The effect of anticoagulation on outcomes after liver and spleen injuries: A research consortium of New England centers for trauma (ReCONECT) study

Management of blunt splenic injury: down the rabbit hole and into the bucket

Management of splenic trauma has changed dramatically over the past 30 years. Many of these advances were driven by the Memphis team under the leadership of Dr. Timothy Fabian. This review article summarizes some of those changes in clinical care, especially related to nonoperative management and angioembolization.

Management of Hemorrhagic Shock: Physiology Approach, Timing and Strategies

Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from progressing from any named and visible vessel is the main stem fundamental praxis of efficacy and effectiveness and an essential, obligatory, life-saving step. Blood loss replacement serves the purpose of preventing ischemia/reperfusion toxemia and optimizing tissue oxygenation and microcirculation dynamics. The "physiological classification of HS" dictates the timely management and suits the 'titrated hypotensive resuscitation' tactics and the 'damage control surgery' strategy. In any hypotensive but not yet critical shock, the body's response to a fluid load test determines the cut-off point between compensation and progression between the time for adopting conservative treatment and preparing for surgery or rushing to the theater for rapid bleeding source control. Up to 20% of the total blood volume is given to refill the unstressed venous return volume. In any critical level of shock where, ab initio, the patient manifests signs indicating critical physiology and impending cardiac arrest or cardiovascular accident, the balance between the life-saving reflexes stretched to the maximum and the insufficient distal perfusion (blood, oxygen, and substrates) remains in a liable and delicate equilibrium, susceptible to any minimal change or interfering variable. In a cardiac arrest by exsanguination, the core of the physiological issue remains the rapid restoration of a sufficient venous return, allowing the heart to pump it back into systemic circulation either by open massage via sternotomy or anterolateral thoracotomy or spontaneously after aorta clamping in the chest or in the abdomen at the epigastrium under extracorporeal resuscitation and induced hypothermia. This is the only way to prevent ischemic damage to the brain and the heart. This is accomplishable rapidly and efficiently only by a direct approach, which is a crush laparotomy if the bleeding is coming from an abdominal +/- lower limb site or rapid sternotomy/anterolateral thoracotomy if the bleeding is coming from a chest +/- upper limbs site. Without first stopping the bleeding and refilling the heart, any further exercise is doomed to failure. Direct source control via laparotomy/thoracotomy, with the concomitant or soon following venous refilling, are the two essential, initial life-saving steps.

Preinjury warfarin does not cause failure of nonoperative management in patients with blunt hepatic, splenic or renal injuries

BACKGROUND

For patients sustaining major trauma, preinjury warfarin use may make adequate haemostasis difficult. This study aimed to determine whether preinjury warfarin would result in more haemostatic interventions (transarterial embolization [TAE] or surgeries) and a higher failure rate of nonoperative management for blunt hepatic, splenic or renal injuries.

METHODS

This was a retrospective cohort study from the Taiwan National Health Insurance Research Database (NHIRD) from 2003 to 2015. Patients with hepatic, splenic or renal injuries were identified. The primary outcome measurement was the need for invasive procedures to stop bleeding. One-to-two propensity score matching (PSM) was used to minimize selection bias.

RESULTS

A total of 37,837 patients were enrolled in the study, and 156 (0.41%) had preinjury warfarin use. With proper 1:2 PSM, patients who received warfarin preinjury were found to require more haemostatic interventions (39.9% vs. 29.1%, p=0.016). The differences between the two study groups were that patients with preinjury warfarin required more TAE than the controls (16.3% vs 8.2%, p = 0.009). No significant increases were found in the need for surgeries (exploratory laparotomy (5.2% vs 3.6%, p = 0.380), hepatorrhaphy (9.2% vs 7.2%, p = 0.447), splenectomy (13.1% vs 13.7%, p = 0.846) or nephrectomy (2.0% vs 0.7%, p = 0.229)). Seven out of 25 patients (28.0%) in the warfarin group required further operations after TAE, which was not significantly different from that in the nonwarfarin group (four out of 25 patients, 16.0%, p = 0.306) CONCLUSION: Preinjury warfarin increases the need for TAE but not surgeries. With proper haemostasis with TAE and resuscitation, nonoperative management can still be applied to patients with preinjury warfarin sustaining blunt hepatic, splenic or renal injuries. Patients with preinjury warfarin had a higher risk for surgery after TAE.

Anticoagulation is Associated with Increased Mortality in Splenic Injuries

INTRODUCTION

Anticoagulation (AC) is associated with worse outcomes after trauma in some but not all studies. To further investigate the effect of AC on outcomes in patients with splenic injury, we analyzed the Trauma Quality Programs Participant Use File (PUF) METHODS: The 2017 PUF was used to identify adult (18+ y) with all mechanisms and grades of splenic injury. Demographics, comorbidities, hospital course and outcomes were compared between AC and non-AC patients.

RESULTS

A total of 18,749 patients were included, 622 were on AC. The AC patients were older but had comparable gender composition to non-AC patients. Injury Severity Score (18.2 versus 22.5) and rates of serious (AIS ≥ 3) injury were all lower in the AC group (P = 0.001). AC patients received fewer units of RBC (5.7 versus 8.0 units, P < 0.001) and FFP (3.9 versus 5.4 units, P < 0.001) in the first 24 h but underwent angiography at similar rates (23.6 versus 24.5%, P = 0.8). Among those who underwent angiography, patients were more likely to undergo embolization if they were on AC (89.7 versus 73.9%, P = 0.04). Rates of splenic surgery were comparable (19.3 versus 21.5%, P = 0.2) between AC versus non-AC patients. Median LOS was longer in AC patients (6.3 versus 5.6 d, P = 0.002). AC patients had a higher mortality (13.3 versus 7.0%, P = 0.001). In a multivariable binary logistic regression, AC was an independent risk factor for mortality with OR 1.4 (95% CI: 1.1-1.9) CONCLUSIONS: Anticoagulation is associated with increased mortality in patients with splenic injury.