Category Archives: Solid organ

Best of AAST #10: Pediatric Contrast Extravasation And Pseudoaneurysms

September 24, 2018 The Trauma Pro Leave a comment

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.

Solid organ

Phlebotomy And Pediatric Solid Organ Injury

August 2, 2018 The Trauma Pro Leave a comment

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.

Solid organ

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

December 7, 2017 The Trauma Pro Leave a comment

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:

Practice guideline for adult solid organ injury management

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.

Complications, Solid organ

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.

Abdomen, Solid organ

Early Mobilization In Solid Organ Injury

September 13, 2016 The Trauma Pro Leave a comment

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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