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Arizona Trauma and Acute Care Consortium

NONOPERATIVE MANAGEMENT OF SOLID ORGAN INJURIES . Arizona Trauma and Acute Care Consortium. SELECT UPDATES. Chris Salvino, MD, MS, MS, MT, FACS Trauma Director John C Lincoln Hospital. AGENDA Select Topics. EVALUATION.

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Arizona Trauma and Acute Care Consortium

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  1. NONOPERATIVE MANAGEMENT OF SOLID ORGAN INJURIES Arizona Trauma and Acute Care Consortium SELECT UPDATES Chris Salvino, MD, MS, MS, MT, FACS Trauma Director John C Lincoln Hospital

  2. AGENDASelect Topics

  3. EVALUATION Throughout this presentation non-operative management (NOM) of blunt solid organ injuries is based on stability and CT scan evaluation

  4. SPLEEN

  5. HISTORY • 1900s • 100% Mortality with NOM • Splenectomy treatment of choice • 1952 • Five cases of fatal infections in infants following splenectomy* • Start of NOM • Modern impetus for attempting NOM was concern for infection * King H, Shumacker HB: Splenic Studies. Susceptibility to Infection After Splenectomy Performed in Infancy. Ann Surg 136: 239,1952

  6. IMMUNOLOGY • Function • Filter • Antigens, bacteria & old RBCs • Regulation • Helper/suppressor T-cell ratios • Produces host defense proteins • Immunoglobulin M • Antibodies produced by lymphocytes sequestered in the spleen that respond to antigens • Tuftsin • Tetra-peptide that stimulates phagocytes to destroy pathogens

  7. IMMUNOLOGY • Partial rationale for NOM • Overwhelming Post-Splenectomy Infection (OPSI) from encapsulated bacteria (S pneumoniae, N meningitidis, H influenzae) • Rare • Younger people with higher risk • Risk greatest 1st year after splenectomy • Risk of death based on population studies • ~0.03%-0.02% adults • ~0.6%--0.3% peds • Vaccine • Reduce OPSI • Risk for early post-operative complications • i.e., pneumonia, sub-phrenic abscess & others* • Immunology plays part of a role in the decision to attempt NOM; but definitely not the sole role * Willis BK, Deitch EA: The Influence of Trauma to the Spleen on Post-Operative Complications and Mortality. J Trauma 26:1074,1986

  8. GRADING SCALE Spleen Grading scale proposed by AAST from Moore EE, Cogbill TH, et al: Organ Injury Scaling: Spleen & Liver . J Trauma 38:1995

  9. DEDICATED STUDY #1 Early study (1989). Success of non-operative management; retrospective review from 6 institutions with 832 blunt splenic injuries. 14% (112) were treated with NOM. Indications for NOM vs. OM; stability? • Findings • Conclusions • Some study limitations • Success of NOM in stable Grade I-III • 98% Children • 83% Adults Cogbill TH, Moore EE, et al: Non-Operative Management of Blunt Splenic Trauma: A Multi-Center Experience. J Trauma 29:1312, 1989

  10. DEDICATED STUDY #2 Prospective study of 190 adult trauma patients with splenic injuries. 102 stable patients underwent 3-5 days of bed rest; regardless of grade • Findings • Of the 102 initially stable patients • 2% Required subsequent laparotomy • 15% Required blood transfusions • 0% Mortality rate • Of the 190 total patients • Infection rate • 31.9% In survivors with splenectomy • 3.2% In survivors who had splenic repair • 0.0% In NOM • Transfusion rate • 0.8 Average units for NOM • 6.0 Average units for splenectomy patients • Conclusions • If stable, a very high NOM rate should be seen • Splenectomy had a markedly higher infection and transfusion rate over NOM • Splenectomy had a markedly higher infection rate over splenic repair patients Pachter HL, Guth AA, et al: Changing Patterns in the Management of Splenic Trauma: The impact of Non-Operative Management. Ann Surge 227:708, 1998

