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Frotan MA, Edmundson P, Cooper C, Tibbs B, Garlow L, Vandertulip K, Miller A, Aryal S, Roden-Foreman JW, Shires GT. Role of Serial Phlebotomy in the Management of Blunt Solid Organ Injury in Adults. J Trauma Nurs 2023; 30:135-141. [PMID: 37144801 DOI: 10.1097/jtn.0000000000000718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND The management of blunt spleen and liver trauma has become increasingly nonoperative. There is no consensus on timing or duration of serial hemoglobin and hematocrit monitoring in this patient population. OBJECTIVE This study examined the clinical utility of serial hemoglobin and hematocrit monitoring. We hypothesized that most interventions occur early in the hospital course, based on hemodynamic instability or physical examination findings rather than serial monitoring. METHODS We conducted a retrospective cohort study of adult trauma patients with blunt spleen or liver injury from November 2014 through June 2019 at our Level II trauma center. Interventions were classified as no intervention, surgical intervention, angioembolization, or packed red blood cell transfusion. Demographics, length of stay, total blood draws, laboratory values, and clinical triggers preceding intervention were reviewed. RESULTS A total of 143 patients were studied, of whom 73 (51%) received no intervention, 47 (33%) received an intervention within 4 hr of presentation, and 23 (16%) had interventions beyond 4 hr. Of these 23 patients, 13 received an intervention based on phlebotomy results alone. Most of these patients (n = 12, 92%) received blood transfusion without further intervention. Only one patient underwent operative intervention based on serial hemoglobin results on hospital day 2. CONCLUSION The majority of patients with these injury patterns either require no intervention or declare themselves promptly after arrival. Serial phlebotomy after initial triage and intervention may add little value in the management of blunt solid organ injury.
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Affiliation(s)
- Mohammad A Frotan
- Department of Surgery (Drs Frotan, Edmundson, Cooper, Tibbs, and Shires) and Trauma Administration (Mss Garlow, Vandertulip, and Miller and Mr Roden-Foreman), Texas Health Presbyterian Hospital Dallas, Dallas, Texas; SaferCare Texas, University of North Texas Health Science Center, Fort Worth, Texas (Dr Aryal)
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Stottlemyre RL, Notrica DM, Cohen AS, Sayrs LW, Naiditch J, St Peter SD, Leys CM, Ostlie DJ, Maxson RT, Ponsky T, Eubanks JW, Bhatia A, Greenwell C, Lawson KA, Alder AC, Johnson J, Garvey E. Hemodilution in pediatric trauma: Defining the expected hemoglobin changes in patients with liver and/or spleen injury: An ATOMAC+ secondary analysis. J Pediatr Surg 2023; 58:325-329. [PMID: 36428184 DOI: 10.1016/j.jpedsurg.2022.10.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Many children with blunt liver and/or spleen injury (BLSI) never bleed intraperitoneally. Despite this, decreases in hemoglobin are common. This study examines initial and follow up measured hemoglobin values for children with BLSI with and without evidence of intra-abdominal bleeding. METHODS Children ≤18 years of age with BLSI between April 2013 and January 2016 were identified from the prospective ATOMAC+ cohort. Initial and follow up hemoglobin levels were analyzed for 4 groups with BLSI: (1) Non bleeding; (2) Bleeding, non transfused (3) Bleeding, transfused, and (4) Bleeding resulting in non operative management (NOM) failure. RESULTS Of 1007 patients enrolled, 767 were included in one or more of four study cohorts. Of 131 non bleeding patients, the mean decrease in hemoglobin was 0.83 g/dL (+/-1.35) after a median of 6.3 [5.1,7.0] hours, (p = 0.001). Follow-up hemoglobin levels in patients with and without successful NOM were not different. For patients with an initial hemoglobin >9.25 g/dL, the odds ratio (OR) for NOM failure was 14.2 times less, while the OR for transfusion was 11.4 times less (p = 0.001). CONCLUSION Decreases in hemoglobin are expected after trauma, even if not bleeding. A hemoglobin decrease of 2.15 g/dL [0.8 + 1.35] would still be within one standard deviation of a non bleeding patient. An initial low hemoglobin correlates with failure of NOM as well as transfusion, thereby providing useful information. By contrast, subsequent hemoglobin levels do not appear to guide the need for transfusion, nor correlate with failure of NOM. These results support initial hemoglobin measurement but suggest a lack of utility for routine rechecking of hemoglobin. LEVEL OF EVIDENCE Level II Prognostic Study.
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Affiliation(s)
- Rachael L Stottlemyre
- Phoenix Children's, Phoenix, AZ 85016, United States; University of Miami Miller School of Medicine, Miami, FL 33136, United States
| | - David M Notrica
- Phoenix Children's, Phoenix, AZ 85016, United States; University of Arizona College of Medicine Phoenix, Phoenix, AZ 85004, United States; Mayo Clinic College of Medicine and Science, Phoenix, AZ 85054, United States.
