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\begin{document}

\title{''Comment on: {[} Role of regional anesthesia in patients with acute
sickle cell pain: A scoping review{]}.}



\author[1]{Adeeb Oweidat}%
\author[1]{Anil A. Marian}%
\author[1]{Melinda Seering}%
\author[1]{Rakesh Sondekoppam V}%
\affil[1]{University of Iowa Hospitals and Clinics}%


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  \date{May 18, 2024}


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\textbf{Adeeb Oweidat MD, DESAIC, EDRA}

\textbf{Anil A. Marian, MD, FRCA, MS}

\textbf{Melinda Seering, MD}

\textbf{Rakesh}

\textbf{V Sondekoppam, MBBS, MD}

Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa
City, Iowa, USA

\textbf{Corresponding author:}

Dr. Rakesh V Sondekoppam

200 Hawkins Dr,

Iowa City, Iowa, USA

Email: rakesh-sondekoppam@uiowa.edu

Ph: +1 319 356 2633

The authors declare that they have no conflict of interest.

To,

The editor,

We read with interest the review elaborating on the role of regional
anesthesia (RA) in patients with acute sickle cell pain by Rizvi and
colleagues. The authors correctly summarize that RA can be a vital
component of a multimodal analgesia regimen in patients getting
admission for sickle cell crisis (SCC) (1). As seen in the review the
main modality often offered for these patients is epidural analgesia as
truncal pain is a significant component of SCC either due to chest,
abdominal or pelvic pain. Lumbar epidurals may also be effective
analgesic modality for lower extremity pain.

We would like to highlight a crucial aspect pertinent to performing
regional anesthesia in these patients that perhaps was not covered in
this comprehensive review. One of the pre-procedural checklists before
we can perform a regional anesthesia technique is to ensure that a
patient is not at a higher risk of bleeding complications from the
procedure. Patients with SCC have a 4-100-fold increased risk of venous
thromboembolism (VTE) and recurrent VTE, and thus there is significant
benefit of decreasing morbidity and mortality with long term
anticoagulant usage (2). Consequently, a significant proportion of
patients with sickle cell disease have a history of ongoing
anticoagulant use whether they have a SCC or not (3). In fact, the
American Society of Hematology guidelines suggests indefinite
anticoagulation in SCD patients having unprovoked VTE (4).
Administration of RA such as epidural analgesia and deep peripheral
nerve blocks may be contraindicated in such situations if one were to
abide by the American Society of Regional Anesthesia (ASRA) guidelines
on the performance of regional anesthesia in patients receiving
antithrombotic therapy (5). To exemplify, we present our institutional
experience on the prevalence of anticoagulant usage in patients being
admitted for SCC. Using the slicer-dicer tool in our institutional
electronic health care record (EPIC Systems, Verona, WI) we found a
staggeringly high percentage of patients admitted for sickle cell crisis
with a pre-admission use of anticoagulants (see Figure 1). In fact, the
trend in the use of pharmacologic thromboprophylaxis in hospitalized
adolescent patients with SCC steadily increased in the last decade owing
to the increased risk of VTE (6,7). Multiple sites of pain a patient
with SCC can present with might be another factor that limits the
effective use of RA techniques in these patients (8). Furthermore,
children with sickle cell disease are at increased risk for bloodstream
infections (9). The prevalence of bacteremia in febrile patients with
sickle cell disease can be as high as 1.9\% (10) making offering
regional anesthesia modalities in sickle cell disease patients even more
challenging.

To summarize, regional anesthesia can be a great tool in the management
of SCC in select group of patients provided the site of pain is confined
to single or congruent body areas and if they do not have
contraindications in terms of recent anticoagulant usage or ongoing
infections.



\textbf{Figure 1:}\selectlanguage{english}
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\textbf{References:}

\begin{enumerate}
\tightlist
\item
  Rizvi MB, Kessler DO, Rabiner JE. Role of regional anesthesia in
  patients with acute sickle cell pain: A scoping review.~\emph{Pediatr
  Blood Cancer} . 2023;70(1):e30063. doi:10.1002/pbc.30063
\item
  Naik RP, Streiff MB, Haywood C Jr, Nelson JA, Lanzkron S. Venous
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\item
  Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE
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  doi:10.1378/chest.11-2301
\item
  Brandow AM, Carroll CP, Creary S, et al. American Society of
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  acute and chronic pain.~Blood Adv. 2020;4(12):2656-2701.
  doi:10.1182/bloodadvances.2020001851
  Horlocker~TT,~Vandermeuelen~E,~Kopp~SL, et al
\item
  Regional Anesthesia in the Patient Receiving Antithrombotic or
  Thrombolytic Therapy:~American Society of Regional Anesthesia and Pain
  Medicine Evidence-Based Guidelines (Fourth Edition) Regional
  Anesthesia \& Pain Medicine~2018;43:263-309.
\item
  Davila J, Stanek J, O'Brien SH. Venous thromboembolism prophylaxis in
  sickle cell disease: a multicenter cohort study of adolescent
  inpatients.~Blood Adv. 2023;7(9):1762-1768.
  doi:10.1182/bloodadvances.2022007802
\item
  Noubiap JJ, Temgoua MN, Tankeu R, Tochie JN, Wonkam A, Bigna JJ.
  Sickle cell disease, sickle trait and the risk for venous
  thromboembolism: a systematic review and meta-analysis.~Thromb J.
  2018;16:27. Published 2018 Oct 4. doi:10.1186/s12959-018-0179-z
\item
  McClish DK, Smith WR, Dahman BA, et al. Pain site frequency and
  location in sickle cell disease: the PiSCES project.~Pain.
  2009;145(1-2):246-251. doi:10.1016/j.pain.2009.06.029
\item
  Bansil NH, Kim TY, Tieu L, Barcega B. Incidence of serious bacterial
  infections in febrile children with sickle cell disease.~Clin Pediatr
  (Phila). 2013;52(7):661-666. doi:10.1177/0009922813488645
\item
  Bala N, Chao J, John D, Sinert R. Prevalence of Bacteremia in Febrile
  Patients with Sickle Cell Disease: Meta-Analysis of Observational
  Studies.~Pediatr Emerg Care. 2021;37(12):e1695-e1700.
  doi:10.1097/PEC.0000000000001944
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