Tag Archives: complications

Abdomen

Activity Guidelines After Solid Organ Injury: How Important Are They?

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Just about every practice guideline out there regarding liver and spleen injury has some physical activity restrictions associated with it. The accepted dogma is that moving around too much, climbing stairs, lifting objects, or getting tackled while playing rugby could exacerbate the injury and lead to complications or surgery.

But is it true? Activity restrictions after solid organ injury have been around longer than I have been a trauma surgeon. And the more people I poll on what they do, the more and very different answers I get. And there are no decent papers published that look critically at this question. Until now. 

A pediatric multi-center study of study on adherence to activity restrictions was published last year. Ten Level I pediatric trauma centers in the US tabulated their experience with solid organ injuries over 3.75 years from 2013 to 2016. Only patients with successful nonoperative management of their injury were included, and those with high-grade renal or pancreatic injuries were excluded.

Since this was a pediatric study, the American Pediatric Surgical Association (APSA) practice guideline was followed (activity restriction = organ injury grade + 2 weeks). Activity restrictions included all sports, any recreational activity with wheels, or any activity involving both feet off the ground. Patients with Grade III-V injuries were seen at an office visit after 2 weeks, and lower grade injuries had a phone follow-up.

Adherence to guidelines was assessed by a follow-up phone call two months after injury. Clinical outcomes assessed at 60 days included an unplanned return to the emergency department (ED), re-admission, complications, and development of new bleeding confirmed by surgery, ultrasound, or computed tomography (CT) at 60 days post-injury.

Here are the factoids:

  • Of the 1007 patients in the study, some 56% were either excluded (178) or lost to follow-up (463)
  • Of the remaining 366, roughly 46% had a liver injury, 44% spleen, and the remaining 10% had both
  • Median age was 10, so this was actually a younger population
  • 76% of patients claimed they abided by the guidelines, 14% said they did not, and 10% “didn’t know.” This means they probably did not.
  • For the 279 patients who said they adhered to activity restrictions, 13% returned to the ED, and half were admitted to the hospital
  • Of the 49 patients who admitted they did not follow the guidelines, 8% returned to the ED at some point, and none were readmitted
  • The most common reasons for returning to ED were abdominal pain, anorexia, fatigue, dizziness, and shoulder pain
  • There were no delayed operations in either of the groups

Bottom line: There were no significant differences between the compliant and noncompliant groups. Unfortunately, the authors did not include an analysis of the “I don’t know if I complied” group, which would have been interesting. However, there is one issue I always worry about in these low-number-of-subjects studies that don’t show a significant difference between groups. Did they have the statistical power to show such a difference? If not, then we still don’t know the answer. And unfortunately, I’m not able to guess the numbers well enough to do the power calculation for this study.

I am still intrigued by this study! Our trauma program originally set a fixed time period (6 weeks) of limited activity in our practice guideline for pediatric solid organ injury patients. This was reduced based on our experience of no delayed complications and guidance from our sister pediatric trauma center at Children’s Hospital in Minneapolis. We are also moving toward making a similar change to our adult practice guidelines. But even our current guideline of injury grade + 2 weeks is probably too much.

Too many centers wait too long to make changes in their practice guidelines. They bide their time waiting for new, published research that they can lean on for their changes. Unfortunately, they will be waiting for a long time because many of our questions are not interesting enough for acceptance by the usual journals. Rely on the expertise and experience of your colleagues and then make those changes. Be sure to follow with your performance improvement program to make sure that they actually do work as well as you think!

Reference: Adherence to APSA activity restriction guidelines and 60-day clinical outcomes for pediatric blunt liver and splenic injuries (BLSI). J Ped Surg 54:335-339, 2019.

Complications, Device

Air Embolism From an Intraosseous (IO) Line

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Intraosseous (IO) lines are a godsend when we are faced with a patient who desperately needs access but has no veins. The tibia is generally easy to locate and the landmarks for insertion are straightforward. They are so easy to insert and use, we sometimes “set it and forget it”, in the words of infomercial guru Ron Popeil.

