Tag Archives: Solid organ injury

Best Of EAST 2023 #10: Early VTE Prophylaxis In Adolescents With Solid Organ Injury

Chemoprophylaxis against venous thromboembolism (VTE) is routine in trauma care. In most cases, it can be initiated shortly after admission in most trauma patients. However, there are a few major exceptions, including eye injuries and brain injuries with intracranial hemorrhage.

Solid organ injury used to be cause for concern when considering prophylaxis, but most trauma centers are now comfortable beginning within 24 to 48 hours after injury. Having said that, those numbers are for adult patients. What about the younger ones?

The University of California Irvine group queried the TQIP database (3 recent years) to examine outcomes for adolescent patients (12-17 years old) given VTE prophylaxis after injury to liver, spleen, and/or kidney. They excluded patients who had TBI, anticoagulation or coagulopathy, immediate laparotomy, transfers in, and patients who died or were discharged within 48 hours. They matched patients for age, comorbidities, grade of injury, overall severity of injury, and hypotension/need for transfusion.

Eligible patients who received chemoprophylaxis early  (within 48 hours) vs. late were reviewed to identify any differences in complications, length of stay, failed non-op management, and mortality.

Here are the factoids:

  • A total of 1,022 cases were isolated from the TQIP database, and 417 adolescent cases were matched to adults
  • VTE rate was statistically the same, 0.6% in the early group vs. 1.7% in the delayed group
  • Failed non-op management was identical at 5.9% vs. 5.6%
  • There was one death in the delayed group and none in the early group (not significant)
  • ICU LOS was the same at 3-4 days
  • One item not mentioned in the body of the abstract: hospital length of stay was significantly longer in the early group: 9 days vs. 6 days

The authors concluded that early VTE prophylaxis in adolescent trauma patients did not increase failure of nonoperative management, nor did it decrease the incidence of VTE.

Bottom line: This is a study that needed to be done. Due to IRB restrictions, it is typically more challenging to perform actual studies on children and adolescents. Retrospective use of databases helps overcome this problem, although it always introduces a few unwanted wrinkles.

We frequently assume that adolescents behave physiologically like adults. Although often true, you can’t always count on it. Those of us who take care of children and young adults know that they tend to do better than adults by most measures. But again, this is an assumption and needed to be studied.

This database study was limited to three years of data and only produced 417 matched cases for study. This is a small number, and I always worry about statistical power. If the results of such a study are negative, one is left wondering if a proper power analysis was done.

One puzzling result left me wondering about the power question. Patients who received early prophylaxis had exactly the same rate of VTE as those who received it late. Adult data indicates that early use should decrease this complication. Is this another indication of a statistical power problem? Would the inclusion of more patients have shown a real difference?

The other result that struck me (and was not commented upon in the body of the abstract) was the statistically significant 50% increase in hospital length of stay for the early prophylaxis group. Is there some unknown variable that was not matched that caused it? This is one of the known pitfalls of these retrospective database studies.

Here are my questions and comments for the presenter/authors:

  • Broken record question: Did you have enough cases to provide adequate statistical power? This study showed a negative result. Did you have enough matched cases to actually be able to detect a difference if there was one? Why not add a few more years of data and recalculate?
  • How do you explain the failure of early VTE prophylaxis to protect these patients from DVT or PE? Is this also a statistical power problem?
  • Why is the hospital length of stay significantly longer in the early prophylaxis group?

This intriguing paper follows my bias toward treating these patients exactly the same as adults with early chemoprophylaxis. I just need a few of the loose ends tied up.

Reference: SIMILAR RATE OF VENOUS THROMBOEMBOLISM AND FAILURE OF NON-OPERATIVE MANAGEMENT FOR EARLY VERSUS DELAYED VTE CHEMOPROPHYLAXIS IN ADOLESCENT BLUNT SOLID ORGAN INJURIES: A PROPENSITY-MATCHED ANALYSIS. EAST 2023 Podium paper #27.

Do We Really Need To Admit Children With Low-Grade Solid Organ Injury?

