Surgical Case Conference

HENRY R. GOVEKAR, M.D. PGY-2 UNIVERSITY OF COLORADO HOSPITAL Objectives

 Introduce Patient  Hospital Course  Management of  Decisions to make  Outcome History and Physical

 50y/o M who was transferred to Denver Health on post day #3.  Patient involved in motorcycle collision in Vail; admit to local hospital.  Patient riding with female companion, tight turn, laid down the bike on road, companion landing on top of patient.  Companion suffered minor injuries including abrasions and knee pain History and Physical

 Our patient – c/o Right shoulder pain, left flank pain  PMH: GERD; peptic ulcer  PSH: hx of surgery for intractable ulcerative disease – distal gastrectomy with Billroth I, ? Of revision to Roux-en-Y gastrojejunostomy  Meds: prilosec  Social: denies tobacco; quit ETOH 13 years ago after MVC; denies IVDA  NKDA History and Physical

 Exam per OSH:  a&ox3, minor distress  HR 110’s, BP 130/70’s, on NRB mask with sats 98%  Multiple abrasions on scalp, arms , knees  c/o right arm pain, left sided flank pain  No other obvious injuries  After fluid – HD stable  Sent to CT for abd/pelvis  Post 10th rib fx  Grade 3 splenic laceration

Spleen Injury Scale Grade I Injury Grade IV injury

http://emedicine.medscape.com/article/373694-media Grade V injury

http://emedicine.medscape.com/article/373694-media What should our plan be? Management of Splenic Injuries

 Stable vs. Unstable  Unstable – OR  Stable – abd CT scan  CT scan  Other significant injury – OR  Documented  Grade I, II, III  nonoperative management  Grade III, IV  possible angio vs OR  Grade IV, V --> OR Management of Splenic Injuries

 Angiography  Best reserved for hemodynamically stable patients  Observation  Admit to ICU/floor  Repeat Hgb/Hct – Q6 hours/24 –Q12/next 24  Transfusion trigger  4 units to keep Hgb above 25  “X” many units in “X” many hours with inappropriate response Salvage Rate of Nonoperative Management Hospital Course (OSH)

• Admitted to floor • Bed rest with f/u Hgb/Hct • Hgb stable from 9.0-10.0 ranges x 1.5 days • Pain controlled with morphine PCA • On night of HD #2 – to 130’s, normotensive with BP 130/70’s – Chest pain - nonspecific – Increased 02 requirement from 2-6L with sats in the low/mid 90’s – No change in abdominal exam Hospital Course (OSH)

• Differential Diagnosis: – Pain; rib fractures – Lung collapse – Pleuritis – / – Bleeding ---- – Pulmonary embolus – Infarction – Other missed injury; bowel? • CBC - nml • Chem-7 nml • CXR - L pleural effusion • EKG - sinus tachy • troponin – • Patient sent to CT scanner for concern of pulmonary embolus

Hospital Course (OSH)

• Bilateral PE’s on CT PE • Transfer to SICU • Discussion of management of PE with grade 3 splenic laceration • Decision to start heparin gtt at 300 units/hr, no bolus --- had Hgb drop from 10.0 to 8.0 on am labs • Call to Denver Health with discussion with on-call staff for potential transfer for further management The Transfer

 Patient now on NRB  Patient with heparin gtt 300 units/hr  Patient received 2 units of PRBC with repeat Hgb 9.7 prior to transfer  Patient now in route with 2 units PRBC’s hanging Hospital Course (DH)

 On admit  T - 38.0; HR 133; BP 120/76; RR 16 95% 8L 02  Exam:  Neuro: GCS15  CV: tachy to 120’s  Pulm: coarse crackles left side, diminished bases  Abd: previous well healed incision, minimally TTP in LUQ  Ext: healing abrasions B knees, leg and arms  Significant Labs: Hgb 10.2; PTT 38 Questions to answer

 Inadequate response to 4 units Hgb  Will need anticoagulation for PE  Heparin gtt  IVC filter placement?  Continue observation?  IR for embolization?  OR for ? Previous ? Hx of abdominal surgery? Nonoperative Management of Blunt Splenic Injury: A 5-Year Experience

