Tag Archives: Practice guideline

Death Knell For The IVC Filter

March 28, 2024 The Trauma Pro Leave a comment

IVC filter insertion has been one of the available tools for preventing pulmonary embolism for decades—or so we thought. Its popularity has swung back and forth over the years and has been in the waning stage for quite some time now. This pendulum-like motion offers an opportunity to study effectiveness when coupled with some of the large datasets that are now available to us.

IVC filters have been used in two ways: prophylactically in patients at high risk for pulmonary embolism (PE) who cannot be anticoagulated for some reason and therapeutically once a patient has already suffered one. Over the years, guidelines have changed and have frequently been in conflict. Currently, the American College of Chest Physicians does not recommend IVC filters in trauma patients, and the Eastern Association for the Surgery of Trauma just released a new practice guideline for them.

A previous study from Boston University reviewed its own experience retrospectively over a 9-year period. This cohort study looked at patients with and without filters, matching them for age, sex, race, and injury severity. The authors specifically looked at mortality and used four study periods during the 9-year interval.

Here are the factoids:

Over 18,000 patients were admitted during the study period, resulting in 451 with an IVC filter inserted and 1343 matched controls
The patients were followed for an average of 4 years after hospitalization
Mortality was identical between patients with filters vs the matched controls

dvt-study

There was still no difference in mortality, even if the patients with the filter had DVT or PE present when it was inserted
Only 8% ever had their “removable” filter removed (!)

And now, there is a paper in press from the Eastern Association for the Surgery of Trauma with their newest practice guideline on IVC filters. They examined the literature on patients with or at risk for venous thromboembolism (VTE) and sought to determine whether IVC filters should be used prophylactically or therapeutically in these situations. They reviewed twenty-one studies, most of which were of the usual low quality. They drew the following conclusions:

IVC filters should not be placed routinely for prophylaxis in patients without DVT who cannot receive chemoprophylaxis.
EAST conditionally recommends that IVC filters not be placed in patients with DVT who cannot receive prophylaxis. This recommendation was conditional due to the very poor quality of the few papers available to answer this question.

Bottom line: It looks like the end is near for the IVC filter. However, I can still foresee a few situations where there might be some utility. Consider the case where a patient has DVT, cannot be anticoagulated, and is showering emboli to the lungs. Otherwise, it appears that this device is on its last legs!

References:

Association Between Inferior Vena Cava Filter Insertion
in Trauma Patients and In-Hospital and Overall Mortality. JAMA Surg, online ahead of print, September 28, 2016.
Role of Vena Cava Filter in the Prophylaxis and Treatment of Venous Thromboembolism in Injured Adult Patients: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery, Publish Ahead of Print DOI: 10.1097/TA.0000000000004289, 2024.

Guidelines

EAST Practice Management Guideline: Handoffs And Transitions Of Care

March 8, 2024 The Trauma Pro Leave a comment

Medicine, in general, and trauma care, specifically, require frequent communication. These communications may be between two providers to maintain continuity of care or between providers and patients to explain it. Unfortunately, the Joint Commission has identified breakdowns in the process as a root cause of preventable events and a significant factor in preventable death.

To address this problem, many centers have sought to standardize this process, which may include some of the principles in my previous post. However, until now, there have been no evidence-based recommendations for this practice.

The Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of the literature to develop a practice guideline. They focused specifically on handoffs for acute care surgery during perioperative interactions, patients arriving in the trauma bay, and patients transitioning to or from the ICU and floor. The goal was to reduce complications, handoff errors, medical errors, and preventable events.

The literature on this topic was searched from 1960 to 2021, and only observational and randomized studies were included. This yielded only ten papers that met all search criteria. The reviewers then used these papers to answer three questions. These and their answers are outlined below.

Question 1. Should perioperative interactions in the care of ACS patients (P) include a standardized handoff versus current process without a standardized handoff to help reduce clinical complications, handoff errors, medical errors, and preventable adverse events?

Patients who received a standardized handoff were significantly less likely to experience a handoff error. However, the impact on medical errors and adverse events could not be gauged because only one paper covered these problems.

Question 2. Should EMS utilize a standardized handoff at the arrival of trauma patients versus the current process without a standardized handoff to help reduce clinical complications, handoff errors, medical errors, and preventable adverse events?

