Journal of Anesthesia and Surgery | Volume 2 | Issue 2 | 2015-03-03

Splenic Rupture Audit-Make that Call…Save a Spleen

Louise Jordan

Abstract

Non-surgical management of paediatric splenic injury is accepted safe practice. Despite this and the increased lifetime morbidity and mortality risk in post-splenectomy patients, discrepancies exist in the management of paediatric patients presenting with splenic trauma. Our audit started following a case where a patient was admitted to a District General Hospital with a grade 4 rupture. The paediatric surgeons at the Major Trauma Centre were not initially consulted and a plan for splenectomy had already been formulated. Embrace Yorkshire & Humber Infant & Children s Transport Service were called for advice by a paediatric consultant and a conference call with the paediatric surgeons resulted in a safe transfer, a conservative management plan and a good outcome. The audit emphasises that conservative management can be achieved and splenectomy avoided in the majority of patients. Education and early communication between referral, transport, and tertiary teams facilitates safe patient observation and surgical/intensive care if required.

Full text

Blunt abdominal trauma occurs in 15% of injured children [1, 2] who have increased susceptibility to visceral injury from a lack of abdominal protection. Discrepancies exist in the management for splenic rupture [3] , despite the life-time risk of severe sepsis post-splenectomy, which in turn promotes splenic preservation as a priority [4,5] . Non-surgical management of paediatric splenic injury is a safe and accepted practice [6,7] . Our aim was to identify cases of splenic rupture that Embrace has been involved in to highlight common themes in those managed conservatively compared to surgically. The objective was to be able to provide clear guidance on the management of splenic rupture to avoid unnecessary splenectomy. Table 1: Criteria and Standards used No Criteria (broad statement) Standards Evidence source 1 Adequate observation and frequent monitoring 100% APLS 2 Precise fluid and Coagulopathy management 100% APLS 3 Paediatric surgical advice and guided management 100% APLS 4 Abdominal CT scan 100% APLS 5 Non-operative management in a trauma centre for those that are haemodynamically stable 100% APLS 6 Consideration of non-operative management and active treatment in order to avoid splenectomy 100% APLS Methodology Sampling 1. Patients discussed with/transferred by Embrace with splenic trauma over last 4 years 2. 8 patients (aged 6 15 years) identified by screening notes on basis of key coding identifiers - Trauma; Abdominal injury; Surgery; A&E Resus; Theatre; HDU; RTA; spleen/splenectomy/splenic - Neonatal patients excluded Data collection Systematic case note review held at Embrace with input from receiving hospitals and collated in the data collection tool for analysis. Results Table 1: Mean counts (CFU/note) of microbial pathogens isolated from paper currency [53] Audit criterion Result Number Percentage Adequate observation and frequent monitoring 8/8 100% Precise fluid and coagulopathy management 6/8 75% Paediatric Surgical Advice and Guided Management 4/8 50% CT scan for diagnosis 6/8 75% Consideration of non-operative management and active treatment to avoid splenectomy 4/8 50% Non-operative management in MTC if haemodynamically stable 4/8 50% Patients Our results showed a patient population that was primarily male ranging in age from 6 15 years with grade 3 and above splenic ruptures. They all presented to District General Hospitals and in the majority it was the day after injury, which was due to a fall or impact. Figure 1: Figure 2: Diagnosis CT scanning gave superior diagnostic value. The alternative method used was FAST scan. Those patients both underwent surgery, one resulting in a negative laparotomy. Four patients had surgery in total. None of the patients had been discussed with paediatric surgeons prior to surgery (figure 5). Figure 3: Figure 4: Figure 5: Conservative measures Patients frequently received fluid boluses (6/8) within the stabilisation period, but only one patient had tranexamic acid, 2 had Fresh Frozen Plasma (FFP) and 3 had Blood transfusions. This may indicate a lack of consideration of these treatments or a lack of need. Figure 6: Complications In the surgical group one patient was investigated for jaundice and another had a wound site hernia. In the conservatively managed group, anaemia, treated with a blood transfusion and pleural effusion, not requiring treatment were observed. Figure 7: Figure 8: Table 3: Additional Findings Patients M > F (6:2) 6 15 years of age Majority present day after injury Place of Care MTC 6/8 (2 post-op) Level 1 DGH (transferred to L2 post-op) Level 2 DGH (kept post-op) Mechanism Fall (4/8) Impact (2/8) RTC (1/8) Resus Fluid 10-60ml/kg (6/8) FFP (2/8) Tranexamic acid (1/8) RBC (3/8) Diagnosis CT (6/8) FAST scan (2/8) FAST scan outcome (2 pnts): - grade 4 rupture and splenectomy - negative laparotomy Surgical management In DGH, not MTC (4 patients had surgery in DGH before discussion. No patients had