Acute chest syndrome in the postoperative sickle cell patient

Splenectomy in Jamaican children with sickle cell disease: Outcome of selective blood transfusion

We reviewed the post-operative morbidity and mortality of open splenectomy undertaken in conjunction with selective blood transfusion in Jamaican children with sickle cell disease. Data were collected on 150 splenectomies performed between November 1994 and October 2017. Selective blood transfusion involved raising haemoglobin levels to approximately 100 g/L in patients with admission haemoglobin ≥10 g/L below steady state. There was no mortality. Mean post-operative stay was 3.2 days with a median of three days. Total morbidity was 19/150 cases (12.7%), with acute chest syndrome accounting for 11/19 (57.9%). Among the non-transfused, acute chest syndrome occurred in 10/117 cases (8.5%), while among transfused, acute chest syndrome occurred in 1/33 cases (2.9%). We recommend this selective blood transfusion protocol for patients with sickle cell disease to surgeons who undertake splenectomies in settings where blood bank reserves are perennially low.

Epidemiology and Perioperative Complications in Patients With Sickle Cell Disease After Orthopaedic Surgery: 26 Years' Experience at a Major Academic Center

INTRODUCTION

Surgical management of patients with sickle cell disease (SCD) poses a unique challenge to orthopaedic surgeons due to increased operative and perioperative risk. Studies evaluating perioperative complications among patients with SCD undergoing orthopaedic surgery have been limited. We sought to review the clinical characteristics and perioperative complications in our patients with SCD who required orthopaedic surgery.

METHODS

Our institution has one of the largest sickle cell centers in the Northeastern United States. We performed a retrospective chart review of all patients referred to the Orthopaedic Surgery Department between 1990 and 2016 and analyzed the demographics, comorbidities, surgical intervention, and perioperative complications.

RESULTS

In total, 96 orthopaedic surgeries were surveyed across 26 years performed at our institution. The majority of the patients with SCD were African American (90.3%) and women (60.4%). The most common surgical intervention was for hip osteonecrosis. Only 11.5% of the patients (11 of 96) experienced a perioperative complication, with the vasoocclusive event being the most common (7 patients; 64%).

DISCUSSION

These data suggest that orthopaedic surgery for a patient with SCD is safe but does require careful multidisciplinary consultation including hematology and anesthesia to medically optimize the patient before surgical intervention.

Antibiotics for treating acute chest syndrome in people with sickle cell disease

BACKGROUND

The clinical presentation of acute chest syndrome is similar whether due to infectious or non-infectious causes, thus antibiotics are usually prescribed to treat all episodes. Many different pathogens, including bacteria, have been implicated as causative agents of acute chest syndrome. There is no standardized approach to antibiotic therapy and treatment is likely to vary from country to country. Thus, there is a need to identify the efficacy and safety of different antibiotic treatment approaches for people with sickle cell disease suffering from acute chest syndrome. This is an update of a Cochrane Review first published in 2007, and most recently updated in 2015.

OBJECTIVES

To determine whether an empirical antibiotic treatment approach (used alone or in combination):1. is effective for acute chest syndrome compared to placebo or standard treatment;2. is safe for acute chest syndrome compared to placebo or standard treatment;Further objectives are to determine whether there are important variations in efficacy and safety:3. for different treatment regimens,4. by participant age, or geographical location of the clinical trials.

SEARCH METHODS

We searched The 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 October 2017), African Index Medicus (1982 to 23 October 2017) and trial registries (23 October 2017).Date of most recent search of the Haemoglobinopathies Trials Register: 10 July 2019.

SELECTION CRITERIA

We searched for published or unpublished randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Each author intended to independently extract data and assess trial quality by standard Cochrane methodologies, but no eligible randomised controlled trials were identified.

MAIN RESULTS

For this update, we were unable to find any randomised controlled trials on antibiotic treatment approaches for acute chest syndrome in people with sickle cell disease.

AUTHORS' CONCLUSIONS

This update was unable to identify randomised controlled trials on efficacy and safety of the antibiotic treatment approaches for people with sickle cell disease suffering from acute chest syndrome. While randomised controlled trials are needed to establish the optimum antibiotic treatment for this condition, we do not envisage further trials of this intervention will be conducted, and hence the review will no longer be regularly updated.