  11. DEDICATED STUDY #3 35,767 Patients with splenic injuries identified in the ACS National Trauma Data Bank; 1994-03. 92.5% Blunt; 85.6% underwent NOM • Findings • > 18 years old 81.8% underwent successful NOM (blunt & penetrating combined) • < 18 years old 91.8% underwent successful NOM (blunt & penetrating combined) • The usage of NOM increased 140% from 1994-2003 • AIS and successful NOM • II 68.0% • III 63.2% • IV 59.9% • V 60.7% • The odds for sucessful NOM were somewhat lower • Increased age • Increased initial systolic BP in the ED • Increased ISS • Conclusions • NOM increased significantly over the 10 years • Success rate of NOM • High in general • Slight decrease with increasing grade as well as ISS, age and initial high ED SBP Hurtuk M, Reed R, et al: Trauma Surgeons Practice What They Preach: The NTDB Story on Solid Organ Injury Management. J Trauma 61:243-255, 2006

  12. DEDICATED STUDY #4 92 Children (average age 8.4 yrs) were evaluated. 53 Underwent NOM; 6 G I, 21G II, 24 G III, 2 G IV. All patients had serial HCT until stable. CT scan follow-up at day 5-7 • Findings • 100% Successful NOM • All CT scans showed healing • LOS 7 days • HCT stabilized ~ PID #2 in non-transfused patients • Transfused patients • G II – mixed with multiple injuries; data not meaningful • G III – 12.5% required (9.7 ml/kg) in first 2 days only • Conclusions in children • No benefit to ICU • HCT checks after 2 days not normally helpful • Most could have been discharged POD 3 • CT scan follow-up was not useful Lynch JM, Ford H, et al: Is Early Discharge Following Isolated Splenic Injury in the Hemodynamically Stable Child Possible?: J Pediatric Surg. 28:1403, 1993

  13. DEDICATED STUDY #5 108 Patients with splenic injuries; 73 (68%) NOM. Routine (not clinically indicated) follow-up CT scans were performed on many (not all) of the patients. 2 G I, 29 G II, 27 G III, 15 G IV, 0 G V • Findings • Children 88% successful NOM • Adults 92% successful NOM • ~2% of Routine CT scans actually changed management • 16 Scans performed < 10 days • 1 Changed management; pseudoaneurysm G IV with subsequent …angiographic embolization • 33 Scans performed > 10 days • No changes • Conclusions • Routine CT scan follow-up is not necessary in most patients undergoing NOM • A subset of patients may benefit from routine CT scans such as higher grades (IV) or initial CT scan blush Bradley TC, Gogbill TH, et al: Non-Operative Management of Splenic Injury: Are Follow-up CT Scans of Any Value?: J Trauma 43:748, 1997

  14. DEDICATED STUDY #6 Retrospective review of Washington State Trauma Registry. 1633 Patients with splenic injury underwent planned NOM. Grades not reported. Which presenting sings/symptoms can predict failure of NOM? • Findings • 15% Failed NOM • Increased risk of failure of NOM • > 55 years • > 25 ISS • Level III/IV > Level I/II • No change in risk of failure of NOM • GCS • Associated injuries • Presenting hemodynamics • Conclusions • Age > 55, ISS > 25 and admission to a Level III/IV were associated with a significant risk of failure • GCS, associated injuries and initial hemodynamics* were not associated with failure • Limited study from a data bank *< 5% of the total patients had a SBP < 90; therefore, is this conclusion valid? McIntyre LK, Schiff M, et al: Failure of Non-Operative Management of Splenic Injuries: Arch Surg140:563, 2005

