Corticosteroids and increased risk of readmission after acute chest syndrome in children with sickle cell disease

Abstract

Background: Acute chest syndrome (ACS) is a frequent cause of hospitalization and mortality in children with sickle cell disease. Transfusion is often required to prevent respiratory failure and treatment with dexamethasone may reduce the length of admission and the need for transfusions. We performed a retrospective cohort study to evaluate risk factors for readmission and prolonged hospitalization after different treatments for ACS.

Procedure: We identified patients <22 years of age hospitalized with ACS at Johns Hopkins Hospital from January 1998 to April 2004 using the hospitals discharge database and by reviewing dictated summaries.

Results: We identified 65 patients with 129 episodes of ACS (mean age 12.5 years, range 1.2-21.9 years). Thirty-nine episodes were treated with corticosteroids and 51 with transfusions. Patients were readmitted within 14 days after 23 episodes (18%). Readmission was strongly associated with report of an inhaler or nebulizer at home [odds ratio (OR) 6.0, P < 0.05], diastolic BP at 48 hr (OR 1.8 per 10 mm increase, P<0.01), corticosteroids (OR 20, P < 0.005), or transfusion (OR 0.03, P < 0.05). Treatment with corticosteroids alone (P < 0.05) and older age (P < 0.001) were associated with longer hospitalization.

Conclusions: These results demonstrate a greatly elevated independent risk of readmission after ACS in children with asthma and after treatment with corticosteroids and a protective effect of transfusion. Although dexamethasone has documented efficacy for reducing the duration of ACS, the substantial risk of readmission for pain should limit its use.

Fig. 1

Kaplan–Meier estimate of time to readmission by treatment in patients without a history of asthma. The label includes the number of patients at risk on day 0 and the number of patients not readmitted by day 14. Treatment with corticosteroids alone was significantly different from no other treatment (P < 0.0001), transfusion (P < 0.005), but not corticosteroids and transfusion (P>0.5). The prevalence of readmission within 14 days of discharge was 58% (95% CI 28–85) in the group treated with corticosteroids alone, 4% (95% CI 1–15) in those receiving no other treatment, 5% (95% CI 1–24) in those receiving transfusion alone, and 10% (95% CI 0.3–45) in those treated with corticosteroids and transfusion.

Fig. 2

Kaplan–Meier estimate of time to readmission by treatment in patients with a history of asthma. The label includes the number of patients at risk on day 0 and the number of patients not readmitted by day 14. Treatment with corticosteroids alone was significantly different from transfusion (P < 0.05), but not corticosteroids and transfusion or no other treatment (P > 0.4). The prevalence of readmission within 14 days of discharge was 50% (95% CI 7–93) in the group treated with corticosteroids alone, 31% (95% CI 9–61) in those receiving no other treatment, 0% (95% CI 0–41) in those receiving transfusion alone, and 33% (95% CI 10–65) in those treated with corticosteroids and transfusion.

Fig. 3

Kaplan–Meier estimate of time to readmission by taper of corticosteroids. The label includes the number of patients at risk on day 0 and the number of patients not readmitted by day 14. Information on readmission was not available for one patient who was treated with both corticosteroids and transfusion. The difference between the two groups was not statistically significant.