Perioperative Management of Sickle Cell Disease

Over 30 million people worldwide have sickle cell disease (SCD). Emergent and non-emergent surgical procedures in SCD have been associated with relatively increased risks of peri-operative mortality, vaso-occlusive (painful) crisis, acute chest syndrome, post-operative infections, congestive heart failure, cerebrovascular accident and acute kidney injury. Pre-operative assessment must include a careful review of the patient’s known crisis triggers, baseline hematologic profile, usual transfusion requirements, pre-existing organ dysfunction and opioid use. Use of preoperative blood transfusions should be selective and decisions individualized based on the baseline hemoglobin, surgical procedure and anticipated volume of blood loss. Intra- and post-operative management should focus on minimizing hypoxia, hypothermia, acidosis, and intravascular volume depletion. Pre- and post-operative incentive spirometry use should be encouraged.

Orthopaedic Manifestations of Sickle Cell Disease

Sickle cell disease (SCD) is an autosomal recessive disorder that results in hemolytic anemia related to abnormal hemoglobin and erythrocyte levels. SCD is characterized by vascular occlusive episodes, visceral sequestration, and aplastic or hemolytic crises. These crises most commonly occur in bone. The orthopaedic manifestations of SCD comprise much of the morbidity associated with this disorder. Osteonecrosis and osteomyelitis are among the most disabling and serious musculoskeletal complications in patients with SCD. Effective management of the bone and joint sequelae requires an accurate diagnosis, an understanding of the pathophysiology of the disease, and knowledge of available medical and surgical treatment alternatives. The major orthopaedic manifestations of SCD are osteonecrosis, osteomyelitis, septic arthritis, and bone infarction. Patients with SCD require close monitoring in the perioperative period because of the risk for vasoocclusive crisis.

Antibiotics for treating acute chest syndrome in people with sickle cell disease

BACKGROUND

The clinical presentation of acute chest syndrome is similar whether due to infectious or non-infectious causes, thus antibiotics are usually prescribed to treat all episodes. Many different pathogens, including bacteria, have been implicated as causative agents of acute chest syndrome. There is no standardized approach to antibiotic therapy and treatment is likely to vary from country to country. Thus, there is a need to identify the efficacy and safety of different antibiotic treatment approaches for people with sickle cell disease suffering from acute chest syndrome. This is an update of a Cochrane review first published in 2007, and previously updated in 2013.

OBJECTIVES

To determine whether an empirical antibiotic treatment approach (used alone or in combination):1. is effective for acute chest syndrome compared to placebo or standard treatment;2. is safe for acute chest syndrome compared to placebo or standard treatment;Further objectives are to determine whether there are important variations in efficacy and safety:3. for different treatment regimens,4. by participant age, or geographical location of the clinical trials.

SEARCH METHODS

We searched The 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 February 2015), African Index Medicus (1982 to 23 February 2015). and the World Health Organization International Clinical Trials Registry Platform Search Portal (23 February 2015).Date of most recent search of the Haemoglobinopathies Trials Register: 20 January 2015.

SELECTION CRITERIA

We searched for published or unpublished randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Each author intended to independently extract data and assess trial quality by standard Cochrane Collaboration methodologies, but no eligible randomised controlled trials were identified.

MAIN RESULTS

For this update, we were unable to find any randomised controlled trials on antibiotic treatment approaches for acute chest syndrome in people with sickle cell disease.

AUTHORS' CONCLUSIONS

This update was unable to identify randomised controlled trials on efficacy and safety of the antibiotic treatment approaches for people with sickle cell disease suffering from acute chest syndrome. Randomised controlled trials are needed to establish the optimum antibiotic treatment for this condition.

Antibiotics for treating acute chest syndrome in people with sickle cell disease

BACKGROUND

The clinical presentation of acute chest syndrome is similar whether due to infectious or non-infectious causes, thus antibiotics are usually prescribed to treat all episodes. Many different pathogens, including bacteria, have been implicated as causative agents of acute chest syndrome. There is no standardized approach to antibiotic therapy and treatment is likely to vary from country to country. Thus, there is a need to identify the efficacy and safety of different antibiotic treatment approaches for people with sickle cell disease suffering from acute chest syndrome.

OBJECTIVES

To determine whether an empirical antibiotic treatment approach (used alone or in combination): 1. is effective for acute chest syndrome compared to placebo or standard treatment; 2. is safe for acute chest syndrome compared to placebo or standard treatment;Further objectives are to determine whether there are important variations in efficacy and safety: 3. for different treatment regimens, 4. by participant age, or geographical location of the clinical trials.