  15. DEDICATED STUDY #7 Retrospective review of 3085 adults with blunt splenic injuries with a AIS > 4 obtained from the NTDB. NOM attempted in 1248 (40.5%). This study looked at higher grade injuries • Findings • NOM unsuccessful in 682 (54.6%) • Failure associated with • Age > 55 • Low (unstable?) admission BP • Higher LOS • 16.9 vs. 8.6 • Higher LOS ICU • 10.1 vs. 3.9 • Mortality of NOM failure (12.3%) similar to successful NOM (13.8%) • Conclusions regarding higher grade splenic injuries • NOM is associated with a high rate of failure and longer LOS • No difference in mortality between success and failure of NOM Watson GA, Rosengart MR, et al: Non-Operative Management of Severe Blunt Splenic Injury: Are We Getting Better?: J Trauma 61:1113-1119, 2006

  16. DEDICATED STUDY #8 Retrospective EAST study from 27 institutions of 1488 adults with splenic injuries; of these, 97 patients failed NOM. 78 of these were available and form the basis of the review. Upon admission; 44% stable, 31% transient responders, 25% unstable • Findings • Failure of NOM • Increased LOS • Mortality of those failing NOM (note ISS similar from one group to the next) • Overall 12.8% • Stable 3% • Responders 8% • Unstable 37% • 60% (6) of the deaths caused by delayed treatment of splenic or other abdominal injuries – all from the Responder (1) and Unstable (5) categories • Conclusion • Majority of deaths were from delayed treatment of splenic or intra-abdominal injuries • Highest death rate of patients failing NOM is with patients presenting with instability • Unstable patients should not undergo an attempt at NOM • Transient responders and NOM? Peitzman AB, Harbrecht GB, et al: EAST Multi-Institutional Trials Working Group: Failure of Observation of Blunt Splenic Injury in Adults: Variability in Practice and Adverse Consequences. J Am Coll Surg 201:179-187, 2005

  17. DEDICATED STUDY #9 Retrospective WEST study from 4 institutionsof 140 patients (96% blunt) with splenic injuries who had (+) CT findings and subsequent Angiography & Embolization (A&E) followed by NOM. It is unclear how many patients with (+) CT had active bleeding vs. aneurysm vs. hemoperitoneum w/o active bleeding. Results compared to EAST • Findings • Success of NOM • Hemoperitoneum did not affect success • Presence of A-V fistula had a high failure rate (40%) despite A & E • Salvage rates similar between main and selective artery • 4.3% (6) developed abscesses • Conclusion • A & E can increase salvage especially at the higher grades Haan JM, Knudson M, et al: WEST Multi-Institutional Trials Committee: Splenic Embolization Revisited: a Multi-Center Review. J Trauma 56:542-547, 2004

  18. SELECT COMPLICATIONSAbscess • Mechanism • Proximity injuries (i.e., stomach) • Contamination of splenic hematoma from systemic infections • Gram (-) enteric bacteria most common • Treatment • Antibiotics • Mechanical • Percutaneous drainage • Splenectomy Sarr MG, Zuidema GD, Splenic Abscess- Presentation, Diagnosis & Treatment. Surgery 1982;92:480-485

  19. CONTROVERSIESAngiography & Embolization (A&E) • No controversy • A & E has a role in certain splenic injuries • Controversy • Indications • All patients with a blush? • Patients without a blush of a higher grade? • Other • Method of embolization • Main artery • Reduce perfusion pressure while maintaining splenic blood flow via short gastric vessels/collaterals to prevent infarcts • Distal (segmental) artery • Attacks vascular injury more directly, but associated with a higher infarct rate? • Complications of T & E • Delayed bleeding • Abscess and false abscess • Difficulty getting angio team in at some hospitals • Other Forsythe RM, Harbrecht BG, et al: Blunt Splenic Trauma. Scan J Surg

