Normal saline bolus use in pediatric emergency departments is associated with poorer pain control in children with sickle cell anemia and vaso-occlusive pain

• Type of Material: Article
• Authors: Marcus A. Carden, University of North Carolina; David C, Brousseau, Medical College of Wisconsin; Fahd Ahmad, Washington University; Jonathan Bennett, Alfred I DuPont Hosp Children; Seema Bhatt, Cincinnati Childrens Hospital Medical Center; Amanda Bogie, University of Oklahoma; Kathleen Brown, Childrens National Medical Center; T. Charles Casper, University of Utah; Laura L. Chapman, Brown University; Corrie E. Chumpitazi, Baylor College of Medicine; Daniel Cohen, Nationwide Childrens Hospital; Carlton Dampier, Emory University; Angela M. Ellison, Childrens Hospital of Philadelphia; Hartmut Grasemann, Hospital for Sick Children; Robert W. Hickey, UPMC; Lewis L. Hsu, University of Illinois; Sara Leibovich, UCSF Benioff Childrens Hospital; Elizabeth Powell, Ann & Robert H Lurie Childrens Hospital Chicago; Rachel Richards, University of Utah; Syana Sarnaik, Childrens Hospital Michigan; Debra L. Weiner, Boston Childrens Hosp; Claudia Morris, Emory University
• Language: English
• Date: 2019-06-01
• Publisher: Wiley
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2019 Wiley Periodicals, Inc.
• Final Published Version (URL): http://dx.doi.org/10.1002/ajh.25471
• Title of Journal or Parent Work: American Journal of Hematology
• Volume: 94
• Issue: 6
• Start Page: 689
• End Page: 696
• Grant/Funding Information: PECARN is supported by the Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB),and Emergency Medical Services for Children (EMSC) through the following grants: DCC-University of Utah (U03MC00008), GLEMSCRN-Nationwide Children’s Hospital (U03-MC00003), HOMERUN-Cincinnati Children’s Hospital Medical Center (U03-MC22684), PEMNEWS-Columbia University Medical Center (U03-MC00007), PRIME-University of California at Davis Medical Center (U03-MC00001), SW NODE-University of Arizona Health Sciences Center (U03MC28845), WBCARN-Children’s National Medical Center (U03-MC00006), and CHaMP-Medical College of Wisconsin (H3MC26201).; MCHB/HRSA Contact: Diane Pilkey, RN, MPH [e-mail]; This study was supported in part by NIH-NHLBI grant R34HL122557 (to CRM), NIH-NCCIH grant K24AT009893 (to CRM) and PECARN funding.
• Keywords: Disease; Fluids; sickle cell anemia; normal saline bolus; Life Sciences & Biomedicine; vaso-occlusive pain; Balanced crystalloids; Hematology; Pediatric Emergency Care Applied Research Network (PECARN); Resucitation; Science & Technology; emergency department; Management
• Research Categories: Biology, Cell; Health Sciences, Medicine and Surgery; Health Sciences, Health Care Management

Abstract

Vaso-occlusive pain events (VOE) are the leading cause of emergency department (ED) visits in sickle cell anemia (SCA). This study assessed the variability in use of intravenous fluids (IVFs), and the association of normal saline bolus (NSB), on pain and other clinical outcomes in children with SCA, presenting to pediatric emergency departments (PED) with VOE. Four-hundred charts of children age 3-21 years with SCA/VOE receiving parenteral opioids at 20 high-volume PEDs were evaluated in a retrospective study. Data on type and amount of IVFs used were collected. Patients were divided into two groups: those who received NSB and those who did not. The association of NSB use on change in pain scores and admission rates was evaluated. Among 400 children studied, 261 (65%) received a NSB. Mean age was 13.8 ± 4.9 years; 46% were male; 92% had hemoglobin-SS. The IVFs (bolus and/or maintenance) were used in 84% of patients. Eight different types of IVFs were utilized and IVF volume administered varied widely. Mean triage pain scores were similar between groups, but improvement in pain scores from presentation-to-ED-disposition was smaller in the NSB group (2.2 vs 3.0, P =.03), while admission rates were higher (71% vs 59%, P =.01). Use of NSB remained associated with poorer final pain scores and worse change in pain scores in our multivariable model. In conclusion, wide variations in practice utilizing IVFs are common. NSB is given to >50% of children with SCA/VOE, but is associated with poorer pain control; a controlled prospective trial is needed to determine causality.