SEARCH METHODS

We searched The 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 19 October 2012), African Index Medicus (1982 to 3 November 2012). and the World Health Organization International Clinical Trials Registry Platform Search Portal (19 October 2012).Date of most recent search of the Haemoglobinopathies Trials Register: 29 October 2012.

SELECTION CRITERIA

We searched for published or unpublished randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Each author intended to independently extract data and assess trial quality by standard Cochrane Collaboration methodologies, but no eligible randomised controlled trials were identified.

MAIN RESULTS

For this update, we were unable to find any randomised controlled trials on antibiotic treatment approaches for acute chest syndrome in people with sickle cell disease.

AUTHORS' CONCLUSIONS

This update was unable to identify randomised controlled trials on efficacy and safety of the antibiotic treatment approaches for people with sickle cell disease suffering from acute chest syndrome. Randomised controlled trials are needed to establish the optimum antibiotic treatment for this condition.

The acute chest syndrome of sickle cell disease following aortic valve replacement

The acute chest syndrome (ACS) of sickle cell disease (SCD) is a leading cause of death in SCD, with a high incidence following surgery, though only one case has been reported following cardiac surgery. We present a case of ACS in an adult undergoing aortic valve replacement (AVR) despite instituting established peri-operative optimization measures to prevent sickling. Early diagnosis of this condition in our patient as a distinct clinical entity facilitated appropriate, specific therapy and a good subsequent postoperative recovery. Greater recognition of this syndrome in the growing number of adult sickle cell patients presenting for cardiac surgery may help improve their outcome.

The spleen in the sickling disorders: an update

In early life, patients with sickle cell disease (SCD) can have acute, life-threatening emergencies related to splenic hypofunction (overwhelming bacterial sepsis), as well as anemic crises from acute splenic sequestration because of sudden pooling of blood in the spleen. The landmark penicillin prophylaxis study in 1985 showed a remarkable decrease in mortality from sepsis in young children with SCD who were treated with oral penicillin prophylaxis compared to placebo. Since that study, newborns are screened for SCD and placed on oral penicillin prophylaxis in nearly all of the United States, as well as in other countries where the disease is highly prevalent. The previously described permanent, complete and nearly universal "autosplenectomy" emerging by late childhood or early adulthood is now challenged by recent findings of reversibility of splenic dysfunction by the antisickling drug hydroxyurea or by successful allogeneic stem cell transplantation, even in older patients. Imaging techniques for hypofunction of the spleen are the most commonly used modalities to guide the clinician in decisions regarding medical or surgical management.

Laparoscopic cholecystectomy in sickle cell disease patients: does operating time matter?

OBJECTIVES

To report the experience of performing laparoscopic cholecystectomy (LC) in patients suffering from sickle cell disease (SCD), and to assess if their postoperative complications can be minimized by shortening the operating time.

METHODS

Strict measures were taken to minimize the operating times and duration of pneumoperitoneum in SCD patients undergoing LC. Data collected included demographics, preoperative haemoglobin, the surgical technique used, operating times, insufflation pressures, perioperative complications and hospital length of stay.

RESULTS

In the 5-year period from July 2003 to June 2008, 19 patients with SCD underwent elective LC. Of these, 84% were female. The mean age was 21.5 years. The most common indication for surgery was symptomatic cholelithiasis (60%). The mean preoperative haemoglobin was 8.2g/dL. No preoperative blood transfusions were given. Four patients had preoperative endoscopic retrograde cholangiopancreatography (ERCP). Mean operating time was 27.9 min (range 20-45 min) which is 2.5-6 times quicker than most reports in the literature. There was no conversion to open surgery. Mean hospital length of stay was 2.5 days. Postoperative complications were noted in four patients with painful crises accounting for 50%. There was no mortality.

CONCLUSION

The study suggests that if stringent measures are taken to shorten the operating time, LC can be safely and effectively performed in SCD patients with minimal perioperative complications.

Acute chest syndrome after splenectomy in children with sickle cell disease

BACKGROUND/PURPOSE

The purpose of this study was to determine the incidence of acute chest syndrome (ACS) in children with sickle cell disease (SCD) undergoing laparoscopic or open splenectomy and to assess factors that may predispose to this complication.

METHODS

A retrospective review of all patients with SCD undergoing splenectomy between 1999 and 2007 in our institution. Charts were screened for demographics, perioperative clinical status (vaso-occlusive crises, sequestration crises), preoperative hemoglobin electrophoresis and preoperative transfusion, postoperative development of ACS, and need for an intensive care unit (ICU) admission.