  20. LIVER

  21. HISTORY • In 1908 Pringle implied that the structural integrity of the liver was incapable of achieving spontaneous hemostasis* • The technical breakthroughs in CT imaging were principally responsible for the reversal of the long standing above belief now that the liver could be imaged and imaged repeatedly • 1983, Karp et al (pediatric surgeons) were the first to demonstrate that the liver is capable of spontaneous hemostasis and healing** • 1990, Knudson et al reported on 52 patients with liver injuries treated successfully with NOM*** Pringle JH: Notes on the Arrest of Hepatic Hemorrhage Due to Trauma: Ann Surg 48:541, 1908 **Karp M, Cooney DR, et al: The Non-Operative Management of Pediatric Hepatic Trauma: J Pediatric Surg. 18:512, 1983 ***Knudson MM, Lim RC, et al: Non-Operative Management of Blunt Liver Injuries in Adults: The Need for Continued Surveillance. J Trauma 30:1494, 1990

  22. GRADING SCALELiver Grading scale proposed by AAST from Moore EE, Cogbill TH, et al: Organ Injury Scaling: Spleen and Liver. J Trauma 38:323-4, 1995

  23. DEDICATED STUDY #1 Retrospective 13 institution study of 404 patients in stable blunt liver injuries. 19% G I, 31% G II, 36% G III, 10% G IV, 4% G V • Findings • 98.5% Success of NOM • 0.4% (2) Mortality attributed to hepatic injury • 5% (21) Complication rate • 14 Bleeding the most common • 3 OR; of these, 2 had underlying hemostatic disorders • 4 Embolizations • 6 Transfusions • 1 Observed • 2 Bilomas (percutaneous drainage) • 3 Abscesses (percutaneous drainage) • 0 Hemobilia • LOS overall and for those with complications was 13.1 and 26.9 respectively • Conclusions • High rate of successful NOM in patients with blunt liver injuries • Mortality attributed to liver injury is very low • Unlike splenic injuries, rate of successful NOM is less dependent on grade • Complications result in a much higher LOS Pachter HL, Knudson MM, et al: Status of Non-Operative Management of blunt Hepatic Injuries in 1995: A Multi-Center Experience with 404Patients. J Trauma 140:31, 1996

  24. DEDICATED STUDY #2 35,510 Patients with hepatic injuries identified in the ACS National Trauma Data Bank; 1994-03. 78% Blunt; 95.1% underwent NOM • Key findings • Age and successful NOM • > 18 years old 91.9% (blunt & penetrating combined) • < 18 years old 96.5% (blunt & penetrating combined) • AIS and successful NOM • II 90.5% • III 76.6% • IV 69.3% • V 62.3% • The usage of NOM increased 17% from 1994-2003 • Mortality was relatively constant • The chance of sucess of NOM was lower • Increased age • Increased initial systolic BP in the ED • Increased Revised Trauma Score • Increased for level II trauma centers Hurtuk M, Reed R, et al: Trauma Surgeons Practice What They Preach: The NTDB Story on Solid Organ Injury Management. J Trauma 61:243-255, 2006

  25. DEDICATED STUDY #3 Single institution retrospective study of 243 hepatic injuries, 95 of these were stable and treated with NOM. 29 G I, 30 G II, 33 G III, 3 G IV*, 0 G V*. 51 (54%) had more than one CT scan • Findings • 0% NOM failure • 0% Direct mortality • 3 Patients (2 G III 1 G IV) with (+) clinical findings (pain & elevated bilirubin) prompted CT scans leading to percutaneous bile drainage • 48 Patients had at least routine 1 F/U CT scan with no intervention performed • Conclusions • No patients failed NOM • Positive clinical findings did lead to helpful CT scans and altered treatment • Findings on routine repeat CT scan did not alter the decision to discharge clinically or change the management plan in stable patients with Grade I-III injuries • Study was weak beyond these global conclusions *Population too small for statistical evaluation Ciraulo DL, Nikkanen HE, et al: Clinical Analysis of the Utility of Repeat CT Scan Before Discharge in Blunt Hepatic Trauma. J Trauma 41:821, 1996

