Tag Archives: spleen

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.

 

Abdomen, Complications

Leukocytosis After Splenic Injury

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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.

Abstracts, Solid organ

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

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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.

Abdomen, Solid organ

Surveillance For Splenic Pseudoaneurysm After Injury

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When it comes to repeat CT scanning after splenic injury, there are believers and there are non-believers. In my experience, the majority of centers in the US are non-believers. However, there is a new paper in press that attempts to convince us that more should become believers.

I think the biggest lesson to be learned from this paper is that WE SHOULD READ THE ENTIRE PAPER before drawing conclusions. I have said this in the past and I will say it again. In this case, not only did I read the entire paper, but I had to dig deep into the references it cited as well.

Nonoperative management of splenic injuries has a very high success rate if done properly. Some papers claim this can be up to 93%, which parallels my experience. This success rate involves excluding unstable patients (they need to be in the operating room) and planned use of angioembolization in select patients. Over the years we have found that we need to do less and less in the management of solid organ injury patients:

  • No bedrest
  • No starvation (NPO status)
  • No serial blood draws
  • No repeat CT scan
  • Few limitations on activity after discharge

For an example of a practice guideline that demonstrates that less is more, use the download link at the end of this post.

But back to the question about repeat CT scanning before discharge. Why do we need to do this? The usual reason is that “we want to find delayed pseudoaneurysms.” And why is that important? “It might bleed!”

Really? Let’s look into that through the lens of this new paper by the group at the University of Cincinnati. They performed a retrospective study of their experience with patients who had sustained blunt splenic injury during a recent three-year period. They were interested in how many underwent splenectomy or splenorrhaphy, who had repeat CT imaging, who went to interventional radiology (IR) and when, and which ones were found to have pseudoaneurysms and what was done about it.

Here are the factoids:

  • There were 539 patients who met inclusion criteria, with an average ISS of 24
  • Of these, 46 died during their hospital stay (none from their splenic injury)
  • Focusing on the 248 patients with higher grade injuries (III-V), 125 (50%) underwent emergent or delayed splenectomy. Early vs late operation was not broken out, but this is a startlingly high number!
  • Of the higher grade injured patients who kept their spleens, 97% underwent repeat CT around day 5
  • Delayed pseudoaneurysms were detected in the following patients:
    • Grade III: 10 of 88 patients (11%). Then 8 of those 10 went to IR, and 5  of 10 had splenectomy!
    • Grade IV: 7 of 24 (29%).  Then 8 of the 7 (error in the paper?) went to IR and 3 of 7 had splenectomy!
    • Grade V: 2 of 5 (40%). Both of these patients went to IR and somehow kept their spleens.

The authors conclude that routine followup CT imaging identifies splenic pseudoaneurysms allowing for interventions to minimize delayed complications.

Bottom line: Whoa! There’s a lot going on here. My first observation is that this center does a lot of splenectomies! Of the 539 patients (all comers) who were included in the study, 129 (24%)  lost their spleens. If grade I-II injuries are excluded that percent rises to 50%!

Only eight splenectomies were performed after the repeat CT. This would imply that there were either a lot of unstable patients with splenic injury, the institutional indications for this procedure arbitrarily include grade, or there is a lot of variability in the decision to perform it.

I think there are really two questions to answer here. 

  1. Does delayed splenic pseudoaneurysm occur? The answer is yes. There are a few studies (performed by believers) that demonstrate new pseudoaneurysms after repeat CT. I’m convinced.
  2. Do we care? The real question is, do these pseudoaneurysms cause harm? The fear is that they might explode at some point after patient discharge and cause a major problem.

Papers written by the believers cite a number of old studies and give numbers between 2% and 27% for incidence of delayed hemorrhage. Well, I tracked down all of these papers, including the ones they cited. And it doesn’t add up.

  • One paper from a believer institution found no delayed bleeds.
  • Several papers were for pediatric patients, whose spleens don’t behave like adult ones. They found one case after discharge in one out of 276 patients across three studies.
  • Of 76 adolescents, none encountered delayed bleeds

Many of the papers cited regarding bleeding complications are very old. CT scanners had less resolution, and in many papers, IR was not even a consideration. 

So here’s my take. Yes, delayed pseudoaneurysms occur. In children we don’t care. They almost never cause a problem. But in adults, they can and do cause issues and should be embolized shortly after the initial scan. 

Once embolized, the ones seen on that initial scan are effectively neutralized and do not need a repeat scan. The small ones that might pop up later may very well be part of the healing process. And they may not even occur if angioembolization is done early. It seems unlikely that anything further is needed.

But remember, clinical judgement trumps all. If your patient starts complaining of new abdominal symptoms while in the hospital or after discharge, get a prompt CT scan to rule out any developing complications.

Sample solid organ injury protocol: click here

Reference: Delayed splenic pseudoaneurysm identification with surveillance imaging. J Trauma Acute Care Surg. 2022 Mar 22. doi: 10.1097/TA.0000000000003615. Epub ahead of print. PMID: 35319540.

 

Solid organ

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

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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.