But complications are possible. The most common is an insertion “miss”, where the fluid then infuses into the knee joint or soft tissues of the leg. Problems can also arise when the tibia is fractured, leading to leakage into the soft tissues. Infection is extremely rare.

This photo shows the inferior vena cava of a patient with bilateral IO line insertions (black bubble at the top of the round IVC).

During transport, one line was inadvertently disconnected and probably entrained some air. There was no adverse clinical effect, but if the problem is not recognized and the line is not closed properly, there could be.

Bottom line: Treat an IO line as carefully as you would a regular IV. You can give anything through it that can be given via a regular IV: crystalloid, blood, drugs. And even air, so be careful!

Complications

Top 10 Worst Complications: #1 Nasocerebral Tube

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Minor complications from nasogastric tube insertion occur relatively frequently. Emesis is fairly common when the gag reflex is stimulated by the tube in the back of the oropharynx. An infrequent but possibly fatal one is insertion through the cribriform plate. 

The cribriform plate is located directly posterior to the nares and is part of the ethmoid bone. It is very porous in nature and weaker than the surrounding portions of the ethmoid. It is easily fractured, and can be seen is association with basilar skull fractures. This is one source for rhinorrhea in patients with these fractures.

Cribriform fracture is a contraindication to unprotected insertion of a nasogastric tube. If you look at the sagittal section below, the plate lies directly behind the nares. When inserting the NG tube, we are usually taught to aim the tube straight back. Unfortunately, this aims it directly at the cribriform. If a fracture is present, it is possible that you may be inserting a nasocerebral tube!

Cribriform plate - sagittal section

The usual symptoms when this occurs consist of immediate neurologic deterioration to coma, and a unilateral or bilateral blown pupil. The tube must not be withdrawn, because it will cause significant injury to the base of the brain. A stat neurosurgical consultation must be obtained, and if the patient is salvageable, the tube must be withdrawn through a craniectomy.

To avoid this dreaded complication, identify patients at risk for cribriform injury. They are:

  • patients with signs of trauma from eyebrows to zygoma
  • comatose patients
  • patients with signs of basilar skull fracture (Battle’s sign, raccoon eyes, oto- or rhinorrhea)

If your patient is at risk, follow these guidelines:

  • first, does the patient really need a gastric tube?
  • if comatose, insert an orogastric tube
  • if awake, don’t put the tube in their mouth, as they will gag continuously. Instead, place a lubricated, curved nasal airway. Then lube up a slightly smaller Salem sump tube and pass it through the airway.
Complications

Complications After Single-Look Laparotomy

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Damage control laparotomy (DCL) has been around now for over 25 years. Many, many papers have been written on its benefits, and the decreased mortality for abdominal trauma specifically. In fact, its use has been generalized to trauma for all other body cavities as well.

However, with this improved mortality came an increase in complications. Incisional hernias remain common, as do episodes of delayed small bowel obstruction. Much of the emphasis in traumatic damage control surgery has now shifted to finding ways to close wounds more quickly and reduce the overall complication rate.

In contrast to damage control laparotomy, much less is known about the potential complications associated with the single-look trauma laparotomy.

This procedure is carried out more frequently than DCL, but we have spent less time studying outcomes and risk factors for complications in this group of patients.

The surgery group at Scripps Mercy Hospital in San Diego conducted a statewide retrospective review of a hospital discharge database of adult trauma patients over an eight-year period. Patients with multiple laparotomies were excluded, as it was assumed that these were damage control patients.

The primary outcomes studied were surgical complications, including bowel obstruction, hernia, fistula, wound infection or dehiscence, and evisceration. Complications were recorded during the initial admission, and during any readmissions in the study period.

Here are the factoids:

  • Over 3700 patients were identified as undergoing trauma laparotomy during the study period
  • About 2100 were left for review after excluding those with multiple laparotomies (DCL) or an unclear trauma mechanism
  • 80% of patients were male and 60% had a penetrating mechanism
  • One third of patients were readmitted for a surgery-related complication: SBO 18%, hernia 12%, infection 9%
  • Median time to readmission was about 4 months (range 1 week to 1.5 years)
  • Patients with blunt injury tended to present with complications earlier (6 days) than penetrating injuries (6 weeks)

Bottom line: This paper is unique in that it is one of the few that was able to follow a large patient population for complications occurring both during and after the initial admission. The overall complication rate was surprisingly high (33%), which is similar to that seen after emergency surgery.