  26. DEDICATED STUDY #4 11 Patients with grade IV/V hepatic injuries and a mean ISS of 36 underwent angiography; 7 were found to have arterial bleeding and underwent embolization. Study entrance criteria included only those patients who were unstable upon presentation & then stabilized only with continuous aggressive resuscitation • Findings • Aggressive resuscitation was successfully withdrawn after embolization in all patients • Mean • 12 PRBCs • 9.1 ICU LOS • 23.9 LOS • 2 Complications • 1 Biloma (percutaneous drainage) • 1 Large devitalized tissue in a Grade V injury -> debridement ((-) for infection). Subsequent MSOF-> death • 14.3% Mortality • Conclusions • Pushed the limits of conservative management • Study was directed to a subset of hepatic injuries; initially unstable G IV/V • Embolization negated the need for surgical intervention in patients that normally would have gone to surgery. • Literature review of patients undergoing surgery for hepatic injuries had similar LOS, blood transfusion and mortality rates (4-76%) Ciraulo DL, Luk S, et al: Selective Hepatic Arterial Embolization of Grade IV and V Blunt Hepatic Injuries: An Extension of Resuscitation in the Non-Operative Management of Traumatic Hepatic Injuries. J Trauma 45:353, 1998

  27. DEDICATED STUDY #5 Single institution review of 126 blunt liver injuries; 74.6%(94) underwent NOM w/o A & E (Group 1) , 4.8% (6) underwent NOM with A & E for bleeding seen on CT (Group 2) (stable?). 90% of Group 1 were G I-III. Group 2 consisted of 3 G III, 3 G IV • Findings of Group 2 • Success? • 66% Successful resolution of bleeding • 33% (2) Unsuccessful embolization • 1 Bad head injury and instability • 1 Inability to cannulate atherosclerotic celiac trunk -OR no liver bleeding; massive retropertioneal bleed • Mortality • 33% Overall • 0 Hepatic related • 3 OR • 1 Delayed nephrectomy • 1 Retroperitoneal bleed; not hepatic • 1 Bile leak • Success of stopping bleeding from embolization 100% • Conclusions • A & E can be used successfully in Grade III and IV liver injuries with bleeding seen on CT • Other meaningful data cannot be extracted Wahl Wl, Ahrns KS, et al: The Need for Early Angiographic Embolization in Blunt Liver Injuries. J Trauma 52:1097-1101, 2002

  28. DEDICATED STUDY #6 Single institution retrospective study of 106 patients with blunt injury; of those, 64 (60%) were stable and evaluated with CT. Angiography was performed on 26 with suspected vascular injuries on CT • Findings • 92% were Grade III • 13 (50%) had positive findings on angiogram • Extra-vascular leakage of contrast • Pseudoaneurysm • A-V fistula • 12 Had successful embolization • 1 A-V fistula was extensive ->OR • Complications associated with A & E • 1 Developed a delayed A-P fistula • Conclusions • A & E can be highly successful stopping bleeding • Not all (+) CT findings (~50%) lead to actual findings of bleeding on angiogram • Higher grades are more likely to have initial bleeding Sugimoto K , Horiike S, et al: The Role of Angiography in the Assessment of Blunt Liver Injury. Injury, 25:283-287, 1994

  29. DEDICATED STUDY #7 Retrospective review of 202 pediatric patients with blunt hepatic injury at a single pediatric level I trauma center, 185 were stable and underwent NOM. 65 G I, 62 G II, 53 G III, 4 G IV, 0 G V, 0 G VI • Findings • 90.8% (168) were managed successfully w/o complications • Mortality • 5.4% Overall • 0% Attributed to the hepatic injury • Complications • 3.8% (7) • Grade III-IV • All right lobe • All with symptoms • 1 Hepatic A-V fistula (embolization) • 5 Bilomas (2 OR, 1 drainage, 2 drainage and stent) • 1 Necrotic gallbladder (OR) • Conclusions • NOM very successful in pediatric patients • Complications • Rate low • Grade III or higher • Most non-operative • All associated with symptoms Giss SR, Dobrilovic N, et al: Complications of Non-Operative Management of Pediatric Blunt Hepatic Injury: Diagnosis, Management, and Outcomes. J Trauma 61:334-339, 2006