RESULTS

Forty-three children with SCD, 17 females and 16 males (mean age 9 years), underwent splenectomy (19 laparoscopy and 24 open). Acute chest syndrome occurred in 9 patients (20%), 1 (5.2%) of 19 in the laparoscopy group, and 8 (33.3%) of the 24 in the open group. All patients with ACS were admitted to the ICU. Acute chest syndrome developed within the first 24 hours in 5 of the 9 patients, on the second postoperative day in 1 patient, and more than 1 month postoperatively in 3 patients. Six of 9 patients with ACS had been transfused preoperatively. All patients with ACS had had vaso-occlusive crises before surgery. Five of 9 patients who developed ACS had previous ACS episodes before surgery. There was no death in our series.

CONCLUSION

The incidence of ACS is in accordance with the literature. Preoperative transfusions did not prevent ACS. There is a clear tendency for laparoscopically operated patients to experience less ACS postoperatively. In our group of patients, there were no clear benefits for routine perioperative admission to the ICU.

Cholecystectomy in sickle cell disease patients: is there more acute chest syndrome after laparoscopy? A case controlled study

Laparoscopy is increasingly being recommended in order to reduce postoperative complications among sickle cell disease patients undergoing cholecystectomy. Acute chest syndrome is the most deadly of these complications. The purpose of this study was to assess if laparoscopic approach reduces postoperative complications related to sickle cell disease after cholecystectomy. A retrospective study of records of sickle cell patients who underwent cholecystectomy for cholelithiasis, from January 1990 to December 2005 was conducted. 136 sickle cell patients underwent surgery: 47 (34.5%) by laparoscopy and 89 (63.5%) by laparotomy. The mean operative time was 71.4+/-18.9 min in the laparoscopy group and 61.2+/-15.3 min in the laparotomy group (non-significant difference). The mortality was not significantly different between the two groups: one patient died in the open cholecystectomy group but no death occurred in the laparoscopic one. The morbidity related to the sickle cell disease was significantly higher in the laparoscopy group [n=5 (10.5%)] than in the laparotomy group [n=4 (4.5%)] (p=0.04). This difference was associated with a higher rate of acute chest syndrome in the laparoscopy group [n=4 (8, 5%)] compared to that in the laparotomy group [n=1 (1.1%)] (p=0.01). There were more complications related to sickle cell disease in the laparoscopy group due to acute chest syndrome. Thus, these data should be confirmed in further randomized studies which must be undertaken.

Laparoscopic versus open abdominal surgery in children with sickle cell disease is associated with a shorter hospital stay

BACKGROUND

Limited information exists comparing the post-operative complication rate of laparoscopic or open abdominal surgeries in children with sickle cell disease (SCD). The primary objective of this study was to compare the outcomes in children with SCD who required laparoscopic or open abdominal surgery for a cholecystectomy or splenectomy.

PROCEDURE

We conducted a retrospective analysis of laparoscopic and open abdominal surgeries performed in children with SCD (ages 0-20 years) at two medical centers from 1984 to 2004. The primary outcome measures were the rates of post-operative pain and acute chest syndrome (ACS) episodes following laparoscopic or open abdominal surgery. The secondary outcome was length of hospital stay following surgery. We also examined the potential contribution of pre-operative (transfusion) and intra-operative factors (operating time, estimated blood loss, and end-operative temperature) to post-operative SCD-related complications.

RESULTS

A total of 140 cases were identified, 98 laparoscopic and 42 open. Episodes of post-operative pain and ACS episodes were comparable between laparoscopic and open procedures (pain: 4% vs. 3%, P = 0.619; ACS: 5% vs. 5%, P = 0.933). Additionally, laparoscopic surgeries were associated with a significantly shorter hospital stay (2.9 vs. 5.4 days, 95% CI -3.7 to -1.4, P < 0.001). There was no difference in the number of hospital readmissions within 1 month of the surgery.

CONCLUSIONS

For children with SCD who need a cholecystectomy or splenectomy, laparoscopy is the preferred strategy because of a shorter hospital stay with a similar complication rate compared to open surgeries.

Antibiotics for treating acute chest syndrome in people with sickle cell disease

BACKGROUND

The clinical presentation of acute chest syndrome is similar whether due to infectious or non-infectious causes, thus antibiotics are usually prescribed to treat all episodes. Many different bacteria have been implicated as causative agents of acute chest syndrome. There is no standardized approach to antibiotic therapy and treatment is likely to vary from country to country. Thus, there is a need to identify the efficacy and safety of different antibiotic treatment approaches for people with sickle cell disease suffering from acute chest syndrome.

