Emergency Medicine Management of Sickle Cell Disease Complications: An Evidence-Based Update

Pulse oximetry in patients with pigmented skin: What I should know

Pulse oximetry is widely used to non-invasively estimate the oxygen saturation of haemoglobin in arterial blood (SpO2). It is used widely throughout healthcare and was used extensively during the Covid-19 pandemic to detect and treat hypoxic patients. Research has suggested that pulse oximetry is less accurate in patients with darker skin. This led the US Food and Drug Administration agency (FDA) to issue a safety statement warning that pulse oximeters may be inaccurate when patients have pigmented skin. Evidence suggests that the oxygen saturation of arterial blood (SaO2) may be being overestimated by measuring SpO2 in those with pigmented skin. The degree of overestimation increases as SaO2 decreases especially when SpO2 reads below 80%. We review how pulse oximetry works and consider the implications for a patient's health when interpreting SpO2 in individuals with pigmented skin.

Acute sickle cell hepatopathy: A case report and literature review

Sickle cell disease (SCD) is an inherited hemoglobinopathy with protean clinical manifestations. The liver could be affected by various SCD-associated complications of an overlapping nature. The clinical presentations of "sickle cell hepatopathy" range from clinically asymptomatic patients to those with life-threatening complications. Herein we report an SCD patient who presented with right upper quadrant abdominal pain and jaundice, eventually diagnosed as a self-limited form of acute sickle cell hepatopathy with overlapping features of acute hepatic crisis and benign intrahepatic cholestasis. Using this patient as an illustration, we will review the spectrum of hepatobiliary presentations in the SCD population.

Jk(a) (Kidd-A) Variant in a Sickle Cell Disease Patient

Sickle cell disease (SCD) is a chronic and prevalent hemoglobin disorder with various manifestations and complications depending on the organs involved. Red cell transfusion either simple or exchange is crucial due to its prophylactic and therapeutic roles. We present a case showing serologic discrepancy between the red cells phenotype and the developed alloantibodies to emphasize the crucial role of molecular testing in SCD patients requiring chronic blood transfusion.

A Quality Improvement Initiative to Decrease Time to Analgesia in Patients With Sickle Cell and Vaso-Occlusive Crisis: A Population With Disparities in Treatment

Introduction: Vaso-occlusive crises (VOCs) are the leading cause of emergency department (ED) visits and hospitalizations in patients with sickle cell disease (SCD). Timely administration of analgesia, within 60 minutes of patient registration, is the standard of care for SCD patients with VOCs. Patients with VOCs have longer times to initial analgesia compared to similar painful conditions. The primary aim of the project is to have 75% of patients with VOCs receive initial analgesia within 60 minutes of being registered, the current recommended time frame from the National Heart, Lung, and Blood Institute (NHLBI).

Methods: A multi-disciplinary team used quality improvement (QI) methodology to develop a plan involving multiple Plan-Do-Study-Act (PDSA) cycles. A rapid evaluation process was employed which included notification of a patient with a VOC being placed in a room, rapid evaluation by all team members and use of an electronic order set.

Results: The aim was met 72% of the time during our intervention period, compared to 17% pre-intervention. Average time to initial analgesia was decreased from 61 minutes to 42 minutes (p-value < 0.001), while time to disposition was also decreased when time goals were achieved.

Conclusion: Using a rapid evaluation process we were able to decrease time to initial analgesia in a patient population that has previously experienced delays in care and decrease overall time to disposition.

Pediatric Acute Liver Failure in Sickle Cell Disease

<b><i>Introduction:</i></b> Sickle cell intrahepatic cholestasis (SCIC) is one of the rarest and the most severe acute hepatic manifestations of sickle cell disease (SCD) and it can rapidly progress to acute liver failure. It is associated with a high mortality rate, demanding prompt recognition and management. <b><i>Case Presentation:</i></b> We report a case of a 7-year-old boy with a history of homozygous HbS SCD who presented to the emergency department with fever, increasing abdominal pain, and jaundice. His course was complicated by acute liver injury (AST 9,472 IU/L, ALT 2,683 IU/L, total bilirubin 15.4 mg/dL; conjugated bilirubin 8.69 mg/dL, hypoalbuminemia 2.6 g/dL, and persistent hypoglycemia), with acute liver failure (coagulopathy not corrected by vitamin K administration with INR 3.26, decreased factors V 10% and VII 28%, and West Haven grade I hepatic encephalopathy associated with mild hyperammonemia of 71 µmol/L). After excluding other causes of acute liver failure, the patient was diagnosed as having SCIC and was successfully treated with manual exchange transfusion. <b><i>Conclusion:</i></b> This case reinforces that exchange transfusion is an effective treatment for SCIC and that it should be introduced promptly to prevent fulminant and potentially fatal liver failure.

