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Delayed Splenic Rupture: Part 2

Yesterday I wrote about the history of “delayed splenic rupture.” Today I’ll discuss how to deal with it.

If possible, try to avoid ever having to mess around with this clinical problem. If you order an abdominal CT after blunt trauma and see a splenic contrast blush of either type (pseudoaneurysm or extravasation, see left photo), then deal with it before the patient even knows he has a problem. A trip to interventional radiology will usually solve the problem. And if embolized, these patients almost never come back with a bleeding problem.

As I’ve said many times before, if the patient is hemodynamically compromised, then an OR visit is required. The usual solution is splenectomy. Some recommend repairing the spleen, but this is technically more difficult than it sounds, and it is difficult for the surgeon to sleep soundly after performing one of these.

Lets say you inherited one of these from someone else, or ignored the warning signs on the initial CT. The usual time frame for presentation to the ED with acute bleeding is 7 to 10 days after the initial injury. If they are not stable, physical exam or FAST will quickly direct you to the OR, once again for splenectomy. Some patients will stabilize with fluids and can safely be sent to CT scan.

Once the CT confirms what the problem is, a trip to interventional radiology is in order if the patient remains stable. Here is the key: the radiologist must embolize something! If they find a bleeding vessel, then they can selectively embolize it. If they don’t, then the main splenic artery should be embolized. This will decrease the arterial pressure head, but won’t eliminate it. It will decrease the likelihood of additional bleeding as much as possible.

At this point, the patient should be admitted to the trauma service and monitored using your solid organ injury protocol. If they have any hemodynamic issues, it’s time to remove the spleen. Remember, this is the third time they’ve had a problem, and like in baseball, their spleen is out! Attempted splenorrhaphy at this point is pointless and may lead to yet another operation.

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Delayed Splenic Rupture: Part 1

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This post was prompted by a paper that somehow got into the Journal of Trauma this month on nonoperative management of delayed splenic rupture after trauma. It’s a bad retrospective review of 15 patients which I’ll say more about tomorrow. There’s very little good literature on this topic, so I wanted to share some personal observations.

Back in the days before CT scan (and unfortunately, I remember them), the diagnosis of abdominal injury was much more difficult. It was primarily qualitative, meaning that we somehow figured out that they either had it or they didn’t. We could not very easily figure out what specific injuries a given patient had. However, management was simple: we went to the operating room, found out and fixed it.

Sometimes, though, we would encounter a patient who had been involved in some type of blunt trauma a week or two earlier who presented to the ED with left-sided abdominal pain, shock and anemia. The diagnosis was “delayed splenic rupture” and they were taken to OR for a splenectomy.

When CT scan came along, we found out that these were actually “delayed recognition of splenic injury.” We still took them to the OR for splenectomy, but with experience this slowly gave way to splenic repair, and then to nonoperative management. 

There is still one subset of these injuries that is problematic: spleen injury with a contrast blush. It turns out that there are really two types of blush: contrast seen within a pseudoaneurysm within the splenic pulp, and extravasation. And furthermore, the pseudoaneurysm is the culprit in most “delayed splenic ruptures.”

Tomorrow, I’ll write about how to recognize this potential problem, what to do about it acutely, and what to do if it was missed and the patient presents to your ED ten days later in shock.

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Reference: Nonsurgical management of delayed splenic rupture after blunt trauma. J Trauma 72(4):1019-1023, 2012.

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When to Give Spleen Vaccines After Splenectomy for Trauma

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I’ve written previously on the (f)utility of giving vaccines after splenectomy for trauma (click here to read). However, it is more or less a medicolegal standard, so pretty much everyone gives them. The big question is, when? 

Some centers give them immediately postop, some before hospital discharge, and some during their postop visit. Who is right? The argument is that major surgery produces some degree of immunocompromise. So if the vaccines are given too early, perhaps the anitbodies will not be processed as effectively, and the response to an actual bacterial challenge might not be as good.

One prospective study randomized patients to receive their pneumococcal vaccine either 1, 7, or 14 days after surgery. IgG levels were measured before vaccination and again after 4 weeks. This study found that antibody concentrations were the same in all groups. However, functional activity of the antibodies was low in the 1 and 7 day groups, and nearly normal in the 14 day group.

