Is Incentive Spirometry Effective in Preventing Post Surgical Acute Chest Syndrome in Sickle Cell Disease Patients

Abstract Persons with sickle cell disease (SCD) are more likely to undergo cholecystectomy and splenectomy than are the general population. Even with meticulous care, surgical complications are seen in approximately 25% to 30% of patients. A chart review of SCD patients who had splenectomies and cholecystectomies and who were treated in 3 centers between1987–2007 was undergone. Data pertaining to clinical events, surgery, perioperative care and outcome were collected and analyzed. Since 1995, laparoscopic surgery was the modality used. Management consisted of preoperative transfusions in 83% of patients, general anesthesia, adequate hydration, temperature conservation, non sedating analgesia and supervised incentive spirometry exercises (after 1995) in all patients. The total number of patients was 120: 81 underwent splenectomy, 59 cholecystectomy and 20 both procedures. Of patients who underwent splenectomy, 43.2% were females and 56.8% males; 64.2% had sickle cell anemia (SCA) and 35.8% sickle-beta thalassemia (ST). For those undergoing cholecystectomy, 39.0% were females and 61.0% males; 79.7% had SCA and 20.3% ST. Patients undergoing splenectomy were significantly younger (mean age 9.28 years) than those undergoing cholecystectomy (mean age 15.28 years) (p=0.037). Median operative time was 50 minutes, and median hospitalization duration was 2 1/2 days. No major intra operative complications or fatalities were noted. Postoperative complications included acute chest syndrome (ACS) in 5 patients (4% of surgeries). The mean time to onset of symptoms of ACS was 36 hrs after surgery (range, 24–96 hr). All patients who developed this complication did not receive incentive spirometry or were noncompliant with this therapy. As for the relation between clinical events and splenectomy/cholecystectomy, bivariate analysis showed a significant association between splenectomy and regular blood transfusion (p=0.005). Borderline significance was found for the association of cholecystectomy with ACS, joint necrosis and stroke (0.05<p<0.10). Predictors of splenectomy were regular blood transfusion (OR=2.38, [1.36–4.17] 95%CI], ACS (OR= 3.42, [1.64–7.15] 95%CI) and ST as compared to SS (OR=1.89, [1.10–3.27] 95%CI). Predictors of cholecystectomy were regular blood transfusion (OR=2.02, [1.10–3.71] 95%CI and sepsis (OR=2.59, [1.04–6.45] 95%CI). Sensitive predictors of postoperative complications could not be studied due to the small number of complications. This survey shows that splenectomy and cholecystectomy can be performed in SCD patients with minimal morbidity and no mortality. The current rate (4%) of post surgical ACS is lower than previously reported and is probably due to strict adherence to meticulous perioperative care. The absence of post surgical ACS in patients treated with supervised incentive spirometry is suggestive of a beneficial effect of this therapy in preventing this serious complication. The small number of patients with post surgical ACS prevents us, however, from drawing definite conclusions about the preventive role of this treatment. Nevertheless, early use of this simple, available and inexpensive tool most likely minimizes surgical morbidity and mortality from ACS, decreases hospitalization time, cuts down expenses and can be helpful particularly in countries with limited resources. Prospective controlled studies are, however, warranted to evaluate the efficacy of incentive spirometry and other perioperative interventions in preventing complications in SCD patients undergoing surgery.