 Objective: examine success of NOM in institution using SAE  Method: retrospective review of CT, management, outcomes  Results: 648 patients with blunt splenic injury were admitted  280 immediate OR; HD unstable, multiple injuries  368 planned NOM  70 patients were treated with observation  CBC Q6,  repeat CT 48-72 hours  166 negative angiogram with nonop salvage of 94%  132 patients underwent embolization, nonop salvage 90%  Reason for op: falling HCT, repeat angio with continued bleeding  Complications: 3 splenic abscess; 3 coil migrations  Conclusions: SAE is a good adjunct in NOM of injuries

J Trauma; March 05; 494-498 The Effects of Splenic Artery Embolization on Nonoperative Management of Blunt Splenic Injury: A 16-Year Experience

 Incorporation of SAE into practice protocol for patients at high risk for NOM  retrospective analysis  Splenic injury grades 3 associated with higher likelihood of failure of NOM  Conclusions: SAE based on CT-defined parameters associated with ongoing bleeding was associated with significant improved success of NOM with splenic injury in HD stable patient  The following protocol was followed on arrival of patients to the ED:  If HD unstable: patients had immediate exlap  HD stable underwent abdominal CT with intravenous contrast  Prospectively defined indications for initial SAE included: contrast extravasation or pseudoaneurysm on CT; grade 3 injuries with a large hemoperitoneum; or grade 4 injuries.  The protocol also suggested that all patients with grade 5 injury should have an immediate operation.  Those who did not fulfill these criteria underwent standard NOM without SAE  88% rate of overall splenic salvage with NOM

The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 3, September 2009 Splenic artery extravasation Post-embolization Pulmonary in Trauma Population

 One study to look at asymptomatic trauma patients by helical CT scan  22/90 (24%) had asymptomatic PE’s  4 patients with major clot burden treated with anticoagulation  DVT prophylaxis:  None or mechanical only: 10/50 (20%) with PE  Pharmacologic: 12/40 (30%) with PE  Patients with PE:  Increased risk if Male, , older IVC Filters

 Indications  Failure of anticoagulation  Contraindication to anticoagulation  Trauma patients with Closed head injuries; pelvic fx’s, spinal cord injuries  Multiple Studies looked at prophylactic placement of IVC filters with few short term complications, need studies to follow for long term complications Morbidity of Splenectomy

 Postsplenectomy thrombocytosis  Lifelong risk of DVT and PE not well defined  Review of autopsies in 20 year period (total of 37,000) and identified 202 patients hx of splenectomy vs 400 pt cohort without splenectomy (control)  PE major or contributory cause of death in 35% vs 10% control  Overwhelming Postsplenectomy Infection  Difficult to determine  Risk 1/800 adults  Begins with fevers, chills  No identifiable focal site of infection with bacteremia  progression to , resp compromise, and death  Organisms: S. , H influenza, Neisseria meningitidis  Vaccinate within 2 weeks Our decision

 Patient failed NOM with falling HCT  Patient in need of anticoagulation for symptomatic PE  With SAE, will still need close obs due to anticoagulation  IVC filter placement?  PE  Splenectomy with ?of postsplenectomy thrombocytosis Hospital Course

 Patient taken to the OR for open splenectomy  Technically difficult dissection due to previous abdominal surgery with multiple adhesions  Returned to ICU with heparin drip restarted at 300 units/hr with goal PTT 60-80  Following morning IR placement of IVC filter

Outcomes

 Patient went to floor on HD#2  Vaccinated against encapsulated organisms  Strep, H flu, Neisseria meningitidis  Therapeutic on hep gtt (goal 60-80) with conversion to coumadin on HD#5, continue 3 months  Stable Hgb’s over hospital course  PO Diet, bowel function, good mobility, off oxygen  DC home Summary

 Management of Splenic trauma  NOM c adjunt SAE  Splenic salvage  Close observation  f/u labs  Transfusion trigger  Possible adjunct with embolization via IR Questions?