Iatrogenic Hyperhydration in Sickle Cell Disease Patients Admitted for Acute Pain Crisis Management: A Retrospective Analysis from a Single Institution

Abstract

Background: Parenteral fluids are an important component of acute pain crisis management in sickle cell disease patients. However, lack of uniform guidelines for fluid replacement coupled with underlying host comorbidities result in risk to patients from complications associated with hyperhydration. Contributing factors include inappropriate choice of fluid, rapid fluid infusion rates with prolonged time periods and inadequate monitoring of signs of hyperhydration. Complications of fluid replacement include excessive weight gain, extremity swelling, pulmonary edema and heart failure. In our study we examined the prevalence of hyperhydration in sickle cell anemia patients admitted for acute pain crisis management at our hospital. Methods: We conducted a retrospective chart review on EPIC of sickle cell anemia patients treated for acute pain crisis in the inpatient unit of John Dempsey Hospital, University of Connecticut between January 2022-December 2022, following IRB approval. To capture patients with signs and symptoms of hyperhydration and its clinical consequences, we looked at surrogate markers such as excessive weight gain during admission, signs of fluid retention, charting of patient fluid intake and output, increased oxygen use, diuretic (Lasix) administration, bronchodilator use, abnormal chest x ray findings indicative of fluid overload pattern, activation of rapid response team for patients developing acute symptoms of fluid overload, and urgent patient transfer to a higher level of care including intensive care unit. Results: 256 admitted patient charts were analyzed representing a total of 95 unique sickle cell disease patients. The median length of hospital stay (LOS) was 3 days. 168 patients had LOS from 3 to 10 days. We observed that 10.7% of the patients experienced an increase in oxygen requirements during their hospital stay. Daily weight was collected in only 27 patients (10.5%) for 3 or more days limiting its usefulness to detect subclinical hyperhydration( figure 1). 69 patients (27%) received parenteral Lasix injection for acute symptoms whose chest x rays also showed pulmonary edema or pleural effusions. 13 patients (18%) were transferred to a higher level of care that included 9 patients to step-down unit and 4 to intensive care for endotracheal intubations and ventilatory support. The median hospital stay was 4 days in patients requiring Lasix compared to 3 days in those who did not. Conclusion : Hyperhydration is undesirable complication associated with fluid administration of sickle cell anemia patients admitted with acute vaso-occlusive pain crisis. It occurs in a significant proportion of affected patients that can result in life threatening complications and prolonged hospitalization. Hyperhydration were missed in this retrospective analysis since daily weight measurements were not available in the majority of patients. Strict charting of fluid intake and output, choice of half normal saline for hydration, as well as clinical monitoring of signs and symptoms of subclinical hyperhydration will help reduce this complication and improve patient outcomes. Improving awareness of this complication among health care providers is important towards achieving this goals. Findings from this study are used to design a prospective quality improvement project in our hospital to improve outcomes and reduce hospitalization in sickle cell anemia patients admitted for acute vaso-occlusive pain crisis.