Tag Archives: Solid organ injury

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.

Bedrest After Pediatric Liver/Spleen Injury? Really?

A set of guidelines for management of blunt solid organ injury in children developed by the American Pediatric Surgical Association was originally published in 1999. One of the elements of the guideline was to place the child on bedrest for a period of time after the injury. Arbitrarily, this period was defined as the injury grade plus one day. So for a grade 3 spleen injury, the child would have to stay in bed for 4 days (!).

A paper published in 2013 looked at the impact of shortening this time interval. Over a 6 year period, all pediatric liver and spleen injuries from blunt trauma were identified and an abbreviated bedrest protocol was implemented. For low grade injuries (grade 1-2), children were kept in bed for 1 day, and for higher grade injuries this was extended to 2 days.

Here are the factoids:

  • 249 patients were enrolled (about 40 per year) with an average age of 10. “Bedrest was applicable for 199 patients, 80%.” Huh? Does that mean that 50 patients were excluded due to surgeon preference?
  • The organ injured was about 50:50 for spleen vs liver. Twelve children injured both.
  • Mean injury grade was 2.7, which is fairly high
  • Mean bedrest was 1.6 days, and mean hospital stay was 2.5
  • Bedrest was the limiting factor for hospital stay in 62% of cases
  • There were no delayed complications of the injury

Bottom line: Come on! Most centers don’t keep adult patients at bedrest this long, and we learned about solid organ injury management from kids! Children almost never fail nonop management, so why treat them more restrictively than adults? And have you ever tried to keep a child at bedrest? Impossible! This study is too underpowered to give real statistically valid results, but it certainly paints a good picture of what works. We recently updated our adult and pediatric protocols to eliminate bedrest and npo status. Let’s get rid of these anachronisms once and for all!

Reference: Follow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Ped Surg 48(12):2437-2441, 2013.

Updated Solid Organ Injury Protocol

Over the past several days, I’ve been writing about updates to our solid organ injury protocol. It eliminates orders for bed rest and NPO diet status afterwards. After looking at our experience over the years, the number of early failures is practically zero. So how many days do you need to keep a patient in bed to make sure they have an empty stomach when they need to be whisked away to the OR. And does walking around really make your injured spleen fall apart?

The answers are none and no. So we’ve updated our protocol at Regions Hospital to reflect this. Feel free to download and modify to your heart’s content. If you want a copy of the Microsoft Publisher file, just email me!

Download the protocol here!

Bedrest After Pediatric Liver/Spleen Injury? Really?

A set of guidelines for management of blunt solid organ injury in children developed by the American Pediatric Surgical Association was originally published in 1999. One of the elements of the guideline was to place the child on bedrest for a period of time after the injury. Arbitrarily, this period was defined as the injury grade plus one day. So for a grade 3 spleen injury, the child would have to stay in bed for 4 days (!).

Recent work looked at the impact of shortening this time interval. Over a 6 year period, all pediatric liver and spleen injuries from blunt trauma were identified and an abbreviated bedrest protocol was implemented. For low grade injuries (grade 1-2), children were kept in bed for 1 day, and for higher grade injuries this was extended to 2 days.

Here are the factoids:

  • 249 patients were enrolled (about 40 per year) with an average age of 10. “Bedrest was applicable for 199 patients, 80%.” Huh? Does that mean that 50 patients were excluded due to surgeon preference?
  • The organ injured was about 50:50 for spleen vs liver. Twelve children injured both.
  • Mean injury grade was 2.7, which is fairly high
  • Mean bedrest was 1.6 days, and mean hospital stay was 2.5
  • Bedrest was the limiting factor for hospital stay in 62% of cases
  • There were no delayed complications of the injury

Bottom line: Come on! Most centers don’t keep adult patients at bedrest this long, and we learned about solid organ injury management from kids! Children almost never fail nonop management, so why treat them more restrictively than adults? And have you ever tried to keep a child at bedrest? Impossible! This study is too underpowered to give real statistically valid results, but it certainly paints a good picture of what works. We’ve been keeping both adults and children at bedrest only overnight, and our average length of stay for isolated solid organs is about 1.5 days. But really, who says that staying in bed for any period of time avoids complications? There are lots of other evil things that can happen!

Related posts:

Reference: Follow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Ped Surg 48(12):2437-2441, 2013.