• 
• 

Three Part Question

In [a patient with sickle cell disease who presents with acute chest syndrome] does [admission to HDU rather than admission to a ward]improve [their outcome]?

Clinical Scenario

A 22 year old woman with sickle cell disease presents with a two day history of pain in her arms, legs and chest. Her pain and symptoms are consistent with an acute chest syndrome. You are about to admit her to the ward when you wonder if her symptoms are severe enough to warrant admission to HDU.

Search Strategy

MEDLINE (1966 to present)
EMBASE (1988 to present)
Cochrane library
OVID: [sickl$.mp.] AND [exp Anemia/ or anaemia$.mp] OR [exp Anemia, Sickle Cell/ or sickle cell crisis.mp.] AND [painful.mp. and crisis.mp.] OR [acute chest syndrome.mp.] AND [high dependency unit.mp. or exp Critical Care/ or exp Hospital Units] limit to English language.

Search Outcome

This search yielded 12 articles. Bibliographic references found in these articles were also examined to identify related literature. Only original research articles were included. No articles directly addressed the question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
			Exacerbation of acute attack after opiate analgesia	No exacerbations occured
			Exacerbation of acute attack after analgesia	No exacerbations occured

Comment(s)

After a thorough search no relevant articles answering my question were found. This is a possible area of further research. Acute chest syndrome is a life threatening and serious condition, which needs to be treated promptly and managed correctly. One article listed the criteria for general admission to HDU.[2] This states that anyone with respiratory failure should be admitted to HDU. The BMJ states that if any patient should require an inspired oxygen concentration of 50% (or more) should ideally be managed on a high dependency unit.[2] The sickle cell information centre indicates that intensive care is needed if severe hypoxia or respiratory distress is present because respiratory decompensation can quickly require mechanical ventilation.[1] HDU is better equipped to deal with acute chest syndrome emergencies being able to provide advanced respiratory support and appropriate airway management.

Clinical Bottom Line

The lack of evidence based medicine on this topic mean no evidence based decision can be made. Admission to HDU should be considered for all patients with acute chest syndrome who start to deteriorate especially those with obvious respiratory distress. Local guidance should be followed.

References

1. C. Kalayi, S.D. Blair, M. Maxwell High-dependency care: findings of a prospective needs assessment study British Journal of Clinical Governance 2001;183-189
2. Gary Smith, Mick Nielsen Clinical review: ABC of intensive care, Criteria for admission BMJ 1999;1544-1547
3. Hsu, L Chest pain and chest syndrome Sickle cell information center protocols 2000