OBJECTIVES

To determine whether an empirical antibiotic treatment approach (used either alone or in combination): (a) is effective in treating acute chest syndrome compared to placebo or standard treatment; (b) is safe in treating acute chest syndrome compared to placebo or standard treatment; (c) differs dependent on the regimen used in treating acute chest syndrome differ from each other with respect to efficacy and safety; and (d) varies between different age groups, regions or countries with respect to efficacy and safety.

SEARCH STRATEGY

We searched The 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 May 2006) and the website: http://www.clinicaltrials.gov (May 2006). Date of most recent search of the Haemoglobinopathies Trials Register: February 2007.

SELECTION CRITERIA

We searched for published or unpublished randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Each author intended to independently extract data and assess trial quality by standard Cochrane Collaboration methodologies, but no eligible randomized controlled trials were identified.

MAIN RESULTS

We were unable to find any randomised controlled trials on antibiotic treatment approaches for acute chest syndrome in people with sickle cell disease.

AUTHORS' CONCLUSIONS

We were unable to identify randomised controlled trials on efficacy and safety of the antibiotic treatment approaches for people with sickle cell disease suffering from acute chest syndrome. Randomised controlled trials are needed to establish the optimum antibiotic treatment for this condition.

Surgery in sickle cell disease

Persons with sickle cell disease (SCD) are more likely to undergo surgery than are the general population during their lifetime. For example, cholecystectomy as a consequence of gallstones is more frequent in persons with SCD, as is hip arthroplasty in younger people as a result of avascular necrosis of the femoral head. Because surgery exposes patients to many of the factors that are known to precipitate red blood cell sickling, persons with SCD undergoing surgery require meticulous clinical care to prevent perioperative sickle cell-related complications. Even with meticulous care, approximately 25% to 30% of patients will have a postoperative complication. This article provides readers with information about the role of surgery in SCD and the measures that should be taken to ensure patients are well cared for in the perioperative period.

Preoperative screening for sickle cell disease in children: clinical implications

PURPOSE

Preoperative screening of at-risk patients for sickle cell disease (SCD) is recommended as a method to decrease perioperative morbidity. However, the effectiveness of pre-operative screening in accomplishing this goal has never been demonstrated. We undertook a retrospective study to determine the prevalence of positive test results among those screened preoperatively at our institution and to determine whether amendments to present screening guidelines can be recommended.

METHODS

The hematology laboratory database of a university teaching hospital was searched to identify all patients who underwent preoperative screening for SCD from October 1999 to October 2003. The medical records of those patients testing positive were reviewed.

RESULTS

Of 1,906 children screened preoperatively, 79 (4.1%) were diagnosed as having sickle cell trait and three (0.16%) as having some form of SCD: one had homozygous hemoglobin S and two had sickle-hemoglobin C disease. Two of the three had a family history for SCD and none had a preoperative hemoglobin concentration < 10 g.dL(-1). No patient developed perioperative sickle-related complications.

CONCLUSION

Preoperative screening of 1,906 children identified only one asymptomatic child with undiagnosed SCD and a negative family history, suggesting that routine preoperative screening for SCD is rarely of significant clinical value in our population. Had preoperative screening not been performed, no child requiring preoperative transfusion would have been missed, representing a long-run probability of at least 99.84% that no at-risk child would require transfusion. We recommend that preoperative screening for SCD be undertaken selectively, giving consideration to the risks and benefits of screening to the individual patient.

Preoperative transfusion in sickle cell disease: a survey of practice in England

OBJECTIVES

To gather data on current preoperative transfusion practice and postoperative complications in sickle cell disease (SCD) as a prelude to a randomised trial.

METHODS

A prospective one year survey of 114 SCD patients undergoing elective surgery in 31 English hospitals was undertaken.

RESULTS

43%, 39% and 23% of patients respectively [corrected] received no transfusion, top-up and exchange transfusion preoperatively. Overall postoperative complication rates were 18%, 26% and 17%, with SCD related complications of 12%, 8% and 0% respectively. 85% of patients with [corrected]HbSC/HbSss(+)thalassaemia and 71% of obstetric and gynaecology patients were not transfused preoperatively, whereas 59% patients undergoing ENT procedures and 83% of hip replacements had top-up and exchange transfusions respectively. Multivariable logistic regression analysis revealed that having moderate/high risk procedures was a predictor of postoperative complications (OR 4.9 (95% CL: 1.3 to 18), P = 0.017) [corrected] while preoperative transfusion was not (OR 1.7, (95% CL: [corrected] 0.5 to 6), P = 0.41).

