Category Archives: Complications

EAST 2017 #12: Revaccination Compliance After Splenectomy

January 12, 2017 The Trauma Pro Leave a comment

The incidence of overwhelming post-splenectomy sepsis, and the need and effectiveness for vaccination after splenectomy is still subject to debate. However, the administration of three vaccines to protect against encapsulated bacteria is a standard of care. For decades, this was a one time thing and the vaccines were usually given before the spelenctomized trauma patient was discharged from the hospital.

Then several years ago, the CDC updated their recommendations to include a booster dose of 23-valent penumococcal vaccine. Trauma professionals have inconsistently advised their patients about this dose, and patients have not reliably sought their booster.

Researchers at Christiana Care in Delaware looked at this potential problem by identifying all of their trauma splenectomy patients over a 10 year period. They were interviewed by phone to determine their understanding of the asplenic state and the need for booster vaccination.

Here are the factoids:

During the 10 year period, 267 trauma splenectomies were performed
196 survived, but only 52 agreed to participate (? – see below)
Although all patients received vaccines before discharge (!), only 23% were aware that they had
Only about half of patients were aware that they may be at risk for infectious complications
Only 19% understood they would require a booster dose, and 22% had actually received one (?? – see below)

Bottom line: Although we still aren’t sure how important these vaccines are, vaccination is the standard of care. This study, although a little confusing, shows that we are falling down in educating our patients about the impact of their splenectomy (surgical or via embolization). And it’s difficult for anyone to remember to get a booster shot. Are you up to date on your tetanus vaccination?

This abstract shows us that we need to counsel these patients prior to discharge regarding their at-risk condition. We also need to make sure they (and their primary care provider) are aware that they need to get a pneumococcal booster five years down the road.

News flash! Take a look at page 3 of the CDC recommendations (download here) to see the official recommendations regarding pneumococcal vaccination. It is recommended that PCV-13 vaccine (Prevnar 13) be given first, then the 23-valent vaccine (Pneumovax) 8 weeks later! This complicates things a bit, since both pneumococcal vaccines cannot be given while the patient is still in the hospital. This will reduce the likelihood that patients will get their second pneumococcal vaccine.

Questions and comments for the authors/presenters:

The number of patients is off by one. There were 267 splenectomy patients, 49 died in the hospital and 23 after discharge. 267-49-23=195, not 196.
Only 52 of this 195 agreed to participate. You were able to find all 195? It seems that some of these 143 patients just could not be located.
Please clarify the numbers in my last bullet point. Of the 52 patients, only 9 were aware of the revaccination requirement, and only 1 got it?
This is important work. What have you done to improve these numbers at your hospital?

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

Related posts:

Reference: Revaccination compliance after trauma splenectomy: a call for improvement. Poster #31, EAST 2017.

Complications

EAST 2017 #11: Use of Incompatible (Type A) Plasma For Massive Transfusion

January 11, 2017 The Trauma Pro 2 Comments

Type AB plasma is considered “universal donor” plasma, as it contains no antibodies to red cells with either A or B antigens on their surface. Unfortunately, only about 4% of the US population have this blood type and can provide the product. Due to this shortage, some trauma centers have decided to use Type A plasma initially for massive transfusion, and switch to type specific plasma once patient blood has been typed and screened.

This works, since only about 13% of the population have red cells with B antigens on the surface. But are there any adverse effects in those patients who receive potentially incompatible plasma? The EAST Multicenter Study group performed a retrospective study using trauma registry and blood bank data from 5 trauma centers. They looked at adult patients who received plasma as part of the massive transfusion protocol (MTP) over a 4+ year period. Incompatible type A plasma transfusion was defined to occur if a patient had either Type B or AB blood.

Here are the factoids:

There were a total of 1212 patients in the study; 93% were compatible and 7% were incompatible type A initial transfusions
The usual trauma demographics were seen (young, male) and the average ISS was 25 (they triggered an MTP, remember?)
By chance, the incompatible group had a slightly higher ISS (29) and penetrating injury rate (45% vs 33%)
The incompatible group received significantly more plasma during the first 4 hours and during the first day
There was no difference in mortality sepsis, ARDS, thromboembolic events, or renal failure
Regression analysis showed that incompatible plasma was not a predictor of mortality or morbidity
There was one hemolytic reaction and one occurrence of TRALI, both in the compatible group

Bottom line: This is the largest study around on the topic, and it does not show any significant problems (at least the ones that were studied) with giving incompatible plasma in acute trauma. How can this be, you ask? Remember, only the first one or two units (the first MTP pack) is potentially incompatible. Hopefully, by the time the second pack is delivered, the blood has been typed. And these patients are potentially receiving multiple units of typed plasma after the initial transfusion which dilutes the incompatible, and multiple transfusions overall which may blunt their immune response.