Over the years, we have slowly gotten wiser about solid organ injuries (SOI). Way back when, before CT and ultrasound, if there was a suspicion a patient had such an injury you were off to the operating room. We learned (from children, I might add) that these injuries, especially the minor ones, were not such a big deal.

However, we routinely admit adults and children with solid organ injury of any grade. Many centers have streamlined their practice guidelines so that these patients don’t spend very long in the hospital, but most are still admitted. A number of researchers from Level I pediatric centers in the US got together to see if this is really necessary.

They combed through 10 years worth of TQIP data for outcomes and timing of intervention in children with low-grade (grades 1 and 2) solid organ injury age 16 or less. Children with “trivial” extra-abdominal injuries were included to make the conclusions more generalizable.  Penetrating injuries and burns were excluded, as were those with “risk of hemorrhage” or need for abdominal exploration for reasons other than the SOI. The risk of hemorrhage was defined as a pre-existing condition or other injury that made it more likely that a transfusion might be necessary for other causes.

Here are the factoids:

  • A total of 1,019 children with low-grade SOI (liver, kidney, or spleen) were enrolled in the study, and 97% were admitted
  • There was an even distribution across age groups. Many studies over-represent teenagers; this was not the case here.
  • Median LOS was 2 days, and a quarter were admitted to the ICU
  • Only 1.7% required an intervention, usually on the first hospital day (transfusion, angiography, or laparotomy)
  • Pediatric trauma centers did not perform any of the 9 angiographic procedures, and they only performed 1 laparotomy of the 4 reported

The authors concluded that practice guidelines should be developed for adult centers caring for children to decrease the number of possibly unnecessary interventions, and that it may be feasible to manage many children with low-grade SOI outside of the hospital.

Bottom line: This is an intriguing study. The admission length and silly restrictions like bed rest, NPO, and multiple lab draws are finally approaching their end. Although this paper does have the usual limitations of using a large retrospective database, it was nicely done and thoughtfully analyzed. 

It confirms that adverse events in this population are very uncommon, and that adult centers are still too aggressive in treating children like adults. The recommendation regarding practice guidelines is very poignant and this should be a high priority.

Individual centers should determine if they have the infrastructure to identify low-risk children who have reliable families and live in proximity to a hospital with a general surgeon, or better yet, near a trauma center. Hopefully this study will help accelerate the adoption of such guidelines and practices, moving treatment for many children to the outpatient setting.

Reference: Hospital-based intervention is rarely needed for children with low-grade blunt abdominal solid organ injury: An analysis of the Trauma Quality Improvement Program registry. JTrauma 91(4):590-598, 2021.

Does Time To Interventional Radiography Make a Difference In Solid Organ Injury?

Solid organ injury is one of the more common manifestations of blunt abdominal trauma. Most trauma centers have some sort of practice guideline for managing these injuries. Frequently, interventional radiology (IR) and angioembolization (AE) are part of this algorithm, especially when active bleeding is noted on CT scan.

So it makes sense that getting to IR in a timely manner would serve to stop the bleeding sooner and help the patient. But in most hospitals, interventional radiology is not in-house 24/7. Calls after hours require mobilization of a call team, which may be costly and take time.

For this reason, it is important to know if rapid access to angioembolization makes sense. Couldn’t the patient just wait until the start of business the next morning when the IR team normally arrives?

The group at the University of Arizona at Tucson tackled this problem. They performed a 4-year retrospective review of the TQIP database. They included all adult patients who underwent AE within four hours of admission. Outcome measures were 24-hour mortality, blood product usage, and in-hospital mortality.

Here are the factoids:

  • Out of over a million records in the database, only 924 met the inclusion criteria
  • Mean time to AE was 2 hours and 22 minutes, with 92% of patients getting this procedure more than an hour after arrival
  • Average 24-hour mortality was 5%. Mortality by hours to AE was as follows:
    • Within 1 hour: 2.6%
    • Within 2 hours: 3.6%
    • Within 3 hours: 4.0%
    • Within 4 hours: 8.8%
  • There was no difference in the use of blood products

The authors concluded that delayed angioembolization for solid organ injury is associated with increased mortality but no increase in blood product usage. They recommend that improving time to AE is a worthy performance improvement project.