Knowing all of this, what should we do? To date, we have not come close to solving the problems of postop adhesive small bowel obstruction, wound infection, and incisional hernia in any surgical population. However, this work points out the importance of counseling our patients about the potential for complications, how to recognize them, and when to present for evaluation and treatment.

Reference: Outcomes after single-look trauma laparotomy: A large population-based study. J Trauma 86(4):565-572, 2019.

Complications, Resuscitation

Are Transfusing Too Much Blood During The MTP?

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The activation of the massive transfusion protocol (MTP) for hypotension is commonplace. The MTP provides rapid access to large volumes of blood products with a simple order. Trauma centers each design their own protocol, which usually includes four to six units of PRBC per MTP “pack.”

This rapid delivery system, coupled with rapid infusion systems, allows the delivery of large volumes of blood and other blood products very quickly. But could it be that this system is too slick, and we are a bit too zealous, and could even possibly transfuse too much blood?

The trauma group at Cedars-Sinai in Los Angeles retrospectively reviewed their own experience via registry data with their MTP over a 2.5 year period for evidence of overtransfusion. All patients who received blood via the MTP were included. Patients who had a continuous MTP > 24 hours long, those who died within 24 hours, and those who had a missing post-resuscitation hemoglobin (Hgb) were excluded.

The authors arbitrarily defined overtransfusion as a Hgb > 11 at 24 hours. They also compared the Hgb at the end of the MTP and upon discharge with this threshold. They chose this Hgb value because it allows for some clinical uncertainty in interpreting the various endpoints to resuscitation.

Here are the factoids:

  • 240 patients underwent MTP during the study period, but 100 were excluded using the criteria above, leaving 140 study patients
  • Average injury severity was high (24) and 38% suffered penetrating injury
  • Median admission Hgb was 12.6
  • At the conclusion of the MTP, 71% were overtransfused using the study definition, 44% met criteria 24 hours after admission, and 30% did at time of discharge
  • Overtransfused patients were more likely to have a penetrating mechanism, lower initial base excess, and lower ISS (median 19)

The authors concluded that overtransfusion is more common than we think. This may lead to overutilization of blood products, which has become much more problematic during the COVID epidemic. They recommend that trauma centers track this metric and consider it as a quality of care measurement.

Bottom line: This is a nicely crafted and well-written study. It asks a simple question and answers it with a clear design and analysis. The authors critique their own work, offering a comprehensive list of limitations and a solid rationale for their assumptions and conclusions. They also offer a good explanation for their choice of Hgb threshold in defining overtransfusion.

I agree that overtranfusion truly does occur, and I have seen it many times first-hand. The most common reason is the lack of well-defined and reliable resuscitation endpoints. How do we know when to stop? What should we use? Blood pressure? Base excess? TEG or ROTEM values? There are many other possibilities, but none seem reliable enough to use in every patient. 

Patients with penetrating injury proceeding quickly to OR more commonly experience overtransfusion. This may be due to the reflexive administration of everything in each cooler and the sheer speed with which our rapid infuser technology can deliver products. The more product in the cooler, the more that is given, which may lead to the overtranfused condition. 

The authors suggest reviewing the makeup of the individual MTP packs, and this makes sense. Are there too many in it? This could be a contributing factor to overtransfusion. It might be an interesting exercise to do a quick registry review at your own center to obtain a count of the number of MTP patients with a final Hgb > 11. If you find that your numbers are high, consider reducing the number of red cell packs in the cooler to just four. But if you already only include four, don’t reduce it any further. And in any case, critically review the clinical indicators your  surgeons use to decide to end the MTP to see if, as a group, they can settle on one to use consistently. 

Reference: Overtransfusion of packed red blood cells during massive transfusion activation: a potential quality metric for trauma resuscitation. Trauma Surg Acute Care Open 7:e000896., July 26 2022.