CONCLUSION

The lack of clear benefit of transfusion confirms the need for a randomised controlled trial of transfusion vs. no transfusion in patients with HbSS and HbSss(0)thalassaemia.

Acute chest syndrome shows a predilection for basal lung regions on the side of upper abdominal surgery

PURPOSE

Upper abdominal surgery for cholecystectomy or splenectomy is the most frequently performed surgical procedure in patients with sickle cell disease (SCD). The acute chest syndrome (ACS) is the most common sickle-related postoperative complication. The objective of the study was to characterize the clinical and radiological presentation of ACS complicating cholecystectomy and splenectomy.

METHODS

The medical records of all children with SCD undergoing cholecystectomy or splenectomy during the 15-year period from January 1988 through December 2002 were reviewed. Patients who experienced ACS within 14 days after surgery were identified. Data collected included demographics, perioperative management, clinical and radiological findings, and outcome.

RESULTS

The overall incidence of postoperative ACS was 16%, occurring in nine of 51 patients having cholecystectomy and in seven of 48 patients having splenectomy. Mean time to onset of symptoms was 49 hr after surgery (range, 24-96 hr). Cough, fever, and an abnormal chest examination were documented for all patients at presentation. Radiologically, ACS involved the basal lobes in all cases and was multi-lobar in 25%. Patients were more likely to have new infiltrates involving the lung on the side of the surgery or bilateral infiltrates than isolated contralateral infiltrates at presentation (P < 0.0001). Isolated upper or middle lobe involvement did not occur. Fifty percent of cases demonstrated evidence of a pleural effusion.

CONCLUSION

ACS complicating cholecystectomy or splenectomy shows a predilection for basal lung regions and for the lung on the side of surgery. These results have implications for the pathogenesis and prevention of postoperative ACS.

Risk factors for acute chest syndrome in children with sickle cell disease undergoing abdominal surgery

BACKGROUND/PURPOSE

The reported incidence of acute chest syndrome (ACS) in children with sickle cell disease (SCD) is 15% to 20%. Our current objective was to assess risk factors and morbidity associated with ACS.

METHODS

The authors reviewed the outcome of children with SCD undergoing abdominal surgery over a 10-year period.

RESULTS

From 1991 to 2003, 60 children underwent laparoscopic cholecystectomy (LC; n = 29), laparoscopic splenectomy (LS; n = 28), or both (LB; n = 3). Mean age was 8.6 (0.7 to 20) years, and 35 (58%) were boys. Fifty-four (90%) had a preoperative hemoglobin greater than 10 g/dL, but only 22 (37%) received routine oxygen after surgery. No surgery was converted to an open procedure. Four children (6.6%), all of whom underwent either LS or LB, had ACS associated with an increased length of stay (7.4 +/- 2.4 days) but no mortality. Factors associated with the development of ACS were age (3.0 +/- 1.7 v 9.4 +/- 5.7 years; P =.03), weight (12.1 +/- 3.0 v 32.6 +/- 18.2 kg; P =.04), operative blood loss (3.2 +/- 0.5 v 1.4 +/- 1.2 mL/kg; P =.03), and final temperature in the operating room (OR; 36.2 +/- 0.4 v 37.6 +/- 0.4 degrees C; P =.01). ACS was not significantly related to duration of surgery, OR fluids, or oxygen usage.

CONCLUSIONS

Younger children with greater blood and heat loss during surgery appear more prone to ACS. Splenectomy also seems to increase the risk of ACS. The authors' current incidence (6.6%) of ACS in children with SCD undergoing abdominal surgery is much lower than previously reported. This may be explained by the aggressive use of preoperative blood transfusion or more routine use of laparoscopy.