surgery in MTC). Grade - 3 or above injury Complications Anaemia/Jaundice (2/8) Hernia/Pleural effusion (2/8) Discussion Our audit showed that there is a potential to improve communications between admitting unit and paediatric surgeons in regards to the management of paediatric splenic trauma. By using Embrace\'s call conferencing system it is possible to facilitate and record effective communication and plan for transfer if required. Early recognition of significant trauma using clinical indicators, CT scans and a high index of suspicion can result in prompt discussions and optimal treatment for splenic preservation. It is important to treat the patient relating to their clinical status, rather than radiological, by experts ensures best care for our paediatric patient population. How can we improve? 1. Treatment in MTCs by expert teams specific to the patient and their clinical (rather than radiological) status 2. Optimising treatment for splenic preservation to ensure Best Care for our patient population Conclusions A high index of suspicion and thorough investigation is required to identify splenic trauma. The majority of patients presented a day after their injury. CT Scanning is an important part of diagnosis and superior to FAST scanning. Early communication between referral, transport and tertiary teams facilitates effective best care. Call-conferencing between DGHs and Paediatric Surgeons can facilitate targeted care, timely transfer to MTC and reduce morbidity and mortality. Management of paediatric splenic trauma is ideally in MTCs. Non-surgical management of paediatric splenic injury is safe & accepted practice and reduces associated morbidity and mortality. This includes precise fluid and coagulopathy management. We need: Education Reduced morbidity and mortality associated with blunt abdominal trauma Effective Communication and Teamwork Linked Regional & National Guidance to avoid un necessary splenectomy Risk Issues Patients often do not present immediately after injury and the majority are taken to DGHs. They may not have obvious clinical signs of a significant underlying splenic injury. 3 out of 8 patients studied required transfer by their referring hospital. With a recommendation to treat splenic trauma patients in MTCs, transfer from DGHs will be required. DGH teams are less skilled for transport, but transport services such as Embrace, the surgeons and ITU team can offer advice. Treatment in MTCs will have an adverse effect on the training and expertise of those working in the non-MTCs. It is therefore important to train the teams in early recognition of major injuries and recommended management. Limitations There are a number of limitations to consider regarding our audit: Difficult to access the notes of the referring and receiving hospitals Some elements of documentation absent No long-term follow-up Due to the number of patients discussed through patients and the numerous ways their notes can be coded, it is possible that we miss some patients with our initial note searching exercise A snap-shot i.e. some cases may not have passed through Embrace Patients identified and case notes reviewed Splenic injury is a relatively Rare occurrence Recommendations We have presented two posters relating to this project at regional meetings (figure 9&10). We believe that our findings reveal a need for development of a regional guideline collaborating with surgical networks and regional network hospitals. Sharing of knowledge and experience with Emergency departments and Adult surgeons from non-MTCs is a key educational stage in the best care process. Figure 9: Poster: YEARN Conference January 2015. Figure 10: Poster: Yorkshire School of Paediatrics Annual Meeting November 2014. Conflicts of Interest: Author has no conflicts of Interest. Acknowledgements: I thank Dr Stephen Hancock (Embrace Yorkshire & Humber Infant & Children\'s Transport Service Consultant), Dr. Guy Millman (Paediatric Consultant), Mr. Crabbe (Paediatric Surgical Consultant), Dr. Stephen Jones (Paediatric Consultant) for their support. References 1. Wesson, E.D. Liver, spleen and pancreas injury in children with blunt abdominal trauma. (2014) Up to Date 2. Gaines, B.A. Intra abdominal solid organ injury in children: diagnosis and treatment. (2009) J Trauma 67(2 Suppl): S135-S139. 3. Stylianos, S. Outcomes from pediatric solid injury: role of standardized care guidelines. (2005) Curr Opin Pediatr 17(3): 402-406. 4. Bisharat, N., Omari, H., Lavi, I., et al. Risk of infection and death among post-splenectomy patients. (2001) J Infect 43(3): 182-186. 5. Cantor, R.M., Leaming, J.M. Evaluation and management of pediatric major trauma. (1998) Emerg Med Clin North Am 16(1): 229-256. 6. Velanovich, V., Tapper, D. Decision analysis in children with blunt splenic trauma: the effects of observation, splenorrhaphy, or splenectomy on quality-adjusted life expectancy. (1993) J Pediatr Surg 28(2): 179-1 85. 7. Pearl, R.E., Wesson, D.E., Spence, L.J., et al. Splenic injury- a 5-year update with improved results and changing criteria for conservative management. (1989) J Pediatr Surg 24(5): 428-431.