Following this, a rat study looked at vaccination timing followed by exposure to pneumococcus. These animals were splenectomized, then given a real or sham vaccination at 1, 7, or 42 days. They then had pneumococcus injected into their peritoneal cavity. About 70% of all rats with sham vaccination died. Only 1.5% of the vaccinated rats died, and there were no differences based on vaccination timing.

Bottom line: Neither antibody titer studies nor rat studies easily translate into recommendations for treating overwhelming post-splenectomy sepsis (OPSS) in humans. And such a study can never be done because of the rarity of this condition (less than 70 cases since the beginning of time). It really boils down to your specific population, balancing your assurance that your patient will get it against the possibility that their immune system may not react to it as much as it could. 

At our center, we give the vaccines as soon as possible postoperatively. This ensures that it is given, and erases any doubt of what might happen if the patient does not show up for their postop check.

References:

  • Immune responses of splenectomized trauma patietns to the 23-valent pneumococcal polysaccharide vaccine at 1 versus 7 versus 14 days after splenectomy. J Trauma 44(5):760-766, 1998.
  • Timing of vaccination does not affect antibody response or survival after pneumococcal challenge in splenectomized rats. J Trauma 45(4):682-697, 1998.

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    EAST Guidelines Update: Spleen Injury

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    The Eastern Association for the Surgery of Trauma is in the process of updating their trauma practice guidelines for spleen injury. The first set of guidelines was introduced in 2003, and several advances in management have occurred since. here is a summary of the current status of the guidelines:

    Level I recommendations (best quality data): 

    • none

    Level II recommendations (good data):

    • Initial management of hemodynamically stable patients should be nonoperative
    • Unstable patients should undergo immediate operation or angiographic embolization (my interpretation: unstable patients belong in the OR, not the angio suite!)
    • Patients with peritonitis should go to the operating room
    • Age, grade of injury, amount of hemoperitoneum and age are not contraindications to nonoperative management. Only hemodynamic stability matters.
    • CT of the abdomen with IV contrast is the most reliable method to assess severity of spleen injury (my interpretation: in the hemodynamically stable patient)
    • Angiography with embolization should be considered if a contrast blush is seen on CT, AAST grade > 3, moderate hemoperitoneum is present, or there is evidence of ongoing bleeding
    • Nonoperative management should only be considered if continuous monitoring and serial exams can be carried out at your hospital, and if an operating room is immediately available if needed

    Level III recommendations (weak data):

    • Clinical status should dictate need and frequency of followup imaging (my interpretation: only do it if the patient condition changes for the worse)
    • Contrast blush is not an absolute indication for operation or angio-embolization. Age, grade of injury and presence of hypotension need to be considered. (My interpretation: don’t operate or do angio on kids without a really good reason)
    • Angio is an adjunct to nonop management in patients who are at high risk for delayed bleeding or to look for vascular injuries (pseudoaneurysms) that may lead to rupture or delayed hemorrhage

    Reference: Trauma Practice Guideline Update, 24th Annual Scientic Assembly, Eastern Association for the Surgery of Trauma, January 2011.

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    Complications of Splenic Embolization for Trauma

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    Angioembolization has become a common procedure that can increase the likelihood of success for nonoperative management for splenic trauma. It does have its own set of complications to be aware of, however.

    The most obvious complication is mechanical injury to the femoral artery. This occurs in 1 to 3% of patients. It is more common in the very young (small caliber artery) and the elderly (arteries of stone). Rarely, the substance or device that is used for the embolization may migrate or end up on the wrong spot, infarcting something important.

    A common issue that occurs is infarction of portions of the spleen. This is actually the desired effect, as it stops the bleeding. Most of the time, we are unaware of the changes that take place in the spleen post-procedure. But every once in a while we get a repeat CT scan days or weeks down the road and see some very interesting things.

    The most common finding is a splenic infarct alone. This is an area of the spleen, sometimes wedge shaped, that does not take up contrast. This is normal. In some cases, gas bubbles are seen within the spleen parenchyma, usually within the infarcted area. In others, large areas of gas are present, and an air-fluid level may also be seen. This is definitely not normal.

    Tiny bubbles are normal after this procedure, and can be ignored if the patient does not appear ill and does not have any systemic evidence of inflammation or sepsis. On the other hand, big bubbles or air-fluid levels probably indicate a developing splenic abscess, and the patient will usually appear ill and have a high WBC count. Unfortunately, the only treatment for this is splenectomy. Insertion of drainage catheters does not work and the patient will only become sicker if it is attempted.