Category Archives: Abdomen

Abdomen, Imaging

EAST 2017 #6: FAST Exam After Rolling to the Right

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The FAST exam is an integral part of trauma evaluation. Even after experience and credentialing of providers, there tends to be some variability in performance. This is especially true when the abnormal findings (or amount of fluid present) is relatively small.

Can we improve this by doing something as simple as using gravity to help? When the patient is supine, fluid tends to pool in the pelvis, where interpretation is a little more complicated.  The surgery program at Guthrie/Packer Hospital created a small pilot study to see if they might improve the sensitivity of FAST by rolling patients to their right briefly, before returning to the supine position and performing the exam.

They enrolled seven participants who were already undergoing peritoneal dialysis (PD), so there was easy access to the peritoneal cavity for administration of known amounts of free fluid. First, each patient was drained of any residual dialysate via their PD catheter. They then underwent a baseline FAST exam. Next, they were placed in the right lateral decubitus position for 30 seconds, then placed supine again and the FAST was repeated. Each patient then had 50cc of dialysate infused, and the process was repeated until a positive FAST was obtained.

Here are the factoids:

  • Of the seven patients recruited, one was excluded because the initial FAST was equivocal due to body habitus and polycystic kidney disease
  • A maximum of 3 aliquots were given (150cc max)
  • Two patients became positive after right side down before any additional fluid was infused
  • None of the four remaining patients had a positive FAST after infusion of any aliquot in the supine position
  • All four became positive after the right side down maneuver,  two after 50cc, one after 100cc, and one after 150cc

Bottom line: The authors conclude that this may be a valuable technique to help detect smaller quantities of fluid than we normally do. I’m not so sure. First, it’s a tiny study in a patient group that is very different from trauma. And it’s impossible to quantify how much dialysate was left after initial drainage of the PD catheter. Finally, we know that FAST can’t “see” small quantities of fluid, but we have constructed our management algorithms around this fact. So we have a good idea of when we should do further imaging or run off to the operating room. Making this test more sensitive may skew these practice guidelines toward doing more (and potentially unneeded) imaging and surgery.

Questions and comments for the authors/presenters:

  • Did you record the volumes and administration times of dialysate given prior to the study? This may correlate with the initial positives and volumes needed to give a positive result.
  • Similarly, did you look at BMI and body habitus to see if there might be a correlation?
  • Are you planning any type of followup study, as you suggested in the abstract?

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related posts:

Reference: Can we be faster? FAST examination after rolling to the right dramatically increases sensitivity. Quick Shot #7, EAST 2017.

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Abdomen, Solid organ

Early Mobilization In Solid Organ Injury

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Most trauma centers have some kind of practice guideline for managing solid organ injury. Unfortunately, the specifics at each center are all over the map. Here are a few common questions:

  • Should you keep the patient NPO?
  • How often should Hgb/Hct be repeated?
  • Should they be at bed rest?
  • What are their activity restrictions after they go home?

spleen-lac

As for activity, some earlier studies have shown that early ambulation is safe. The group at Hahnemann University Hospital in Philadelphia tried to determine if early mobilization would decrease time in ICU and/or the hospital, or increase complications.

Until 2011, their trauma service kept all patients with solid organ injury at bed rest for 3 days(!). They modified this routine to allow ambulation the following morning for Grade 1 and 2 injuries, and after 24 hours for Grade 3 and above, or those with hemoperitoneum. They examined their experience for 4 years prior (PRE) and 4 years after (POST) this change. They excluded patients with penetrating injury, or other significant injuries that would impact the length of stay.

Here are the factoids:

  • 300 solid organ injury patients were identified in the PRE period, and all but 89 were excluded
  • 251 were identified in the POST period, and all but 99 were excluded
  • Hospital length of stay was significantly shorter (5.9 vs 3.7 days) after implementation of the new guideline
  • ICU length of stay also decreased significantly, from 4.6 to 1.8 days
  • The authors extrapolated a cost savings of about $40K for the ICU stay, and $10K for the ward stay, per patient
  • There was one treatment failure in each group

Bottom line: It’s about time we recognized what a waste of time these restrictions are! Unfortunately, the study groups became very small after exclusions, but apparently the statistics were still valid. But still, it continues to become clear that there is no magic in keeping someone starving in their bed for any period of time.

At my hospital, we adopted a practice guideline very similar to this one way back in 2004 (download it below). Hospital lengths of stay dropped to about 1.5 days for low grade injury, and to about 2.5 days for high grade.

And earlier this year, we eliminated the NPO and bed rest restrictions altogether! How many patients actually fail and end up going urgently to the OR? So why starve them all? And normal activity started immediately is no different than activity started a few hours or days later.

Don’t starve or hobble your patients, adults or children!

Related posts:

Reference: Early mobilization of patients with non-operative liver and spleen injuries is safe and cost effective. AAST 2016, Poster #5.

