Category Archives: Solid organ

APSA Activity Restrictions After Solid Organ Injury: Aren’t We Done With That Yet?

Nearly 20 years ago, the American Pediatric Surgical Association (APSA) published a clinical guideline for management of solid organ injury in children. Part of the guideline included activity restrictions, specifically for a period of time after injury. This was generalized by many clinicians to include a period of in-hospital bed rest.

A paper has just been published that examines the usefulness of restricting activity in pediatric patients with solid organ injury. It was authored by a consortium of 10 Level I pediatric trauma centers, and included all patients through age 18 who did not have a concomitant significant renal injury and no pancreatic injury. All injuries were diagnosed by CT scan over a 33 month period.

Activity restrictions were given to all patients upon discharge, which limited sports, wheeled recreational activities, and anything else requiring two feet off the ground. A phone survey was conducted 60 days post-discharge to judge compliance. Unplanned return to ED, readmission, and complications were also assessed.

Here are the factoids:

  • A total of 1007 patients were studied, and 99 were excluded due to concomitant pancreatic or high grade renal injury. An additional 79 were excluded due to missing injury grade or operative management.
  • Of the remaining patients, only 366 were available for 60-day followup
  • 279 claimed to adhere to activity restrictions; 13% returned to the ED and 6% were readmitted.
  • 49 admitted that they did not pay attention to the restrictions, and only 4 (8%) returned to the ED. None were hospitalized.
  • Even in the high-grade injury patients, there was no difference between compliant or noncompliant groups
  • No patient in either group bled post-discharge

Bottom line: Due to the nature of this study (specifically the phone survey component), there will be degradation of the data. Some patients do not want to admit that they didn’t follow the doctor’s orders. In theory, this could increase the number of complications / returns to ED in the “compliant” group. But it did not. 

The other issue I have with this study is that it was not stratified by age. The spleen of an 18 year old is very different than that of a 6 year old. Sixty years ago, we used to take spleens out in adults with a diagnosed injury. The reason we moved toward nonoperative management in adults was the very favorable experience we had in children. Unfortunately, nowhere in this paper is age broken out. Typically, the number of older children (who are really adults) with the injury far outnumber the younger ones, which also tends to increase the number of complications seen. But once again, we did not. Small numbers? Possibly. 

So what are we to make of all this? Basically, it tells us that we’ve been trying to restrict activity in our patients with liver and spleen injury for no good reason. And this applies especially to the children. Look at your own clinical experience, and try to recount how many “failures” you’ve seen due to failure to follow activity restrictions. More typically, failures are due to undiagnosed or untreated pseudoaneurysms. 

It’s time to rethink your solid organ management protocol, if you haven’t already. Do you really need a period of NPO status? Or bedrest? Or activity restriction? And have you ever tried to restrict activity in a 6-year old? Have a look at the guideline we’ve used at my hospital for nearly 20 years! We got rid of the NPO and bedrest restrictions a while ago. Now it’s time to start reducing the activity restrictions!

References:

  • Evidence-Based Guidelines for Resource Utilization in Children With
    Isolated Spleen or Liver Injury. J Ped Surg 35(2):164-169, 2000.
  • Adherence to APSA activity restriction guidelines and 60-day clinical outcomes for pediatric blunt liver and splenic injuries (BLSI). J Ped Surg in Press, 2018.
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Best of AAST #10: Pediatric Contrast Extravasation And Pseudoaneurysms

There is a significant amount of variation in the management of pediatric solid organ injury. This is well documented between adult and pediatric trauma centers in t, but also apparently between centers in different countries. A poster from a Japanese group in Okinawa Japan will be presented this week detailing the relationship between contrast extravasation after spleen or liver injury and pseudoaneurysm formation.

In adults, the general rule is that pseudoaneurysms just about anywhere slowly enlarge and eventually rupture. This group sought to define this relationship in the pediatric age group. They performed a multi-center observational study of retrospectively enrolled children, defined as age 16 and less. Those who had contrast extravasation on initial CT were monitored for later pseudoaneurysm formation.

Here are the factoids:

  • 236 patients were enrolled across 10 participating centers, with about two-thirds having liver injury and the remainder with splenic injury
  • 80% of patients underwent followup CT scan (!!)
  • 33 patients (15%) underwent angiography (!!!!)
  • 17 patients with CT scan (2%) had pseudoaneurysm formation and 4 of them had a delayed rupture
  • Overall, pseudoaneurysms occurred in 29% of those with contrast extravasation and 5% without extravasation
  • The authors concluded that contrast extravasation was significantly associated with pseudoaneurysm formation after adjusting for variables such as ISS, injury grade, and degree of hemoperitoneum

Bottom line: This is an abstract, so a lot is missing. What was the age distribution, especially among those who underwent angiography? Was the data skewed by a predominantly teenage population, whose organs behave more like adults? The abstract answers a question but ignores the clinical significance.

For those trauma professionals who routinely care for pediatric patients, you know that contrast extravasation in children doesn’t act like its adult counterpart. Kids seldom decompensate, and for those who are mistakenly taken for angiography, the extravasation is frequently gone. The authors even admitted in the conclusion that aggressive screening and treatment for pseudoaneurysm was carried out.