Esplenectomia laparoscópica nas doenças hematológicas

OBJETIVO: Relatar a experiência inicial do Centro Infantil Boldrini com a esplenectomia laparoscópica (EL) em crianças e adultos jovens. MÉTODO: Foram revisados os prontuários de 40 pacientes (mediana da idade de 6,6 anos; 1 a 22,8) submetidos à EL entre Julho de 2000 e Maio de 2002. As principais indicações de acordo com a doença de base foram: doença falciforme (DF) em 20 pacientes (50%), esferocitose hereditária em 10 (25 %), púrpura trombocitopência idiopática em oito (20 %), doença de Hodgkin em um e anemia hemolítica a esclarecer em um. RESULTADOS: Trinta e oito esplenectomias foram completadas por via laparoscópica (duas conversões) e em doze foi realizada adicionalmente a colecistectomia. A mediana do tempo operatório foi de 127,5 minutos (90-240 min) e sete (17,5 %) baços acessórios foram encontrados. Sangramento intra-operatório foi significativo apenas nas duas conversões, mas não houve necessidade de transfusões. A mediana do peso dos baços foi de 250 g (106-1000; n=36). Complicações pós-operatórias ocorreram em sete (17,5 %) pacientes e, nos portadores de DF, 35% desenvolveram síndrome torácica aguda. A mediana da permanência hospitalar pós-operatória foi de dois dias (2 - 14). O seguimento variou de 23 dias a dois anos (mediana de 11 meses). CONCLUSÕES: A EL pode ser realizada de modo seguro mesmo em baços de grande tamanho e é opção atrativa que pode substituir o procedimento aberto. Em pacientes com DF, a taxa de complicações permanece alta, sugerindo mecanismos outros que vão além da escolha da via de acesso cirúrgica.

Mycoplasma disease and acute chest syndrome in sickle cell disease

BACKGROUND

Acute chest syndrome (ACS) is the leading cause of hospitalization, morbidity, and mortality in patients with sickle cell disease. Radiographic and clinical findings in ACS resemble pneumonia; however, etiologies other than infectious pathogens have been implicated, including pulmonary fat embolism (PFE) and infarction of segments of the pulmonary vasculature. The National Acute Chest Syndrome Study Group was designed to identify the etiologic agents and clinical outcomes associated with this syndrome.

METHODS

Data were analyzed from the prospective study of 671 episodes of ACS in 538 patients with sickle cell anemia. ACS was defined as a new pulmonary infiltrate involving at least 1 complete segment of the lung, excluding atelectasis. In addition, the patients had to have chest pain, fever >38.5C, tachypnea, wheezing, or cough. Samples of blood and deep sputum were analyzed for evidence of bacteria, viruses, and PFE. Mycoplasma pneumoniae infection was determined by analysis of paired serologies. Detailed information on patient characteristics, presenting signs and symptoms, treatment, and clinical outcome were collected.

RESULTS

Fifty-one (9%) of 598 episodes of ACS had serologic evidence of M pneumoniae infection. Twelve percent of the 112 episodes of ACS occurring in patients younger than 5 years were associated with M pneumoniae infection. At the time of diagnosis, 98% of all patients with M pneumoniae infection had fever, 78% had a cough, and 51% were tachypneic. More than 50% developed multilobar infiltrates and effusions, 82% were transfused, and 6% required assisted ventilation. The average hospital stay was 10 days. Evidence of PFE with M pneumoniae infection was seen in 5 (20%) of 25 patients with adequate deep respiratory samples for the PFE assay. M pneumoniae and Chlamydia pneumoniae was found in 16% of patients with diagnostic studies for C pneumoniae. Mycoplasma hominis was cultured in 10 (2%) of 555 episodes of ACS and occurred more frequently in older patients, but the presenting symptoms and clinical course was similar to those with M pneumoniae.

CONCLUSIONS

M pneumoniae is commonly associated with the ACS in patients with sickle cell anemia and occurs in very young children. M hominis should be considered in the differential diagnosis of ACS. Aggressive treatment with broad-spectrum antibiotics, including 1 from the macrolide class, is recommended for all patients as well as bronchodilator therapy, early transfusion, and respiratory support when clinically indicated.

Anaesthetic management of the child with sickle cell disease

Sickle cell disease (SCD) is a relatively common inherited disorder of haemoglobin with significant morbidity and mortality. This review describes the epidemiology and pathophysiology of the disease, and discusses the clinical manifestations found in children with SCD. A discussion of the evidence concerning the perioperative management of such children is presented.

Current concepts in minimal access surgery for children

Since the introduction of minimal access surgery to general surgeons in the 1980s, pediatric surgeons have been employing this innovative technology to perform surgery on children. Video technology and miniaturized instruments have brought the laboratory to the operating room; in many cases several small incisions are the only access necessary to perform complicated procedures that would otherwise require a large wound. Additional benefits of minimal access surgery may include reduced postoperative analgesic requirements, shortened length of stay, and faster resumption of normal activities. Increased operative costs offset some of these gains. The pediatric surgical community has embraced minimal access techniques for some operations; others remain controversial.