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Abdomen

Spleen Injury, Angiography, And Splenectomy

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The shift toward initial nonoperative management of spleen injuries began in the early 1990’s, as the resolution of early CT scans began to improve. Our understanding of the indicators of failure also improved over time, and success rates rose and splenectomy rates fell.

Angiography was adopted as an adjunct to early management, especially when we figured out what contrast extravasation and pseudoaneurysms really meant (bad news, and nearly certain failure in adults). At first, it was used in a shotgun approach in most of the higher grade injuries. But we have refined it over the years, and now it is used far more selectively at most centers.

A group at Indiana University was interested in looking at the impact of angio use on splenic salvage over a long time frame. They queried the National Trauma Data Bank, looking specifically at high grade splenic injury care at Level I and II centers from 2008-2014. Patients undergoing splenectomy were divided into early (<= 6hr after admission) and late (> 6 hrs). Over 50,000 records were analyzed.

Here are the factoids:

  • There was a shift from early splenectomy to late splenectomy over the study period that was statistically significant
  • Use of angio increased from 5 to 12% during the study period
  • Overall splenectomy rate remained about the same

So the authors recognize that late splenectomy has decreased. But they also state that early splenectomy has increased. They attribute it to increased recognition of patient requiring early splenectomy. They then call into question the need to use angiography if it hasn’t decreased the overall splenectomy rate.

Problem: The early splenectomy rate increased from about 13% to 14%, reading their graph, and is probably not significant. These are the failures that occur in the trauma bay and shortly thereafter that must be taken to the OR. The late splenectomy rate decreased from 5% to 3%, which may be significant (p value not included in the abstract). These are failures during nonoperative management, and are decreasing over time. And BTW, the authors do not define what “high grade” splenic injuries they are looking at.

AAST2016-Paper35

Bottom line: This abstract illustrates why it is important to read the entire article, or in this case, listen to the full presentation at AAST. It sounds like one that’s been written to justify not having angiography available as it is currently required. 

The authors showed that overall splenectomy rate was the same, but delayed splenectomy (late failure) has decreased with increasing use of angiography. But remember, this is an association, not cause and effect. Most of the early failures are still probably ones that can’t be prevented, but we’ll see if the authors can dissect out how many went to OR very early (not eligible for angio), or later in the 6 hour period (could have used angio). It looks to me like the use of angiography is having the desired effect. But undoubtedly we could use that resource more wisely. What we really need are some guidelines as to exactly when a call to the interventional radiologists is warranted.

Related posts:

Reference: Overall splenectomy rates remain the same despite increasing usage of angiography in the management of high grade blunt splenic injury. AAST 2016, paper 35.

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Abdomen

Solid Organ Injury Tips

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Over the years, I’ve written about solid organ injury management many times. Here is a summary of some practical pointers and tips, some old and some new. They are as evidence-based as I can get them. This kind of stuff is not always in the doctor and nursing books.

  • Please refer to our solid organ injury protocol, which you can download here.
  • Ward and ICU branches are order sets at my hospital, not necessarily admitting locations. If you have a special unit or step-down area that can provide ICU-level monitoring, use it for the ICU order set.
  • Strongly consider interventional radiology (IR) and angiography in all adult patients with contrast extravasation (children generally do not qualify unless they show signs/sx of ongoing volume loss). Consider also in high grade injuries, because they may have active bleeding that isn’t quite brisk enough to see on CT.
  • Serial hemoglobin measurements are not part of the protocol. They are only used to help decide if transfusion might be needed. Vital signs will always signal failure before the hemoglobin does.
  • Nearly all patients may be up and eating immediately, or certainly by the next morning. No need for protracted NPO status or bed rest. Really no need for it at all!
  • Failure really falls into 2 types: hard and soft. Hard failure is a single episode of definitive hypotension (usually 80s or less) or development of peritoneal signs, and requires an emergency trip to the OR. Soft failure is transient or modest hypotension that responds rapidly to a fluid bolus. If IR has not already been used, a quick trip there may obviate the need for operation. However, another one of these bouts makes it a hard fail. Time for OR.
  • Hard failure can only be treated with blood, some crystalloid, and a knife. Pressors, steroids, or other drugs can only be used if they come in liter bags and can be given at over 1000cc/hr. That means never.
  • In IR, give the radiologist 30 minutes to stop the bleeding. Don’t let them dawdle for hours. If the patient has a hard fail, abort and go to OR; do not let the radiologist persist.

After discharge, our usual orders are:

  • Normal activity (non-impact) for 6 weeks
  • All activity (except high impact) thereafter
  • High impact activity (tackle football, rugby, serious extreme sports) only after 12 weeks (no good data for this one)
  • No repeat CT scanning to judge healing
  • Warn patients of the good possibility of a transient increase in pain on days 7-10. This is common in many unless they’ve been embolized.
  • Patient to call if unrelenting increase in pain, or increasing orthostatic symptoms, fevers chills

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