Bottom line: This study has the usual limitations of a retrospective database review. But it is really the only way to obtain the range of data needed for the analysis. 

The results seem straightforward: early angioembolization saves lives. What puzzles me is that these patients should be bleeding from their solid organ injury. Yet longer delays did not result in the use of more blood products.

There are two possibilities for this: there are other important factors that were not accounted for, or the sample size was too small to identify a difference. As we know, there are huge variations in how clinicians choose to administer blood products. This could easily account for the apparent similarities between products given at various time intervals to AE.

My advice? Act like your patient is bleeding to death. If the CT scan indicates that they have active extravasation, they actually are. If a parenchymal pseudoaneurysm is present, they are about to. So call in your IR team immediately! Minutes count!

Reference: Angioembolization in intra-abdominal solid organ injury:
Does delay in angioembolization affect outcomes?  J Trauma 89(4):723-729, 2020.

Serial Hemoglobin / Hematocrit – Huh? Part 1

In my last post, I waxed theoretical. I discussed the potential reasons for measuring serial hemoglobin or hematocrit levels, the limitations due to the rate of change of the values, and conjectured about how often they really should be drawn.

And now, how about something more practical? How about an some actual research? One of the more common situations for ordering serial hemoglobin draws occurs in managing solid organ injury. The vast majority of the practice guidelines I’ve seen call for repeating blood draws about every six hours. The trauma group at the University of Florida in Jacksonville decided to review their experience in patients with liver and spleen injuries. Their hypothesis was that hemodynamic changes would more likely change management than would lab value changes.

They performed a retrospective review of their experience with these patients over a one year period. Patients with higher grade solid organ injury (Grades III, IV, V), either isolated or in combination with other trauma, were included. Patients on anticoagulants or anti-platelet agents, as well as those who were hemodynamically unstable and were immediately operated on, were excluded.

Here are the factoids:

  • A total of 138 patients were included, and were separated into a group who required an urgent or unplanned intervention (35), and a group who did not (103)
  • The intervention group had a higher ISS (27 vs 22), and their solid organ injury was about 1.5 grades higher
  • Initial Hgb levels were the same for the two groups (13 for intervention group vs 12)
  • The number of blood draws was the same for the two groups (10 vs 9), as was the mean decrease in Hgb (3.7 vs 3.5 gm/dl)
  • Only the grade of spleen laceration predicted the need for an urgent procedure, not the decrease in Hgb

Bottom line: This is an elegant little study that examined the utility of serial hemoglobin draws on determining more aggressive interventions in solid organ injury patients. First, recognize that this is a single-institution, retrospective study. This just makes it a bit harder to get good results. But the authors took the time to do a power analysis, to ensure enough patients were enrolled so they could detect a 20% difference in their outcomes (intervention vs no intervention). 

Basically, they found that everyone’s Hgb started out about the same and drifted downwards to the same degree. But the group that required intervention was defined by the severity of the solid organ injury, not by any change in Hgb.

I’ve been preaching this concept for more than 20 years. I remember hovering over a patient with a high-grade spleen injury in whom I had just sent off the requisite q6 hour Hgb as he became hemodynamically unstable. Once I finished the laparotomy, I had a chance to pull up that result: 11gm/dl! 

Humans bleed whole blood. It takes a finite amount of time to pull fluid out of the interstitium to “refill the tank” and dilute out the Hgb value. For this reason, hemodynamics will always trump hemoglobin levels for making decisions regarding further intervention. So why get them?

Have a look at the Regions Hospital solid organ injury protocol using the link below. It has not included serial hemoglobin levels for 18 years, which was when it was written. Take care to look at the little NO box on the left side of the page.

I’d love to hear from any of you who have also abandoned this little remnant of the past. Unfortunately, I think you are in the minority!

Click here for the Regions Hospital Solid Organ Injury Protocol

Reference: Serial hemoglobin monitoring in adult patients with blunt solid organ injury: less is more. J Trauma Acute Care Open 5:3000446, 2020.

Early Mobilization In Solid Organ Injury

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.