Tag Archives: spleen

Use Of A Solid Organ Injury Protocol For Pediatrics

Kids are frequent flyers when it comes to abdominal injury, with about 15% of their injuries involving this anatomic area. Solid organ injuries, mainly the liver and spleen, are the most prevalent ones. The American Pediatric Surgical Association (APSA) published a practice guideline way back in 2000 that outlined a consistent way to care for children with solid organ injuries.

Unfortunately, they were very conservative, recommending days of bedrest, extended NPO status, very frequent blood draws, and a lengthy hospital stay. Many hospitals, including mine, developed less conservative management routines, noting that children nearly always tolerate liver and spleen injury better than adults.

The trauma group at Vanderbilt modified the APSA guidelines and, more recently, made additional changes based on a new algorithm released by the organization. This new guideline moved away from organ injury grade-based factors and embraced hemodynamic status as the overall guide to care. The Vanderbilt group performed a retrospective study comparing hospital and ICU length of stay, patient costs, readmission, and death rates using the two guidelines.

Under the old protocol, grade I-III injuries were admitted to a floor bed and higher grades to an ICU at the discretion of the surgeon. The minimum hospital stay was, at minimum, the organ injury grade. Children were kept NPO overnight and placed on bed rest for nearly one day per injury grade.

With the new protocol, children were admitted to the floor if their vital signs normalized after volume resuscitation.  Hematocrit was obtained on admission and possibly again after 6 hours, then only repeated if < 21 or a change in vitals was noted. There were no diet or activity restrictions. Children with abnormal vital signs after volume were admitted to the ICU and kept on bed rest until they normalized. Labs were drawn regularly. Length of stay was based on meeting pain control, diet, and activity goals.

Here are the factoids:

  • There were 176 children (age < 18) enrolled in the old protocol during a four-year period and 170 in the new protocol over 3.5 years
  • Both groups were similar demographically and in injury grade and ISS
  • ICU length of stay was “significantly” shorter under the new protocol (.54 vs .78 days)
  • Hospital length of stay was also “significantly” shorter (2.9 vs 3.5 days)
  • Inflation-adjusted costs were slightly higher under the new protocol ($68,042 vs $65,437) even though the authors claim the opposite in the abstract once injury grade and ISS are factored in
  • Survival was the same at 99.4%
  • Readmission rates were significantly higher under the new protocol (7.1% vs 2.3%)

The authors’ conclusions parroted these results and recommended larger studies to detail any cost advantage and identify the cause for the difference in readmission rates.

Bottom line: This study leaves a lot to be desired. The authors’ definition of “pediatric” is age < 18. As we all know, there is a big difference in “kids” who are pre- vs post-puberty. The good news is that the mean and median ages are about 11 in the study, so there should be fewer older “kids” to cause interference.

The authors reported hazard ratios for the lengths of stay, which were statistically significantly different. However, their clinical significance is in doubt. A difference of 6 ICU hours? Or two-thirds of a hospital day? I’m not impressed. 

Cost differences are basically a wash, and a deep read of the paper shows that many kids did not have an isolated solid organ injury. Non-abdominal injuries could have an Abbreviated Injury Scale score of up to 3. It is easy to imagine that these could impact both length of stay and cost.  

Finally, the readmission rates include many problems related to non-abdominal injuries, including the thorax, soft tissues, and even an epidural hematoma. After excluding these non-abdominal complications, the numbers for both protocols are so low it’s hard to believe that a good significance test can be performed.

The authors’ conclusions are correct: more work needs to be done. This paper doesn’t really teach us much since all the conclusions are extremely weak. A much better, prospective, multicenter trial should be performed. Unfortunately, getting buy-in from multiple centers/surgeons to use the same protocol in children is hard.

But with all that being said, there is no reason you can’t adopt something similar to the new protocol at your center. My own experience has shown that a more aggressive guideline gets kids home sooner and healthier and that there is no difference in readmission rates. I just need a bunch of other surgeons to duplicate these results and write them up!

Reference: A Protocol Driven Approach to Reduce Lengths of Stay for Pediatric Blunt Liver and Spleen Injury Patients. Journal of Trauma and Acute Care Surgery ():10.1097/TA.0000000000004259, January 26, 2024. | DOI: 10.1097/TA.0000000000004259 

New EAST Practice Guideline: Spleen Vaccines After Angioembolization

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.

The End Of Serial Hemoglobin/Hematocrit In Solid Organ Injury

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.

 

Leukocytosis After Splenic Injury

Any trauma professional who has dealt with spleen injuries knows that the white blood cell (WBC) count rises afterwards. And unfortunately, this elevation can be confusing if the patient is at risk for developing inflammatory or infectious processes that might be monitored using the WBC count.

Is there any rhyme or reason to how high WBCs will rise after injury? What about after splenectomy or IR embolization? An abstract is being presented at the Clinical Congress of the American College of Surgeons next month that examines this phenomenon.

This retrospective study looked at a convenience sample of 75 patients, distributed between patients who had splenic injury that was either not treated, removed (splenectomy), or embolized. Data points were accumulated over 45 days.

Here are the factoids:

  • 20 patients underwent splenectomy, 22 were embolized, and 33 were observed and not otherwise treated
  • Injury severity score was essentially identical in all groups (19)
  • Splenectomy caused the highest WBC counts at the 30 day mark (17.4K)
  • Embolized patients had mildly elevated WBC levels (13.1K) that were just above the normal range at 30 days
  • Observed patients had high normal WBC values (11.0K) after 30 days
  • Values in observed and embolized patients normalized to about 7K after 30 days; splenectomy patient WBC count remained mildly elevated at 14.1K.
  • The authors concluded that embolization does not result in permanent loss of splenic function (bad conclusion, rookie mistake!)