| | - Aaron S Cohen
- University of Miami Miller School of Medicine, Miami, FL 33136, United States
| | - Lois W Sayrs
- Children's Hospital of Orange County Research Institute, Orange, CA 92868, United States
| | | | | | - Charles M Leys
- American Family Children's Hospital, Madison, WI 53792, United States
| | - Daniel J Ostlie
- Phoenix Children's, Phoenix, AZ 85016, United States; American Family Children's Hospital, Madison, WI 53792, United States
| | - R Todd Maxson
- Arkansas Children's Hospital, Little Rock, AR 72202, United States
| | - Todd Ponsky
- Dell Children's Medical Center, Austin, TX 78723, United States; Akron Children's Hospital, Akron, OH 44308, United States
| | - James W Eubanks
- Le Bonheur Children's Hospital, Memphis, TN 38103, United States
| | - Amina Bhatia
- Children's Healthcare of Atlanta, Atlanta, GA 30303, United States
| | | | - Karla A Lawson
- Dell Children's Medical Center, Austin, TX 78723, United States
| | - Adam C Alder
- Children's Medical Center Dallas, Dallas, TX 75235, United States
| | - Jeremy Johnson
- The Children's Hospital at OU Medical Center, Oklahoma City, OK 73104, United States
| | - Erin Garvey
- Phoenix Children's, Phoenix, AZ 85016, United States; University of Arizona College of Medicine Phoenix, Phoenix, AZ 85004, United States; Mayo Clinic College of Medicine and Science, Phoenix, AZ 85054, United States
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Poupore NS, Boswell ND, Baginski B, Cull J, Pellizzeri KF. The Utility of Serial Hemoglobin Monitoring in Non-Operative Management of Blunt Splenic Injury. Am Surg 2021; 88:692-697. [PMID: 34730033 DOI: 10.1177/00031348211048829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Eastern Association for the Surgery of Trauma (EAST) states there is not enough evidence to recommend a particular frequency of measuring Hgb values for non-operative management (NOM) of blunt splenic injury (BSI). This study was performed to compare the utility of serial Hgb (SHgb) to daily Hgb (DHgb) in this population. METHODS We conducted a retrospective chart review of patients with BSI between 2013 and 2019. Demographics, comorbidities, lab values, clinical decisions, and outcomes were gathered through a trauma database. RESULTS A total of 562 patients arrive in the trauma bay with BSI. In the NOM group, 297 were successful and 37 failed NOM. Of those that failed NOM, 8 (21.6%) changed to OM due to a drop in Hgb. 5 (62.5%) were hypotensive first, 2 (25%) were no longer receiving SHgb, and 1 (12.5%) had a repeat CT scan and was embolized. DHgb patients were not significantly different from SHgb patients in injury severity, length of stay, the largest drop in Hgb, and incidence of failing NOM. Patients taking aspirin were more likely to fall below 7 g/dl at 48 and 72 hours into admission. CONCLUSIONS These results suggest that that trending SHgb may not influence clinical decision-making in NOM of BSI. Besides taking aspirin, risk factors for who would benefit from SHgb were not identified. Patients who received DHgb had similar injuries and outcomes than patients who received SHgb. Prospective studies are needed to evaluate the clinical utility of SHgb compared to DHgb.
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Affiliation(s)
- Nicolas S Poupore
- 368074University of South Carolina School of Medicine Greenville, Greenville, SC, USA
| | - Nicole D Boswell
- 368074University of South Carolina School of Medicine Greenville, Greenville, SC, USA
| | - Bryana Baginski
- Department of Surgery, 22683Baylor University Medical Center, Dallas, TX, USA
| | - John Cull
- Department of Surgery, 3626Prisma Health, Greenville, SC, USA
| | - Katherine F Pellizzeri
- 368074University of South Carolina School of Medicine Greenville, Greenville, SC, USA.,Department of Surgery, 3626Prisma Health, Greenville, SC, USA
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Shahi N, Shahi AK, Phillips R, Shirek G, Bensard D, Moulton SL. Decision-making in pediatric blunt solid organ injury: A deep learning approach to predict massive transfusion, need for operative management, and mortality risk. J Pediatr Surg 2021; 56:379-384. [PMID: 33218680 DOI: 10.1016/j.jpedsurg.2020.10.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 10/20/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The principal triggers for intervention in the setting of pediatric blunt solid organ injury (BSOI) are declining hemoglobin values and hemodynamic instability. The clinical management of BSOI is, however, complex. We therefore hypothesized that state-of-art machine learning (computer-based) algorithms could be leveraged to discover new combinations of clinical variables that might herald the need for an escalation in care. We developed algorithms to predict the need for massive transfusion (MT), failure of non-operative management (NOM), mortality, and successful non-operative management without intervention, all within 4 hours of emergency department (ED) presentation. METHODS Children (≤18 years) who sustained a BSOI (liver, spleen, and/or kidney) between 2009 and 2018 were identified in the trauma registry at a pediatric level 1 trauma center. Deep learning models were developed using clinical values [vital signs, shock index-pediatric adjusted (SIPA), organ injured, and blood products received], laboratory results [hemoglobin, base deficit, INR, lactate, thromboelastography (TEG)], and imaging findings [focused assessment with sonography in trauma (FAST) and grade of injury on computed tomography scan] from pre-hospital to ED settings for prediction of MT, failure of NOM, mortality, and successful NOM without intervention. Sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve (AUC) were used to evaluate each model's performance. RESULTS A total of 477 patients were included, of which 5.7% required MT (27/477), 7.2% failed NOM (34/477), 4.4% died (21/477), and 89.1% had successful NOM (425/477). The accuracy of the models in the validation set was as follows: MT (90.5%), failure of NOM (83.8%), mortality (91.9%), and successful NOM without intervention (90.3%). Serial vital signs, the grade of organ injury, hemoglobin, and positive FAST had low correlations with outcomes. CONCLUSION Deep learning-based models using a combination of clinical, laboratory and radiographic features can predict the need for emergent intervention (MT, angioembolization, or operative management) and mortality with high accuracy and sensitivity using data available in the first 4 hours of admission. Further research is needed to externally validate and determine the feasibility of prospectively applying this framework to improve care and outcomes. LEVEL OF EVIDENCE III STUDY TYPE: Retrospective comparative study (Prognosis/Care Management).
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Affiliation(s)
- Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, University of Massachusetts, Worcester, MA, USA.
| | - Ashwani K Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Gabrielle Shirek
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Denis Bensard
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Steven L Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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