The real question is, what is the significance of a solid organ pseudoaneurysm in children? Based on my clinical experience and reading of the US literature, not much. Of course, there is a gray zone as children move into adulthood in the early to mid-teens. But this does not warrant re-scanning and there should be no routine angiography in this age group. Contrast extravasation in pediatric patients warrants close observation for a period of time. But intervention should only be considered in those who behave clinically like they have ongoing bleeding. 

Reference: Association between contrast extravasation on CT scan and pseudoaneurysm in pediatric blunt splenic and hepatic injury: a multi-institutional observational study. Poster 31, AAST 2018.

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Phlebotomy And Pediatric Solid Organ Injury

A pediatric trauma paper published a while back tried to focus on reducing the rate of phlebotomy in children who were being observed for solid organ injury. I was more excited about the overall protocol being used to manage liver and spleen injury, as it was a great advance over the original APSA guideline. But let’s look at the phlebotomy part as well.

This is an interestingly weird study, and you’ll see what I mean shortly. Two New York trauma hospitals that take care of pediatric patients pooled 4 years of registry records on children with isolated blunt liver and/or spleen injuries. Then they did a tabletop excercise, looking at “what if” they had applied the APSA guideline, and “what if” they had applied their new, proposed guideline.

Interestingly, this implies that they were using neither! I presume they are trying to justify (and push all their partners) to move to the new protocol from (probably) random, individual choice.

Here are the factoids:

  • 120 records were identified across the 2 hospitals that met criteria
  • Late presentation to the hospital, contrast extravasation, comorbidities, lack of imaging, operative intervention at an outside hospital excluded 59 patients, leaving 61 for analysis. Three of those patients became unstable and were also excluded.
  • None of the remaining patients required operation or angioembolization
  • Use of the “new” (proposed) protocol would reduce ICU admissions by 65%, reduce blood draws by 70%, and reduce hospital stay by 37%
  • Conclusion: use of the protocol would eliminate the need for serial phlebotomy (huh?)

Bottom line: Huh? All this to justify decreasing blood draws? I know, kids hate needles, but the data on decreased length of stay in the hospital and ICU is much more important! We’ve been using a protocol similar to their “new” one at Regions Hospital for almost 10 years, which I’ve shared below. We’ve been enjoying decreased resource utilization, blood draws, and very short lengths of stay for over a decade. And our analysis showed that we save more than $1000 for every patient entering the protocol, compared to the old-fashioned and inefficient way we used to manage them.

In general, kids (and adults) with low grade injuries (I-III) need 2 blood draws, and those with high grade need about 3. Check out our guidelines below to see how it works!

Related posts:

Reference: Reducing scheduled phlebotomy in stable pediatric patients with liver or spleen injury. J Ped Surg 49(5):759-762, 2014.

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Does Trauma Center Level Make A Difference In Treating Solid Organ Injury?

In the last two posts, I reviewed contrast anomalies in solid organs, specifically the spleen. Today, I’ll be more general and examine a recent paper that compared management and outcomes after the other major solid organ injury, liver, at Level I vs Level II trauma centers.

There are several papers that have detailed overall differences in outcomes, and specifically mortality, at Level I and II centers. Some of these show outcomes that are not quite as good at Level II centers when compared to Level I. On paper, it looks like these two levels should be very similar. Take away research and residents, and maybe a few of the more esoteric capabilities like reimplantation, and aren’t they about the same?

Well, not really. They can be, though. Level I criteria are fairly strict, and the variability between difference Level I centers is not very great. Level II criteria are a bit looser, and this allows more variability. Many Level II centers function very much like a Level I, but a few are only a bit higher functioning than a Level III with a few extra surgical specialists added in.

A paper currently in press used the Michigan Trauma Quality Improvement Program (MTQIP) data from all 29 ACS verified Level I and II centers in the state (wow!). Six years of information was collected, including the usual demographics, outcome data, and management. A total of 538 patients met inclusion criteria, and this was narrowed down to 454 so statistical comparisons of similar patients could be made for Level I vs Level II centers.

Here are the factoids:

  • Mortality was significantly higher in Level II centers compared to Level I (15% vs 9%) and patients were more likely to die in the first two days, suggesting hemorrhage as the cause
  • Patients were more likely to die in the ED at Level II centers, despite a significantly lower Injury Severity Score (ISS)
  • Pneumonia and ARDS were significantly more likely to develop in Level II center patients
  • Level II centers used angiography less often and took patients to the OR more frequently
  • Level II centers admitted fewer patients to the ICU, but ICU admission was associated with significantly decreased mortality
  • Complications were fewer at Level II centers, but they were less likely to rescue patients when they occurred

Bottom line: Level I and II centers are supposed to be roughly the same, at least on paper. But a number of studies have suggested that there are more disparities than we think. Although this paper is a retrospective review, the sheer number of significant differences and its focus on one particular injury makes it more compelling.

So what to do? Tighten up the ACS Orange Book criteria? That’s a slow and deliberate process that won’t help our patients now. The quickest and most effective solution is for all centers to adopt uniform practice guidelines so they all perform like the highly successful Level I programs in the study. There are plenty of them around. If you are not yet using one, I urge you to have a look at the example below. Tweak it to fit your center. And use your PI program to trend the outcomes!

Related post:

Reference: Variability in Management of Blunt Liver Trauma and Contribution of Level of ACS-COT Verification Status on Mortality. J Trauma, in press, Dec 1, 2017.

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EAST 2017 #12: Revaccination Compliance After Splenectomy

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:

  1. 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.
  2. 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.
  3. 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?
  4. 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.

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