Is sickle cell disease a risk factor for severe COVID-19 outcomes in hospitalized patients? A multicenter national retrospective cohort study

Introduction

Studies that examine the association between sickle cell disease (SCD) and COVID‐19 outcomes are lacking. This study aims to determine whether SCD is a risk factor for severe COVID‐19 infection in regard to the requirement of noninvasive ventilation/high flow nasal cannula (NIV/HFNC), mechanical ventilation (MV), or death in hospitalized patients.

Methods

Retrospective cohort study included COVID‐19 patients admitted to four COVID‐19 treatment facilities in Bahrain between February 24, 2020 and July 31, 2020. All SCD patients with COVID‐19 were included and compared to a randomly selected sample of non‐SCD patients with COVID‐19. Data were collected from the medical records. Multivariate logistic regression models were used to control for confounders and estimate the effect of SCD on the outcomes.

Results

1792 patients with COVID‐19 were included; 38 of whom were diagnosed with SCD as well. In the SCD group, one (2.6%) patient required NIV/HFNC, one (2.6%) required MV, and one (2.6%) death occurred. In comparison, 56 (3.2%) of the non‐SCD patients required NIV/HFNC, 47 (2.7%) required MV, and death occurred in 58 (3.3%) patients. Upon adjusting for confounders, SCD had an odds ratio of 1.847 (95% CI: 0.39–8.83; p = 0.442).

Conclusion

Our results indicate that SCD is not a risk factor for worse COVID‐19 outcomes in hospitalized patients.

The Use of Religion in the Management of Depression in Sickle Cell Disease: A Systematic Review

The incidence of depression in individuals with sickle cell disease (SCD) is significantly higher compared to the general population. This systematic literature review was conducted to: (1) describe depressive symptoms in SCD individuals and (2) explore religiosity as a coping mechanism for alleviating depressive symptoms. Emerging themes were physical depressive symptoms and psychosocial depressive implications. Despite uptake of religion and religiosity as a coping strategy in other chronic illnesses, no studies were found that used religiosity to cope with depressive symptoms in SCD. Future research should explore the use of religiosity as an alternative therapy to cope with depression symptoms.

Emergency Department Provider Survey Regarding Acute Sickle Cell Pain Management

Sickle cell disease (SCD) can lead to potentially devastating complications that occur secondary to vaso-occlusion. Current national clinical guidelines are largely based on expert opinion, resulting in significant variation of management. Provider awareness regarding emergency department (ED) management of vaso-occlusive crises (VOC) remains unknown. A 23-question assessment of VOC management was administered to all eligible ED providers at Riley Hospital for Children between September and November 2018. Univariate analyses were performed to evaluate responses between groups. Of 52 respondents comprised of ED staff attendings (27%), resident trainees (58%), and ED nurses (15%), the majority were not aware of SCD management guidelines being available. Approximately 54% of providers endorsed a high comfort level in managing VOC, with staff and nurses more likely to report this than trainees (P=0.02). Less than 10% of all providers knew the recommended timeframe from triage to initial medication administration. Prolonged time between pain assessments was reported by 25% of providers with a high comfort level in managing VOC, which was similar to providers with a lower comfort level (13%, P=0.217). Only one fourth of all respondents appropriately did not use vital signs as an indication of a patient's pain level, and >10% reported not utilizing patient-reported pain scores. This was not significantly different between provider comfort levels (P=0.285 and 0.412, relatively). Our results suggest education regarding recommended practices was inadequate regardless of reported provider comfort. Further provider education and/or standardized ED VOC management guidelines may serve as areas for improvement in SCD care.

Imaging review of sickle cell disease for the emergency radiologist

Sickle cell disease (SCD), one of the most common inherited genetic syndromes in the USA, is characterized by recurring episodes of acute illness and progressive multisystem organ injury. Individuals with SCD frequently present to the emergency department for a spectrum of complications, such as vaso-occlusive crises, infection, cholecystitis, and stroke. Imaging correlates for most of these presentations exist, positioning the emergency radiologist to play a pivotal role in facilitating patient care. Using a systems-based approach, we describe the acute and chronic imaging manifestations of SCD that an emergency radiologist can expect to encounter in most practice settings, highlighting the unique pathophysiology of this disorder that typically underlies the imaging findings.

Interventions for treating intrahepatic cholestasis in people with sickle cell disease

BACKGROUND

Sickle cell disease is the most common hemoglobinopathy occurring worldwide and sickle cell intrahepatic cholestasis is a complication long recognized in this population. Cholestatic liver diseases are characterized by impaired formation or excretion (or both) of bile from the liver. There is a need to assess the clinical benefits and harms of the interventions used to treat intrahepatic cholestasis in people with sickle cell disease. This is an update of a previously published Cochrane Review.

