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Solid organ

The End Of Serial Hemoglobin/Hematocrit In Solid Organ Injury

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Here’s the final post on my series covering serial hemoglobin testing in the management of solid organ injury.

We developed our first iteration of a solid organ injury practice guideline at Regions Hospital way back in 2002. It was borne out of the enormous degree of clinical variability I saw among my partners. We based it on what little was publicly available, including an EAST practice guideline.

Recognizing that the EAST guideline couldn’t dictate bedside care, we gathered together to meld it with our own clinical experience. We fashioned our first practice guideline later that year and tested it.  It included instructions for bedrest (only overnight), vital signs monitoring, and lab testing (on admission and once the next day).

That last bit about serial lab tests is an important one. We had seen anecdotal evidence in our patients that it wasn’t very helpful. For example, I had one patient in the ICU whose serial Hgb had just returned normal. However, a minute later they experienced a hard hypotensive episode, and I took him immediately to the OR and took out a ruptured and bleeding spleen.

I’ve written several posts on how quickly Hgb changes after hemorrhage. Unfortunately, this lab test just lags too long to be a reliable indicator of anything. A very recent study has been published by Texas Health Presbyterian in Dallas. The retrospectively reviewed patients with liver or spleen injury over five years. They examined how often serial hemoglobin determinations influenced management during the study period. Possible interventions were none, operation, angioembolization, or blood transfusion.

Here are the factoids:

  • There were 143 patients enrolled, and half had no interventions, a third had interventions within 4 hours, and the remainder (16%) had an intervention after 4 hours
  • In the early intervention group, one-third underwent laparotomy, 42% angiography, and 9% had both; 17% received transfusions based on clinical parameters alone and not lab results
  • Of the 16% that did have a later intervention (23 patients), 12 received a blood transfusion only based on a Hemoglobin value, and all but one had no further interventions. That patient had a laparotomy based on the lab test.
  • All other patients in the late intervention group went to OR or angioembolization based on hemodynamics or a change in physical exam.
  • The number of blood draws was phenomenal, with an average of 19 in the early intervention group, 17 in the delayed intervention group, and 7 in the no-intervention group

The authors concluded that serial hemoglobin measurements were not well-supported by the literature and that the decision for intervention was nearly always driven by hemodynamics or physical exam.

Bottom line: Although this study is small, the results are very clear. As we were taught in our surgical training, hemodynamics and physical exam are vital in managing solid organ injury. Unfortunately, hemoglobin is a lagging indicator, and the repeated discomfort and unnecessary cost overshadow its clinical value. This is most significant when treating pediatric patients.

Try to recall the last time you and your trauma colleagues had a patient whose need for intervention was based on a lab draw. Now take your practice guideline back to the drawing board and eliminate the serial exams!

Click here for an example of a serial Hgb-free solid organ injury practice guideline

Reference: Role of Serial Phlebotomy in the Management of Blunt
Solid Organ Injury in Adults. J Trauma Nurs 30(3), 135–141, 2023.

 

Solid organ

VTE Prophylaxis After Solid Organ Injury

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Venous thromboembolism (VTE)  is a common potential complication after traumatic injury. But typically, injury is associated with bleeding, so the trauma professional has to strike a balance between preventing bleeding and preventing clots.

Solid organ injury (liver and spleen, typically) is a common diagnosis after blunt trauma. Most trauma centers have protocols for VTE prophylaxis which apply to patients with those injuries. Older literature that I wrote about eight years divided the time frames for prophylaxis into early (within 3 days), late (greater than 3 days), and none. The authors of that article found that there was no association with untoward bleeding in the early group. And interestingly, there seemed to be less in that group. Unfortunately, the selection of the groups was biased, and the early VTE prophylaxis group had less severe injuries.

The surgery group at the Massachusetts General Hospital tried to clarify current practice by performing a deep dive into the Trauma Quality Improvement Program database. They searched the database to identify patients with “isolated” liver, spleen, kidney, and pancreas injury. They did this by excluding TBI, femur and pelvic fractures, spinal cord injury, and penetrating trauma. They also excluded patients with other other severe injuries with an abbreviated injury scale score of 3 or more.

The authors stratified patients into three groups: early VTE prophylaxis receiving the drug within 48 hours of arrival, intermediate within 48-72 hours, and late after 72 hours.

Here are the factoids:

  • A total of 3,223 patients met inclusion criteria
  • Prophylaxis was classified as early in 57%, intermediate in 22%, and late in 21%
  • About 3/4 received low molecular weight heparin and the remainder received unfractionated heparin
  • Late prophylaxis was associated with a 3x increase in both VTE and pulmonary embolism (PE)
  • Intermediate prophylaxis patient had a 2x increase in VTE but no increase in PE
  • Early prophylaxis showed a 2x increase in bleeding complications, especially in those with diabetes (?), spleen, and high-grade liver injury
  • A total of 60 of the 1,832 patients in the early group had bleeding events: 39 failed nonop mangement and were taken to OR, 8 underwent angioembolization, and 21 received blood transfusions

The authors concluded that early prophylaxis should be considered in patients who do not fall out as higher risk (spleen, high-grade liver, diabetics).

