PM2046: Intravenous Fluid Resuscitation and Development of Acute Chest Syndrome in Pediatric Sickle Cell Disease

Background: Children hospitalized with complications of sickle cell disease (SCD) are at risk of developing acute chest syndrome (ACS). Patients receive fluid resuscitation upon presentation to the emergency department (ED), either due to clinical features of sepsis or for pain management. Due to ongoing systemic inflammation, they are at risk for extravascular fluid accumulation. Many hospitals limit the volume of intravenous fluid (IVF) given to persons with SCD during an episode of ACS, but prior to the development of ACS there is no consensus on fluid management. We sought to identify a relationship between IVF resuscitation during the first hours of hospitalization and the development of ACS during hospitalizations for febrile illness or pain.

Methods: A retrospective chart review of patients with SCD, age < 22 years old, that were admitted from January 2019-December 2020 was conducted. Hospitalizations due to pain and fever were included. Transfers from outside hospitals were excluded. ACS during the hospitalization was defined by administration of azithromycin greater than 24 hours after presentation. Patients without ACS did not receive azithromycin. The ACS group was then matched 1:2 by age using a random number generator to patients who did not develop ACS. IVF volume was measured as a continuous variable, and the study was powered for a detectable odds ratio (OR) of 1.5. Demographics and past medical history were collected including history of ACS, asthma, and hydroxyurea use. Additional admission data including laboratory studies and admission location were collected. The total volume of IVF, including bolus fluids in ED, and average rate were calculated from time of presentation in the ED throughout the duration of the hospital stay. Data were analyzed using Microsoft Excel and GraphPad Prism.

Results: 91 cases of ACS were identified accounting for 63 unique patients. The control group included 126 unique patients. The ACS and control groups had similar ages, genotype distribution, hydroxyurea use, and history of asthma (Table 1). Among the control group, 64.3% had a history of ACS compared to 88.9% of the ACS group. Without including bolus volumes, the average IVF rate on day one of hospital admission was 0.98 ml/kg/hr for the control group and 1.03ml/kg/hr for the ACS group (p = 0.65, 95% CI [-0.31, 0.19]). When bolus volumes were included, the average IVF rate was 4.60ml/kg/hr and 4.19mg/kg/hr for controls and ACS, respectively (p = 0.80, 95% CI [-2.79, 3.62]) (Table 2).

Conclusion: Initial fluid resuscitation rates appear similar between patients with SCD who did and did not develop ACS during a hospitalization. Initial fluid resuscitation does not appear to play a critical role in the subsequent development of ACS in these patients.