OBJECTIVES

To assess the benefits and harms of the interventions for treating intrahepatic cholestasis in people with sickle cell disease.

SEARCH METHODS

We searched the Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register, which comprises references identified from comprehensive electronic database searches and handsearching of relevant journals and abstract books of conference proceedings. We also searched the LILACS database (1982 to 21 January 2020), the WHO International Clinical Trials Registry Platform Search Portal and ClinicalTrials.gov (21 January 2020). Date of last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register: 25 November 2019.

SELECTION CRITERIA

We searched for published or unpublished randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Each author intended to independently extract data, assess the risk of bias of the trials by standard Cochrane methodologies and assess the quality of the evidence using the GRADE criteria; however, no trials were included in the review.

MAIN RESULTS

We did not identify any randomised controlled trials.

AUTHORS' CONCLUSIONS

This updated Cochrane Review did not identify any randomised controlled trials assessing interventions for treating intrahepatic cholestasis in people with sickle cell disease. Randomised controlled trials are needed to establish the optimum treatment for this condition.

The vaso-occlusive pain crisis in sickle cell disease: Definition, pathophysiology, and management

Early diagnosis, treatment, and prevention of a vaso-occlusive crisis (VOC) are critical to the management of patients with sickle cell disease. It is essential to differentiate between VOC-associated pain and chronic pain, hyperalgesia, neuropathy, and neuropathic pain. The pathophysiology of VOCs includes polymerization of abnormal sickle hemoglobin, inflammation, and adhesion. Hydroxyurea, L-glutamine, crizanlizumab, and voxelotor have been approved by the US Food and Drug Administration for reducing the frequency of VOCs; the European Medicines Agency has approved only hydroxyurea. Other novel treatments are in late-stage clinical development in both the United States and the European Union. The development of agents for prevention and treatment of VOCs should be driven by our understanding of its pathophysiology.

Asymptomatic Hepatic Sequestration with Extreme Hyperbilirubinemia in an Adult Homozygous Sickle Cell Patient

It has been estimated that there are greater than 100,000 individuals in the US with sickle cell disease. Hepatic sequestration is a known sequelae of sickle cell disease that rarely leads to extreme hyperbilirubinemia (total serum bilirubin greater than 20 mg/dl). Our 26-year-old male patient, though compliant with regular transfusion exchanges, presented with hepatic sequestration, with minimal symptoms and hyperbilirubinemia up to approximately 40 mg/dl. The severity of asymptomatic hepatic sequestration seen in our patient has never been reported in the literature. This mandates a low threshold to screen for sickle cell complications and promptly treating these patients admitted to the hospital with exchange transfusions.

Critical Care Education Day: A Novel, Multidisciplinary, and Interactive Critical Care Education Session for Emergency Medicine Residents

Critical care medicine (CCM) is central to emergency medicine (EM) resident education. We feel that the traditional lecture format is not the ideal way to teach EM critical care, which requires integration and prioritization of diagnostic workup and team-based resuscitation under time pressure. We describe a novel critical care education day where an interactive, practical, and multidisciplinary critical care educational experience was provided for EM residents using case-based small-group sessions and fast-paced simulation.

The impact of sickle cell anemia on the quality of life of sicklers at school age

Background

Sickle cell anemia (SCA) is prevalent in Sudan in general, and in particular in the western part of the country among Misseria tribe. School absence, depressive symptoms, embarrassment, social disturbances, and emotional disturbance present negative impact for sicklers. Therefore, an urgent call for improving the quality of life of sicklers is needed.

Objectives

To examine the impact of SCA on the quality of life of school-age children affected by the disease from the perspective of three dimensions: psychological, social, and schooling.

Materials and Methods

This is a prospective, cross-sectional, observational study carried out over 2 weeks' period in April 2011 in Western Sudan, Gineana District. This study included 107 patients within the age group of 7-15 years with confirmed diagnosis of SCA in a steady state. A sickler with SCA who had hemoglobin genotype "SS" on hemoglobin electrophoresis without crises over the past 4 weeks was considered to be in steady state. Questionnaires designed by expert covering social and psychological aspects of the disease were filled by the authors.

Results

Of 107 patients with confirmed diagnosis of SCA in steady state, 54.2% of them were male. About 17.8%, 29.6%, 23.4%, 48.6%, 16.8%, and 45.8% of the patients suffered from school absence, teasing, embarrassment due to bedwetting, embarrassment due to jaundice, failure to contribute to school activities such as sport, and depressive symptoms, respectively. Around 8.4% of the patients repeated classes. Divorce and anxiety among sicklers' families were found in 6.5% and 8.4%, respectively. Twenty-one (19.6%) families had less interest in social activities in the community.