  30. Findings Mortality 66% OM 8.3% NOM Conclusions Data analysis was limited ~ 50% Of severe hepatic injuries overall will require surgery Mortality is high with OM Mortality was much lower in those undergoing NOM; however, this may be a function of other factors not just liver grade Bleeding is common in those undergoing NOM of G IV-V and subsequently A & E was useful and sucessful This does not extrapolate to a recommendation that all NOM G IV-V have A & E automatically DEDICATED STUDY #8 Single institution retrospective review of 80 G IV-V hepatic injuries; 36 underwent NOM and 44 underwent OM. All 36 NOM had a CT. Indications for NOM vs. OM? Duane TM, Como JJ, et al: Re-Evaluating the Management and Outcomes of Severe Blunt Liver Injury. J Trauma 57:494-500, 2004

  31. DEDICATED STUDY #9 Single institution retrospective review of 135 patients with blunt hepatic trauma who were treated with NOM; 24% (32) of which developed complications that required additional interventional treatment. Of the 135; 18 G I, 22 G II, 43 G III, 35 G IV, 17 G V. Of the 32; 0 G I-II, 2 G III, 18 G IV, 12 G V • Findings • 58% of G IV-V developed complications requiring intervention • 94% of those (32) developing complications were G IV-V • Interventional treatment • 12 A & E 2 unsuccessful -> OR • 10 CT drainage of abscesses 2 unsuccessful -> OR • 8 ERCP and stenting 1 unsuccessful -> OR • 2 Laparoscopy • 15% Unsuccessful non-operative intervention • 0% Mortality • Conclusions • Complications with severe hepatic trauma managed with NOM are common; > 50% in G IV-V • The majority of complications can be managed with non-operative intervention Carrillo ED, Spain DA, et al: Interventional Techniques Are Useful Adjuncts in Non-Operative Management of Hepatic Injuries. J Trauma 46:619-624, 1999

  32. INFLAMMATORY HOST RESPONSE SYNDROME • Occurs PID 2-5 • Generalized inflammatory response; similar to sepsis • Fever, WBC, tachycardia, tenderness, ileus • Normal Hgb • Mechanism? • Liver ischemia • Inflammatory mediators • Bile and/or blood • Infection ~ 7-13% • Treatment • Infected – drain and ABX • Non-infected • Watch • Drain? Reduction in inflammatory response duration? • Laparoscopically • Open Carrillo EH, Wohltmann Chris, et al: Current Problems in Surgery. 9-60, 2001

  33. HEMOBILIA • 0.2-3% Of blunt liver injuries • Etiology • Communication between arterial and biliary system • Presentation • RUQ pain, jaundice, GI hemorrhage • Diagnosis • Angiography • Treatment • Selective embolization • OR for failures Carrillo EH, Richardson JD: The Current Management of Hepatic Trauma. Advances in Surgery 35:39-59, 2001

  34. DELAYED HEMORRHAGE • 0-3.5% Of blunt liver injuries • More frequent at higher grades • Blood transfusion requirements • 20% Of the patients • Most requiring < 4 units Carrillo EH, Richardson JD: The Current Management of Hepatic Trauma. Advances in Surgery 35:39-59, 2001

  35. NOM BENEFITS Overview summary from 5 articles regarding additional benefits of NOM vs. OM • Less • Transfusions • Abdominal complications • LOS • ICU LOS Stein DM, Scalea TMl: Non-Operative Management of Spleen and Liver Injuries. J of Intensive Care Med 21:296-294, 2006

  36. CONTROVERSYRoutine Follow-Up CT Scan • Is there a role in stable patients with no clinical symptom to have routine CT scans in follow-up to blunt liver injury with NOM? • Adults vs. peds • If not for all grades, then certain grades? • Discharge from the ICU? • Discharge in general? • Activity? Stein DM, Scalea TMl: Non-Operative Management of Spleen and Liver Injuries. J of Intensive Care Med 21:296-294, 2006

