in this population. Disclosures No relevant conflicts of interest to declare.

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