Bottom line: This study is interesting because it gives us a glimpse of the time course of leukocytosis in patients with injured spleens. If you need to follow the WBC for other reasons, if gives a little insight into what might be attributable to the spleen. Splenectomy generally results in a chronically elevated WBC count, which tends to vary in the mid-teens range. Embolization (in this study) transiently elevates the WBC count, but it then drops back to normal.

The big problem with this study (besides it being small) is that it fails to recognize that there are many different shades of embolization. Splenic artery? Superselective? Selective? I suspect that the WBC count in main splenic artery embolization may behave much like splenectomy in terms of leukocytosis. And the conclusion about splenic function being related to WBC count was pulled out of a hat. Don’t believe it.

Reference: Leukocytosis after Splenic Injury: A Comparison of Splenectomy, Embolization, and Observation. American College of Surgeons Scientific Forum Abstracts pg S164, 2015.

Best Of AAST 2022 #6: The “Missed” Splenic Pseudoaneurysm

Like so many things in trauma, there are two camps when it comes to repeat CT scan after solid organ injury: the believers vs the non-believers. In my experience, a minority of US trauma centers incorporate this repeat CT study in their practice guidelines. 

Yet the question keeps coming up in the literature. Earlier this year, I reviewed a paper from the University of Cincinnati from a group of believers. I was not very kind, and you can read the review here. The biggest problem with most believer papers is that they cite very old literature that overstates the incidence of delayed hemorrhage. They then use this to justify an extra CT scan to find more of these “dangerous” pseudoaneurysms. Unfortunately, those old papers are just not very good and many overstate the problem.

So let’s look at this year’s abstract from the LAC+USC group. They open by stating that the natural history is unclear but that “risk for spontaneous rupture and exsanguination exist.” The authors sought to further define the utility of using a delayed CT angiogram (dCTA) in diagnosing and triggering intervention after high-grade blunt solid organ injury.

They performed a retrospective study of all patients arriving at their Level I center over a nearly five year period with a Grade 3 or higher injury to liver, spleen, or kidney. They excluded the young, patients transferred in, early deaths, and patients who underwent immediate operation on their spleen or kidney. The primary outcome was intervention triggered by the dCTA.

Here are the factoids:

  • A total of 349 patients with 395 high grade solid organ injuries were analyzed (42% liver, 30% spleen, 28% kidney)
  • Median injury grade for each organ was 3
  • Initial management was “typically” nonoperative or angioembolization (liver 83%, spleen 95%, kidney 89%)
  • Delayed CT angiogram was typically performed on day 4 and identified a lesion in 16 spleen, 10 liver, and 6 renal injuries
  • The dCTA prompted an intervention in 12 spleen, 8 liver, and 5 kidney injuries

The authors conclude that delayed CTA identified a significant number of vascular lesions requiring endovascular or surgical intervention. They recommend further examination and consideration of universal screening to avoid missing these pesky pseudoaneurysms.

Bottom line: Once again, we have a paper that conflates finding a pseudoaneurysm with the need to get rid of it. Granted, I was always taught that pseudoaneurysms (in adults) found on initial CT required an intervention. In the old days of “delayed splenic rupture” a pseudoaneurysm was the likely culprit. 

But the majority of centers do not go looking for pseudoaneurysms days later. And there are precious few patients coming back with delayed hemorrhage after discharge. So what gives?

Could it be that there is a difference between a “fresh” pseudoaneurysm and a “delayed” one? Perhaps the fresh ones portend a real risk of bleeding, but delayed ones are just a normal part of the healing process and rarely bleed? We just don’t know for sure.

This paper shows that if you look for a delayed pseudoaneurysm you will find them. And at this center, if you find them you will be compelled to angioembolize or even operate on them. Yet we really don’t know if that is necessary. It certainly adds to length of stay and hospital charges.

My take is that we desperately need a broad tally of patients discharged with a liver or spleen injury who return within a few weeks for bleeding complications. I would exclude kidneys because they act so differently. And I would not look at all returns because most liver injury readmissions are for bile problems. Just focus on readmissions for bleeding. Once we see what the real incidence is, we can decide whether these pseudoaneurysms are a problem significant enough to pursue with delayed scans, etc.

Here are my questions for the authors and presenter:

  1. What is your assessment of the incidence of delayed rupture and exsanguination? Have you read through the old papers in detail to assure yourselves that they are actually correct?
  2. Do you hold patients in the hospital for their delayed CT angiogram? The studies were typically performed on days 3-7. Do you really keep your solid organ injured patients in the hospital that long? At our center, a grade 3 injury could be discharged home in two days!
  3. How do you decide to take a patient to interventional radiology or the OR after the delayed CT? Is it an unwritten rule? It seemed like most, but not all, had some type of intervention. A (very) few had the lesion but nothing was done. Please explain the difference.

This is an interesting paper just because of the intuitive leap it makes from pseudoaneurysm to intervention. I’m anticipating your presentation so I can hear all the details.

Reference: PSEUDOANEURYSMS AFTER HIGH GRADE BLUNT SOLID ORGAN INJURY AND THE UTILITY OF DELAYED CT ANGIOGRAPHY. Plenary paper #34, AAST 2022.