This is an important paper that all centers should consider as they update their massive transfusion protocols!

Questions and comments for the authors/presenters:

The abstract states that 5 centers participated, but the tables only list 4. Please explain this.
It is not stated explicitly whether all centers used type A plasma initially. Is this the case?
This is important work! Have any other centers converted to initial use of type A plasma?

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

Related posts:

Reference: Use of incompatible type A plasma transfusion in patients requiring massive transfusion protocol: outcomes of an EAST multicenter study. Paper #16, EAST 2017.

Complications, Head

EAST 2017 #8: When Is “Mild TBI” Not So Mild?

January 6, 2017 The Trauma Pro Leave a comment

Traumatic brain injury (TBI) is very common, with the majority falling into the “mild” category. This is usually defined as patients with injury to the head and a GCS of 13-15. These uncomplicated patients are frequently discharged from the emergency department, or undergo only a brief evaluation if admitted for other reasons.

The group at Shock Trauma focused on a less appreciated subset of mild TBI patients, those whose condition is a little more complicated. Specifically, these are patients with GCS 13-14 with positive findings on head CT leading to a calculated abbreviated injury score (head) of > 2, and some persistence of their symptoms while in the hospital. At many hospitals (including my own), these patients receive an inpatient TBI evaluation. But if they pass this initial screening, they are not consistently referred for any outpatient TBI followup.

Are these mild, complicated TBI patients (mcTBI) unique? Do they behave the same as the uncomplicated ones? The research group performed a prospective study on patients who sustained an mcTBI over a 4 month period. They excluded patients with mental illness, dementia, and non-English speaking and homeless patients. They tried to contact patients up to three times after discharge to administer several standard tests and determine if they had any specific residual symptoms.

Here are the factoids:

Of the 142 patients with mcTBI during the study period, there was substantial attrition over time, with only 25 remaining at 6 months and 10 at one year
64% of patients who responded at 6 months remained symptomatic. Depression, dizziness, and a feeling of impaired health were common.
80% of patients still described symptoms at one year. The same complaints were most common, and some required changes in activities of daily living or assistive devices.

Bottom line: Although small and fraught with the usual problems in long-term tracking of urban trauma patients, this study is eye-opening. We too often dismiss “mild TBI” and being almost nothing, even in patients with positive findings on head CT. This work suggests that we are underestimating the needs of those patients. The authors used this data to design longer-term care processes for this subset of patients. Other centers should follow suit to make sure these patients’ post-injury needs are better met.

Questions and comments for the authors/presenters:

Describe the possible biases that patient selection and attrition may have had on the study
What type of TBI screening do you use in the hospital?
Given that a number of assessments were administered over the phone, I look forward to hearing some of the other details not listed in the abstract
Was there any correlation between specific CT findings and later symptoms?
Provide details of your long-term care programs for these patients
I enjoyed this thought provoking abstract!

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

Related posts:

A quick and dirty TBI screening test
Download the Short Blessed Test instrument (TBI screen)

Reference: Mild TBI is not ‘mild’… survivors tell their complicated stories. Quick Shot #3, EAST 2017.

Complications

EAST 2017 #3: My Neck Is Broken And It Doesn’t Hurt?

December 30, 2016 The Trauma Pro Leave a comment

Clinical clearance of the cervical spine is a standard of care. It is usually the first method to determine if there might be an injury in patients who are awake, cooperative, and don’t have other painful distracting injuries. But appreciation of pain may be different in elderly patients, and they will frequently not notice pain from some injuries. Could this possibly impact clearance of the cervical spine?

A group at Iowa Methodist performed a retrospective review of patients > 55 with diagnosed cervical spine fractures over a four year period. They were considered to have an asymptomatic injury if they did not complain of pain, or of tenderness to palpation.