  37. RESUMPTION OF ACTIVITES Overview review • Trauma patients typically show complete resolution of injury • 9-12 weeks in one pediatric study • 4-12 weeks in other studies • In an experimental model wound breaking strength of an injury is normal at 3-6 weeks • This topic is still unclear Carrillo EH, Wohltmann Chris, et al: Current Problems in Surgery. 9-60, 2001

  38. KIDNEY

  39. IMAGING • CT scan > IVP • Fast • Allows evaluation of other organ injuries • Identifies contusions • Depth and extent of injuries • Size of surrounding hematoma • Other • IVP • Some usage in the OR • Angiography • Acute • Arterial bleeding/embolization • Chronic • Renal hypertension

  40. GRADING SCALEKidney Grading scale proposed by AAST from Moore EE, Cogbill TH, et al: Organ Injury Scaling: Spleen, Liver & Kidney. J Trauma 29:1989

  41. HISTORY • Conservative management of blunt renal has evolved over the past 30-40 years as investigators have realized that the nephrectomy rate is higher for renal exploration than NOM • 1987 Bergen et al reported on renal trauma* • 12.6% Overall nephrectomy rate • 35% Nephrectomy rate in those explored *Bergen CT, Chan TN, et al: IVP Results in Association with Renal Pathology and Therapy in Trauma Patients. J Trauma 27:515, 1987

  42. DEDICATED STUDY #1 Single institution retrospective review of 2 series of patients with diagnosed/suspected renal injuries (series I 1964-73, series II 1977-81). Series II much more reliant on imaging to dictate surgical intervention and OR management. Series I – 185 pts, series II – 190 pts • Findings • Conclusions • Early study 1960s <-> early 80s • High NOM success rate • Imaging helped reduce the incidence of nephrectomy McAninch JW, Carroll PR: Renal Trauma: Kidney Preservation Through Improved Vascular Control: A refined Approach. J Trauma 22:285, 1982

  43. DEDICATED STUDY #2 Single institution retrospective review of 1007 blunt trauma patients with hematuria most who underwent radiographic evaluation. Shock =SBP < 90 in field/ED *408 did not get imaged so excluded from this chart • Conclusions • Definition of “microscopic hematuria”? • Did not evaluate other groups; for example, macrohematuria • No imaging required if no shock AND only microhematuria or dip positive • Imaging of those in shock AND with micro/marcohematuria should be done Mee SL, et al: Radiographic Assessment of Renal Trauma: A 10-Year Prospective Study of Patient Selection. J Urol 141:1095-1098, 1989

  44. DEDICATED STUDY #3 Single institution retrospective review of 329 children with blunt trauma. 97 Had a CT upon admission – indications? 22% (21) had a renal injury. Of these, 6 had isolated renal injuries; this study specifically looks at these 6 • Findings • All had a painful tender flank with bruises, micro/macro-hematuria • Grade and management • 2 G III NOM • 3 G IV OM • 1 G V OM • Conclusions • Small study with limitations • Is flank pain/bruising and micro/marco-hematuria always associated with significant renal injuries? • This subset of patients all had positive clinical findings and G III-IV injuries • Operative rate appears high; 66% Rathaus V, Pomeranz A, et a: Isolated Severe Renal Injuries After Minimal Blunt Trauma to the Upper Abdomen and Flank: CT Findings Emergency Radiology 10:190-192, 2004