We instituted a trauma team EMS timeout process in 2012, which persists to this day. Please take a look at my post here. The prehospital providers like it because they feel like they are more a part of the team. The receiving team can listen to their report without distraction. But what does the literature say? Unfortunately, we don’t know yet. Only one published paper covered this topic, and it included only 18 patients. Thus, no conclusions can be drawn.

Question 3. Should intra/inter floor and ICU interactions in the care of ACS patients include a standardized handoff versus currently process without a standardized handoff to help reduce clinical complications, handoff errors, medical errors, and preventable adverse events?

Significantly fewer preventable adverse events occurred when a standardized handoff was used. There was no difference in clinical complications. The impact on medical errors could not be evaluated because only one study assessed this.

Bottom line: The general belief is that using a standardized handoff is a good thing. But I think you see the theme here. As in most EAST systematic reviews, there is painfully little high-quality data available for us to prove it. Most of the mundane, day-to-day things we do and decisions we make as trauma professionals are too dull to perform a study about.

From the few papers available for this guideline, standardized handoffs are a good thing. They decrease handoff errors and reduce preventable adverse events as well. The EMS to trauma team handoff is well-received and is subjectively valuable. Unfortunately, there is little real data to prove this.

Overall, the real data on this topic is weak, and much more work needs to be done. I would encourage all trauma professionals to develop and refine their handoff processes. I strongly recommend coupling that with your own study so you can teach the rest of us how good it really can be.

Reference: Handoffs and Transitions of Care: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma, Publish Ahead of Print
DOI: 10.1097/TA.0000000000004285

Practice guidelines, Solid organ

New EAST Practice Guideline: Spleen Vaccines After Angioembolization

August 25, 2023 The Trauma Pro Leave a comment

I am trying to figure out how I missed it! The Eastern Association for the Surgery of Trauma (EAST) snuck a new practice management guideline into the Injury journal last fall. And it desperately tries to answer a question that has been hanging around for several years. Do we vaccinate spleen injury patients who undergo angioembolization or not?

I’ve been pondering this for some time and have reached my own conclusion based on some very old literature. Decades ago, we figured out that removing the spleen significantly affects immune function. Splenectomy patients are known to be more susceptible to encapsulated bacteria like Neisseria meningiditis, Streptococcus pneumoniae, and Haemophilus influenzae. Most trauma centers routinely vaccinate these patients before they are discharged home.

With the more recent emphasis on splenic salvage and nonoperative management of injury to this organ, angioembolization has become commonplace. This technique can be done in two ways: proximal and distal. Proximal embolization blocks the splenic artery, so there is no further blood flow to the spleen through it. Distal embolization (selective or super-selective) strives to block flow to very specific areas of the organ.

Do we need to give the vaccines if we cut off blood flow to pieces of the spleen or the main splenic artery? Based on my appreciation of very old splenectomy and partial splenectomy papers, it looked like we should in some cases. One report showed that splenic protection from encapsulated bacteria required about 50% of the spleen to be present and perfused by the splenic artery. This caveat stems from a time when we would perform a trauma splenectomy, dice the spleen up on the back table, and then implant a bunch of spleen cubes into the mesentery to try to provide some immune protection. Turns out that the pieces lived but didn’t do a damn thing.

My practice, then, has been to look at the fluoro images and estimate how much of the spleen was left. I would order the vaccines if a main splenic artery embolization (proximal) was performed. If a distal embolization were performed, I would eyeball the amount of devascularized spleen and give the vaccines if it looked like more than half was dark. Not very precise, I know.

But what would EAST say? They tried to perform a systematic review and meta-analysis of studies that compared outcomes in splenectomy vs. angioembolization patients. Unfortunately, there isn’t a lot of research material out there. So they settled on looking at papers that analyzed immune function, typically using B-cells, T-cells, and antibodies. The authors performed two comparisons: angioembolization vs. splenectomy and angioembolization vs. control.

Angioembolization vs. Splenectomy

These papers compared embolization patients who may or may not have spleen function to splenectomy patients who definitely have none. Embolization patients had fewer infectious complications during their hospital stay and better immune function using the indirect methods noted above. Unfortunately, the data quality was poor, with a significant risk of bias. There was no stratification of proximal vs. distal embolization. Nevertheless, this suggests that, at least overall, the embolization patients retained immune function.