Bottom line: This retrospective study is probably as good as it’s going to get from a data quality standpoint. It’s larger than any single-institution series will ever be, although it suffers from the usual things most large database studies do. 

But it does show us strong associations with DVT and PE as the consequences of waiting to start VTE prophylaxis beyond 48 hours. The caveat is to be careful in certain patients, most notably diabetics and those with liver and spleen injuries, as they are at higher risk to develop complications leading to the OR or interventional radiology suite. 

I urge all of you to re-examine your VTE prophylaxis guideline and modify it to start your drug of choice as early as possible given the cautions for patients with spleen and high-grade liver injuries. The diabetes thing, well, that’s a mystery to me and I will wait for further confirmation to break those patients out separately.

If you are interested, you can see the Regions Hospital trauma program VTE guideline by clicking here.

References:

  • Thromboembolic prophylaxis with low-molecular-weight heparin in patients with blunt solid abdominal organ injuries undergoing nonoperative management: current practice and outcomes. J Trauma 70(1): 141-147, 2011.
  • Timing of thromboprophylaxis in patients with blunt abdominal solid organ injuries undergoing nonoperative management. J Trauma pulish ahead of print, October 12, 2020, doi: 10.1097/TA.0000000000002972
Guidelines

Solid Organ Injury Practice Guideline Updated

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Regions Hospital developed a clinical practice guideline for solid organ management in 2002-2003. It has been revised a few times over the years, as any good guideline should with the availability of new data.

I’ve just put the finishing touches on the latest revision as a result of the updated organ scaling rules published by the American Association for the Surgery of Trauma. I reviewed the new scales for both liver and spleen earlier this year (links below). In the previous iteration of the scaling system, the importance of contrast pooling (pseudoaneurysm) or extravasation beyond the organ was not well defined. 

The new guideline explicitly includes these injuries in the high grade group, which for us is grade IV or V. Technically, pseudoaneurysm of the liver is only grade III, but in my opinion demands angiographic investigation and embolism. Thus the inclusion in the high grade / angiography arm of our guideline.

For those of you who have not seen this guideline before, there are several important directives that are listed on the left side of the page:

  • Patients are NOT made NPO
  • They do NOT have activity restrictions (such as bed rest)
  • Serial hemoglins are NOT drawn
  • An abdominal CT scan is NOT repeated

These changes were made in 2015 based on our clinical experience that properly selected patients almost never fail. And they still don’t, so why starve, restrain, poke, and re-irradiate them?

Additionally, we included explicit impact activity restrictions for post-discharge so that patients would get the same message from all members of our team.

Click the image below to download the guideline and have a look. I’m interested in your comments!

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Solid organ

Update: Kidney Injury Scaling

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Over the past two days, I’ve reviewed the new AAST organ injury scaling updates for spleen and liver injuries. Today, I’ll cover the new kidney grading scale.

Liver and spleen grading is generally simple, focusing on laceration depth and subcapsular hematoma coverage to determine the exact value. However, the kidney is totally different. Although technically a solid organ, it’s got a bunch of hollow, urine-containing stuff inside. This is the main determinant of the original scaling system: collection system involvement.

Like liver and spleen, the kidney scale was updated to take advantage of CT information. But once again, bleeding identified via the CT angiogram is incorporated into the higher grades. Active bleeding contained within Gerota’s fascia is assigned a grade of III. Extravasation escaping this fascia is assigned a IV.  The other grades remain unchanged.

Here are the updated guidelines. Click the image or link below it to open a bigger image in a new window.

Click to download larger image

Links:

Solid organ

Update: Liver Injury Scaling

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In my last post, I reviewed the updated AAST organ injury scaling (OIS) for the spleen. Today, I’ll share details of the new version of liver grading.

First, the overall focus of the updated liver scale is similar to the spleen one: it incorporates a listing of criteria identified by CT scan that parallels the old anatomic criteria. The CT column contains all the old anatomic stuff, but now includes scaling for active bleeding.

The confusing part? Whereas contained active bleeding within the spleen was Grade IV and active bleeding escaping the spleen was Grade V in the updated scale, these drop down a grade in the liver. So bleeding contained with the liver parenchyma is Grade III and active extravasation escaping into the peritoneal cavity is only Grade IV. I presume this has to do with the abbreviated injury score (AIS) used to calculate ISS, and that the mortality hit from this degree of bleeding is less than that of the spleen.

The final difference between the updated scale and the original is the removal of Grade VI. This was previously described as hepatic avulsion, which is a nonsurvivable injury. The AIS for Grade VI liver used to be 6, which causes an immediate ISS calculation short circuit to 75. Which also means that survival is approximately 0%. This is not part of the OIS update, which may be due to the fact that it never occurs in anyone who makes it to a trauma center alive.

Here are the updated guidelines. Click the image or link below it to open a bigger image in a new window.

Click to download larger image

In the next post, I’ll review the new features of the kidney injury scale.