Here are the factoids:

A total of 173 elderly patients presented with a cervical spine injury during the study period
38 of them (22%) were asymptomatic
The asymptomatic patients tended to have higher injury severity (ISS 15 vs 10), have a significant injury in another body region (71% vs 47%), and stayed in the hospital longer (7 days vs 5)
A third of patients had multiple cervical fractures (symptomatic or asymptomatic?)
C2 was the most common fracture level

Bottom line: I have witnessed this phenomenon myself. Not all of our elders perceive pain the same way younger patients do. This study shows that it is a very significant problem. Most of the previous papers and the only review I could find do not separate out the elderly when making cervical clearance recommendations. We will probably have to develop some specific criteria to determine when a CT scan is necessary in the asymptomatic elderly patient. In the algorithm used at my hospital, age > 65 is already used to bypass clinical clearance. Looks like I’ll have to drop that to 55!

Questions and comments for the authors/presenters:

Since they were asymptomatic, how do you know that you didn’t miss any patients?
Do you have a practice guideline for cervical spine evaluation? Has it changed based on your study?
Be sure to break your data down by mechanism of injury for the presentation. Were there more asymptomatic patients from falls rather than car crashes? Associated fracture patterns for each mechanism?
What do you now recommend for clearance?
Suggestion: change your title to “cervical spine fractures”, not “neck fracture”.

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

Related posts:

Reference: Asymptomatic neck fractures: current guidelines can fail older patients. Paper #8, EAST 2017.

Complications

Enoxaparin And anti-Xa Levels: Who Cares? Part 3

December 27, 2016 The Trauma Pro Leave a comment

Today is the final installment in a series about the use of anti-Factor Xa levels to titrate enoxaparin dosing to prevent venous thromboembolism (VTE). This is another study that tries to show that “hitting the number” actually makes a difference in patient care. You decide.

This study identified a subset of patients at high-risk for VTE based on a commonly used and very good risk screening tool, the Risk Assessment Profile (RAP). It takes some 17 factors into account to arrive at a numerical score. In this paper, the authors chose a score of 10 or greater to denote high risk. The patients were all seriously injured, and were in the trauma ICU of this established Level I trauma center.

This retrospective study excluded non-ICU patients, ones who did not receive enoxaparin or anti-Xa levels, and two patients with DVT on admission. This brought the number of eligible patients from 621 to 127 (the treatment group). They then narrowed the field down to the high-risk treatment group by excluding patients with a RAP score < 10. Now we are down to 86. But then 30 more (35%) were excluded because they did not undergo duplex ultrasound screening, leaving only 56 to study (!).

The control group was a “similar” historical cohort from a two year period from 2009 to 2012. You can tell that this group is getting a little stale, because the only patients included were those who received unfractionated heparin for prophylaxis (remember those days?). Of the 106 patients in the control group, 20 (28%) were reported as have VTE. However, it included 6 patients with DVT on admission, which were excluded in the study group. This makes the DVT rate look higher in the control group. It also included 2 upper extremity DVT and 1 septic pelvic venous thrombosis. Excluding all of these brings the historical VTE rate down to only 10%. Remember this.

So let’s get on to the factoids:

Only 35% of the 127 patient treatment group “hit the number” for anti-Xa (0.2-0.4 IU/ml) after three 30mg doses of enoxaparin
An additional 25% managed to achieve the desired anti-Xa level after dose adjustment, but 51 patients (40%) never did get there
There were 10 VTE events in the 127 treatment group patients, 9 of whom had high RAP scores, giving them a 7.8% rate of VTE
Nine of the 10 VTE patients occurred in patients with low anti-Xa levels
The authors compared their 7.1% DVT rate with the 21% in their historical controls, concluding that titrating anti-Xa levels reduced this rate. They did not include PE for some reason, and do not claim a statistical difference. They admit that the study was underpowered to detect differences in VTE. There is no significant difference in VTE rates in the study or control groups.

Bottom line: This is the last paper on the topic. I promise. At least for a while. Here’s what we know:

VTE is a problem in trauma patients, particularly seriously injured ones
We are not very good at sticking to a prophylaxis or screening regimen (note how many patients are excluded in all of these studies)
We can’t seem to generate the numbers to conduct a good study that can detect differences in what we do
It’s difficult to “hit the number” for anti-Xa using standard enoxaparin dosing
We don’t even know if it makes a difference if we do “hit the number”. VTE rates seem to be the same regardless.

So we are struggling to make a lab test look right to adjust enoxaparin dosing, and we don’t even know if it makes a difference. Will somebody put a good, multi-center study together and help us to figure all of this out?

Related posts:

Reference: Anti-Xa-guided enoxaparin thromboprophylaxis reduces rate of deep venous thromboembolism in high-risk trauma patients. J Trauma 81(6):1101-1108, 2016.

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