Angioembolization vs. Controls

What about comparing embolization patients to spleen-injured patients who did not undergo any procedure? They should have normal function. Again, the quality of the very few papers available was low. But overall, there was no difference in immune function between the groups.

Bottom line: The EAST review team conditionally recommended against routine spleen vaccines after angioembolization for spleen injury. They concluded that immune function was maintained, so it should not be necessary.

What, you ask, about patients with proximal splenic embolization? The reality is that this only stops inflow from the splenic artery, and only for a few days or weeks. It may slowly resume over time. And it does nothing to the inflow from the short gastric arteries. Apparently, this is enough to provide immune protection against infection.

Whether this is actually true is open to debate. We have no idea if the numbers of T- and B-cells seen and the antibody titers are actually enough to avoid overwhelming post-splenectomy sepsis. And unfortunately, this condition is so rare that we will never accumulate enough cases to make a definitive statement.

But for now, it is probably okay to forgo the vaccines in patients undergoing angioembolization. Besides, the differing guidelines on which vaccines to use, when to give them, and when to schedule boosters were getting way out of hand! Please keep it simple!

Reference: Vaccination after spleen embolization: a practice management guideline from the Eastern Association for the Surgery of Trauma. Injury 53:3569-3574, 2022.

Complications

NSAIDs And Fracture Healing Revisited – Yet Again!

March 29, 2023 The Trauma Pro Leave a comment

I’ve written so many posts about the use of non-steroidal anti-inflammatory drugs (NSAIDs) it’s practically getting old. To summarize, some old animal studies suggested that using NSAIDs during fracture healing could impair the process. However, human studies were not so convincing.

Over the years, there has been quite a bit of conflicting evidence. This generally means the association between healing and NSAID use is weak. However, after this period of time, we should have become aware of a significant cause/effect relationship.

The Eastern Association for the Surgery of Trauma recently released a practice management guideline regarding the use of NSAIDs for the treatment of acute pain after orthopedic trauma. They used a standard methodology to identify and analyze published research. They focused on human studies specifically relating to this drug class’s use in fractures. The group ultimately identified 19 pertinent research papers for analysis, 10 of which were prospective, randomized studies.

Here are the three questions they asked, with their answers:

Should NSAIDs be used in analgesic regimens for adult patients
(≥18 years old) with traumatic fracture versus routine analgesic
regimens that do not include NSAIDs to improve analgesia and
reduce opioid use without increases in non-union and acute kidney
injury rates? Although the quality of the studies for this question was low, EAST conditionally recommended using NSAIDs in pain control regimens. In the higher-quality studies in this group, there was no increased risk of non-union.
Should ketorolac be used in analgesic regimens for adult patients with traumatic fracture versus routine analgesic regimens that do not include ketorolac to improve analgesia and reduce opioid use without increasing non-union
rates? This is the same question asked above, but with a specific drug rather than the class in general. The answer was basically the same.
Should selective NSAIDs (COX-2 inhibitors) be used in analgesic
regimens for adult patients (≥18 years old) with traumatic fracture versus routine analgesic regimens that include non-selective NSAIDs to improve analgesia and reduce opioid use without increasing non-union rates? COX-2 inhibitors are a subset of NSAIDs that are more selective in their action, blocking only the COX-2 receptor. Several years ago, there was a scandal regarding the COX-2 inhibitor rofecoxib (Vioxx). These selective drugs tended to have a higher incidence of cardiac complications. The manufacturer covered up this fact for several years, resulting in many unneeded deaths before it was removed from the market. The only COX-2 inhibitor available in the US is celecoxib. Only a few studies were performed using this drug during bone healing. There were not enough to make a recommendation.

Bottom line: EAST made conditional recommendations for using NSAIDs in general and ketorolac specifically in adults with fractures. “Conditional” only means that the authors did not have a consensus. Some voted to strongly recommend, and the remainder to conditionally recommend. There were no votes to recommend against their use.

The use of NSAIDs should complement a well-thought-out opioid regimen, which should also be combined with other non-narcotic medications and appropriate mobilization and therapy.

Reference: Efficacy and safety of non-steroidal anti-inflammatory
drugs (NSAIDs) for the treatment of acute pain after orthopedic trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma and the Orthopedic Trauma Association. Trauma Surg Acute Care Open. 2023 Feb 21;8(1):e001056. doi: 10.1136/tsaco-2022-001056. PMID: 36844371; PMCID: PMC9945020.

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