Conclusion

Sickle cell disease has many social and psychological problems which need to be addressed. Enuresis, depressive symptoms, school absentees, and deterioration in school performance were the common problems encountered.

Radiological Patterns in Sickle Cell Disease Patients with Acute Chest Syndrome: Are There Age-Related Differences?

Background:

Acute chest syndrome is a major cause of pulmonary disease and mortality in sickle cell disease patients. Its diagnosis can be delayed due to differing imaging patterns between children and adults.

Objective:

The purpose of this study was to describe the pulmonary and extrapulmonary imaging findings in sickle cell disease patients with acute chest syndrome and determine differences in findings between adult and pediatric patients.

Patients and Methods:

This retrospective study analyzed the data of all sickle cell disease patients who were admitted with a diagnosis of acute chest syndrome to King Fahd Hospital of the University, Al Khobar, Saudi Arabia, between January and June 2015 (n = 150). After grouping the patients into adults and pediatrics, the pulmonary and extrapulmonary characteristics were identified and the digital radiography, computed tomography and laboratory findings were compared.

Results:

A total of 116 patients with 163 acute chest syndrome episodes met the inclusion criteria, of which 69 (60%) were adults. In both adult and pediatric patients, the most frequent pulmonary finding was consolidation of the lung parenchyma. The right lung was most frequently involved: the lower lobe in adult patients and the middle lobe in pediatric patients. In addition, pleural effusion was observed in both age groups. Extrapulmonary radiological findings, such as avascular necrosis and cardiomegaly, were significantly more common in adult patients than in pediatric patients (P < 0.05). Compared with adults, pediatric patients had significantly lower hemoglobin levels (P = 0.001) and oxygen tension fraction in arterial blood (P = 0.007).

Conclusions:

Pediatric and adult sickle cell disease patients with acute chest syndrome typically exhibited similar pulmonary characteristics, whereas extrapulmonary findings were more prominent in adult patients. Furthermore, low levels of hemoglobin and oxygen tension fraction were dependent predictors of acute chest syndrome.

A prospective study of the association between sickle cell disease and hepatobiliary effects in Bahrain

Background

Sickle cell disease is a genetic disorder that leads to abnormally high levels of hemoglobin sickling in erythrocytes. Patients suffer debilitating and severe complications that affect multiple organs, though mainly the liver, gallbladder, spleen, bones, and kidneys. It has a significant impact on morbidity and mortality rates and is associated with substantial health care costs.

Methods

For this study, the researchers prospectively reviewed the charts of 154 sickle cell disease patients who had been treated in Salmaniya Medical Complex hospital in Bahrain between September 2013 and December 2014.

Results

The results obtained showed that 95% of patients had sickle cell hemoglobin type. Of the sample patients, 80% exhibited bone pain, with all patients exhibiting bone crisis. Biochemical tests revealed reduced hemoglobin concentration, elevated bilirubin, compromised liver function, and lower white blood cell counts. The incidence of hepatitis B and C was very low, at 0% and 9%, respectively. There were a large number of hospital admissions, with 11 days as an average length of stay. The most common ultrasound findings in this study were hepatomegaly, hepatosplenomegaly, cholelithiasis, gallbladder sludge, and splenomegaly.

Conclusion

Sickle cell disease had profound negative effects on multiple organs, with a particularly large number of complications related to the hepatobiliary system.

Interventions for treating intrahepatic cholestasis in people with sickle cell disease

BACKGROUND

Sickle cell disease is the most common hemoglobinopathy occurring worldwide and sickle cell intrahepatic cholestasis is a complication long recognized in this population. Cholestatic liver diseases are characterized by impaired formation or excretion (or both) of bile from the liver. There is a need to assess the clinical benefits and harms of the interventions used to treat intrahepatic cholestasis in people with sickle cell disease. This is an update of a previously published Cochrane Review.

OBJECTIVES

To assess the benefits and harms of the interventions for treating intrahepatic cholestasis in people with sickle cell disease.

SEARCH METHODS

We searched the Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register, which comprises references identified from comprehensive electronic database searches and handsearching of relevant journals and abstract books of conference proceedings. We also searched the LILACS database (1982 to 23 May 2017), the WHO International Clinical Trials Registry Platform Search Portal (23 May 2017) and ClinicalTrials.gov.Date of last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register: 12 April 2017.

SELECTION CRITERIA

We searched for published or unpublished randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Each author intended to independently extract data and assess the risk of bias of the trials by standard Cochrane methodologies; however, no trials were included in the review.

MAIN RESULTS

There were no randomised controlled trials identified.

AUTHORS' CONCLUSIONS

This updated Cochrane Review did not identify any randomised controlled trials assessing interventions for treating intrahepatic cholestasis in people with sickle cell disease. Randomised controlled trials are needed to establish the optimum treatment for this condition.