Sickle cell anemia

Sickle cell anemia (SCA) is a disease caused by production of abnormal hemoglobin, which binds with other abnormal hemoglobin molecules within the red blood cell to cause rigid deformation of the cell. This deformation impairs the ability of the cell to pass through small vascular channels; sludging and congestion of vascular beds may result, followed by tissue ischemia and infarction. Infarction is common throughout the body in the patient with SCA, and it is responsible for the earliest clinical manifestation, the acute pain crisis, which is thought to result from marrow infarction. Over time, such insults result in medullary bone infarcts and epiphyseal osteonecrosis. In the brain, white matter and gray matter infarcts are seen, causing cognitive impairment and functional neurologic deficits. The lungs are also commonly affected, with infarcts, emboli (from marrow infarcts and fat necrosis), and a markedly increased propensity for pneumonia. The liver, spleen, and kidney may experience infarction as well. An unusual but life-threatening complication of SCA is sequestration syndrome, wherein a considerable amount of the intravascular volume is sequestered in an organ (usually the spleen), causing vascular collapse; its pathogenesis is unknown. Finally, because the red blood cells are abnormal, they are removed from the circulation, resulting in a hemolytic anemia. For the patient with SCA, however, the ischemic complications of the disease far outweigh the anemia in clinical importance.

Acute chest syndrome after abdominal surgery in children with sickle cell disease: Is a laparoscopic approach better?

BACKGROUND/PURPOSE

Acute chest syndrome (ACS) is the leading cause of hospitalization and death among patients with sickle cell disease (SCD). Surgery is a risk factor for the development of ACS. It has been suggested that laparoscopic surgery could diminish the risk of sickle-related complications; therefore, more procedures may be encouraged in asymptomatic patients. The goal of the authors was to determine the incidence of postoperative ACS and assess for predisposing factors in all sickle cell patients undergoing abdominal surgery.

METHODS

A retrospective analysis of all sickle cell patients receiving abdominal surgery (open and laparoscopic) between 1994 and 1998 was conducted. Data pertaining to demographics, perioperative clinical status, postoperative care, and outcome were collected and analyzed using Student's t test or chi(2) where appropriate.

RESULTS

Fifty-four children underwent 62 procedures (35 abdominal and 27 extracavitary). All abdominal cases were either cholecystectomy or splenectomy (22 laparoscopic and 13 open). ACS occurred in 7 of 62 (11.3%) overall, and all were in abdominal cases 7 of 35 (20%). ACS occurred in 5 of 22 (22.7%) laparoscopic cases and 2 of 13 (15.4%) open cases. Operating time was significantly longer in the laparoscopic group compared with open cases (P <.05). A higher percentage of patients who had ACS had at least 1 previous episode (71.4% v 39.3%; P value not significant) and a smaller percentage of ACS patients received a preoperative blood transfusion (14.3% v 32.1%; P value not significant). Postoperative hospitalization was prolonged if ACS occurred (9 +/- 2 v 3 +/- 2 days; P <.05).

CONCLUSIONS

Abdominal surgery carries a significantly high risk (20%) of ACS. Laparoscopy does not decrease the incidence of ACS compared with open approach. Predisposing factors were not significant in predicting postoperative ACS. There is considerable morbidity and potential cost implications in patients with ACS.

Acute chest syndrome of sickle cell disease: new light on an old problem

The pulmonary findings of acute chest syndrome of sickle cell disease have been well characterized in numerous studies. Whereas a third of patients have a documented infection associated with this syndrome, and fat embolism from necrotic marrow is the etiologic factor in another approximately 10%, no cause is discovered in the majority of patients. In most patients, however, the underlying pathophysiology is the presence of a hypoxia-driven, adhesion-related occlusive event in the pulmonary microcirculation. This may be accompanied by a decrease in the levels of normal cytoprotective and anti-adhesive mediators such as nitric oxide. In the patient with sickle cell disease, the lung is also a uniquely vulnerable target organ because its vasculature constricts with hypoxia in contrast to other vascular beds. This review will establish the links between known etiologic agents and the pathophysiology of this syndrome. An additional section of this review will deal with experimental therapies. The use of inhaled nitric oxide will be explored in depth because advances in this area are current and uniquely relevant to acute chest syndrome.