Are You Keeping Up With Best Practices of Medicine?
Let’s find out with one simple example.

The practice of medicine is constantly evolving, as research reveals new insights into the most efficient workups and best treatments. Long-held beliefs often get modified or are even proven to be outrightly wrong and dangerous. Despite the current rapid dissemination of data, medical providers can take years to adapt best practices into their own practice. One of these issues seems to be regarding the care of patients with Sickle Cell Disease (SSD) that are in a vaso-occlusive crisis (VOC), and the administration of fluids. Routine care of SSD patients in VOC has long included pain medications and IV fluids. Prior to 2017, however, there were no well performed trials or any randomized studies looking at the efficacy of hydrating patients in VOC.¹ Providers were encouraged to administer early pain control and to aggressively hydrate the patient. This made sense, since early research revealed that cellular dehydration was a major contributing factor to the sickling of red blood cells (RBCs).¹ In the ED, the most common hydrating fluid is normal saline (0.9% NS), and providers like me would give 2 liters of IV NS quite liberally to the average adult. As it turns out, though, this practice is controversial and likely detrimental. There are better ways to hydrate SSD patients that are in VOC, both in the type of fluid used and the amount administered.²

All of this, and more on the care of patients in sickle cell crisis, is reviewed in the Endocrine, Hematology, and Oncology module of EMCT³, but we will give relevant highlights here for the purposes of this discussion. First of all, current evidence recommends hydrating patients in VOC only to the point of euvolemia. Do not overhydrate, simply treat dehydration. Second, do not use normal saline. This is slightly hypertonic and very hyperchloremic (relative to physiological levels), and both lead to an increase in sickling of RBCs, not a decrease. Excessive chloride ions administered in NS displace serum bicarb, the body’s major buffer, leading to metabolic acidosis. Acidosis causes increased sickling of RBCs and a worsening of VOC. Instead, give a balanced electrolyte solution for rehydration, such as lactated ringers or Plasma-Lyte, or even use half normal saline (0.45% NS) for hydration and maintenance fluid. This will help RBCs rehydrate in a non-acidotic environment and will lead to less sickling and an improved condition for the patient.

There is much more to the science and recommendations of treating SSD patients in crisis from vascular occlusion, but simply be aware that there are new treatments and diagnostic protocols for numerous medical conditions, and providers need to stay up to date on these. Let EMCT get you prepared for your practice of emergency and urgent care medicine, and let us help you to stay informed on the most contemporary patient management strategies.

References:

1. Okomo U, Meremikwu MM. Fluid replacement therapy for acute episodes of pain in
   people with sickle cell disease. Cochrane Database Syst Rev. 2017 Jul
   31;7(7):CD005406. doi: 10.1002/14651858.CD005406.pub5. PMID: 28759112; PMCID:
   PMC6483538.
2. Journal of Hematology, ISSN 1927-1212 print, 1927-1220 online, Volume 11, Number 5,
   October 2022, pages 159-166
   https://www.thejh.org/index.php/jh/article/view/1058/669
3. https://emcoretraining.com/