  45. DEDICATED STUDY #4 Single institution retrospective review of CT findings in 47 children with blunt renal trauma. 18 G I, 9 G II, 7 GIII, 7 G IV, 6 G V. This study looked at the subset with GIV-V • Findings • Other injuries • 50% abdominal • 33% Head • 13 G IV-V • 4 Nephrectomy (indications?; 2 from outside facilities before transfer) • 9 Non-nephrectomy • 2 Renal repair • 1 Return of kidneys to abdomen from thorax • 6 Observation • Neither the nephrectomy or non-nephrectomy group required hemodialysis, had significant HTN or elevated Creatine at the time of D/C • 66% Non-nephrectomy & 100% nephrectomy groups were available for f/u (mean 120 months) and were normotensive • Conclusions • Indications for the 4 nephrectomies? • Conservative management, when performed in these high grade lesions, was successful without long term sequele and should be attempted in all stable severe pediatric patients with renal injuries • No patient developed significant reno-vascular HTN Barsness KA, Bensard DD, et al: Reno-Vascular Injury: An Argument for Renal Preservation. J Trauma 57: 310-315, 2004

  46. DEDICATED STUDY #5 Single institution retrospective review of 178 initially stable adults with blunt renal trauma. 26 With G IV-V form the basis of this review • Findings • All patients had micro or macroscopic hematuria • 14 NOM • 1 required a stent; otherwise uneventful • 12 OM Patients developed • 9 Instability -> nephrectomy & other organ injury repair in some? • 3 Acute abdomen -> renal repair & other organ injury repair • Morbidity same between NOM and OM • 50% available for f/u average 7.5 months; none with renal insufficiency or HTN • Conclusions • This subset of patients all had micro/macro-hematuria • Stable G IV-V have a high rate of successful NOM • Unstable G IV-V undergoing OM have a high nephrectomy rate (75%) Bozeman C, Carver B, et al: Selective Operative Management of Major Blunt Renal Trauma. J Trauma 57:305-309, 2004

  47. DEDICATED STUDY #6 Retrospective review of the NTDB of 742,774 patients; 6890 blunt trauma patients with renal injuries. NOM and OM combined • Findings • Overall • 4.1% Nephrectomy • 0.5% Dialysis • 10.2% Death • Grade of injuries • Nephrectomy, dialysis and death increased with grade • Nephrectomy rate highest correlation for grade • ~0.1% Grade II • ~10% Grade V • Conclusions • Grading predicts nephrectomy, dialysis and death • Nephrectomy correlation strongest Kuan JK, Wright JL, et al: AAST Organ Injury Scale for Kidney Injuries Predicts Nephrectomy, Dialysis, and Death in Patients with Blunt Injury and Nephrectomy for Penetrating Injuries. J trauma 60:351-356, 2006

  48. RENOVASCULAR HTN & NOM • Etiology • Renal artery stenosis or occlusion • Internal – thrombosis or flap • External – compression • Restrictive fibrous capsule around kidney (“Page” kidney) • Compress parenchyma and restrict blood flow • Incidence – low • 3.2% Monstrey et al, 1989 • 0.0% Barsness et al, 2004 (peds) • “Low” Montgomery et al, 1998

  49. DEDICATED STUDY #7 Single institution retrospective review over 20 years to identify those with arterial hypertension as a direct result of renal injury. 7 patients found who developed new onset of HTN after discharge that was renal in origin. Study was not designed to look at frequency. • Findings • Time from injury to diagnosis of HTN 2-32 weeks • No history of HTN before accident or during hospital • Initial w/u at time of accident • 1 No workup • 3 Negative CT • 3 Negative IVP • All 7 underwent renal angiography and 6 had renal-vein renin sampling • 100% abnormal renin analysis • Conclusions • Development of renal HTN is not immediate • Angiography & renin analysis important • Treatment based on response to RX and angio findings • This study only “guesses” at renal HTN as “low” by the authors Montgomery RC, Richardson JD, et al: Post-Traumatic Reno-Vascular Hypertension After Occult Renal Injury. J Trauma 45:106-110, 1998

  50. VASCULAR INJURIES Bux S, Tarry WF, et al: Contemporary Management of Renal Trauma. W Virg Medical J. 88:152-155, 2002

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