Preserved function after angioembolisation of splenic injury in children and adolescents: a case control study.

BACKGROUND: Non-operative management for blunt splenic injuries was introduced to reduce the risk of overwhelming post splenectomy infection in children. To increase splenic preservation rates, splenic artery embolization (SAE) was added to our institutional treatment protocol in 2002. In the presence of clinical signs of ongoing bleeding, SAE was considered also in children. To our knowledge, the long term splenic function after SAE performed in the paediatric population has not been evaluated and constitutes the aim of the present study. METHODS: A total of 11 SAE patients less than 17 years of age at the time of injury were included with 11 healthy volunteers serving as matched controls. Clinical examination, medical history, general blood counts, immunoglobulin quantifications and flowcytometric analysis of lymphocyte phenotypes were performed. Peripheral blood smears were examined for Howell-Jolly bodies (H-J bodies) and abdominal ultrasound was performed in order to assess the size and perfusion of the spleen. RESULTS: On average 4.6 years after SAE (range 1-8 years), no significant differences could be detected between the SAE patients and their controls. Total and Pneumococcus serospecific immunoglobulins and H-J bodies did not differ between the study groups, nor did general blood counts and lymphocyte numbers, including memory B cell proportions. The ultrasound examinations revealed normal sized and well perfused spleens in the SAE patients when compared to their controls. CONCLUSION: This case control study indicates preserved splenic function after SAE for splenic injury in children. Mandatory immunization to prevent severe infections does not seem warranted.

Evaluation of TEG(®) and RoTEM(®) inter-changeability in trauma patients.

BACKGROUND: Massive haemorrhage is a leading cause of preventable deaths in trauma. Traumatic coagulopathy is frequently present early after trauma, and is associated with increased mortality. A number of recent trials suggest that viscoelastic haemostatic assays (VHA), such as thromboelastography and thromboelastometry, are useful tools in guiding transfusion. Treatment algorithms exist for the use of VHAs but are not validated in traumatic haemorrhage. In this study we examined the inter-changeability of two commonly used VHAs, TEG(®) and RoTEM(®). METHODS: A total of 184 trauma patients over the age of 18, requiring full trauma team activation, were included at three different hospitals in three different countries (Copenhagen, Denmark, San Francisco, CA, USA and Oslo, Norway). Blood samples were drawn immediately upon arrival, and TEG(®) and RoTEM(®) analyzed simultaneously. Correlations were calculated using. Spearman's rank correlation coefficient. Agreement was evaluated by Bland-Altman plots and calculation of limits of agreement. RESULTS: The mean ISS in the total population was 17, and the mortality was 16.5%. Mean base excess was -2.8 (SD: 4.2). The correlation coefficient for corresponding values for the two devices was 0.24 for the R-time vs CT in all centres combined. For the K-time vs CFT the correlation was 0.48, for the α-angleTEG vs α-angleRoTEM 0.44, and for MA vs MCF 0.76. Limits of agreement exceeded the preset clinically acceptable deviation of 10% for all variables in all centres except for MA/MCF in one centre (Copenhagen). Generally, correlation coefficients were lower and agreement poorer in the one centre (Oslo) where measurements were performed bedside by clinicians. CONCLUSION: Inter-changeability between TEG(®) and RoTEM(®) is limited in the trauma setting. Agreement seems poorer when clinicians operate the devices. Development and validation of separate treatment algorithms for the two devices is required.

Red blood cell transfusion at Ullevål University Hospital--indications, consumption and blood group immunisation.

BACKGROUND: Knowledge of clinical transfusion practice should be improved to ensure that therapy is optimally effective, to avoid waste of resources and to ensure a safe supply of blood. MATERIAL AND METHOD: All patients who received a transfusion of red blood cell concentrate at Ullevål University Hospital in two 14-day periods in 2003 were included. Diagnoses, haemoglobin values and intervention codes were recorded from the patient records for which consent to access had been given. Blood samples were taken from consenting survivors to be tested for blood group immunisation. RESULTS: 348 patients were included. The median age was 62.8 years. They were given 1,162 concentrates in 471 transfusion episodes, of which 373 (79 %) consisted of one or two concentrates. As at 1 February 2009, 181 patients (52 %) were registered as having died. Access was possible to the records of 218 patients. The primary diagnosis was cancer for 76 patients (35 %), injuries for 36 (17 %) and cardiovascular disease for 34 (16 %). The transfusion was given to 89 (41 %) of patients in connection with a surgical intervention during the period covered by the patient records. A note about the transfusion was lacking in 46 (21 %) of the records. Transfusions were given to 52 patients whose haemoglobin concentration was above a threshold level of ≥ 8 g/100 ml (43 % of the patients). Blood group immunisation was found in one (3 %) of 38 survivors. INTERPRETATION: Red blood cell transfusion is most commonly given to elderly patients with chronic disorders and uncertain long-term prognoses. The clinical documentation is not infrequently incomplete. There is probably scope for a reduction in consumption if indications are based more on established scientific evidence and well-defined transfusion protocols. Blood group immunisation is not a frequent complication.

Preserved splenic function after angioembolisation of high grade injury.

BACKGROUND: After introducing splenic artery embolisation (SAE) in the institutional treatment protocol for splenic injury, we wanted to evaluate the effects of SAE on splenic function and assess the need for immunisation in SAE treated patients. METHODS: 15 SAE patients and 14 splenectomised (SPL) patients were included and 29 healthy blood donors volunteered as controls. Clinical examination, medical history, general blood counts, immunoglobulin quantifications and flowcytometric analysis of lymphocyte phenotypes were performed. Peripheral blood smears from all patients and controls were examined for Howell-Jolly (H-J) bodies. Abdominal doppler, gray scale and contrast enhanced ultrasound (CEUS) were performed on all the SAE patients. RESULTS: Leukocyte and platelet counts were elevated in both SAE and SPL individuals compared to controls. The proportion of memory B-lymphocytes did not differ significantly from controls in either group. In the SAE group total IgA, IgM and IgG levels as well as pneumococcal serotype specific IgG and IgM antibody levels did not differ from the control group. In the SPL group total IgA and IgG Pneumovax(®) (PPV23) antibody levels were significantly increased, and 5 of 12 pneumococcal serotype specific IgGs and IgMs were significantly elevated. H-J bodies were only detected in the SPL group. CEUS confirmed normal sized and well perfused spleens in all SAE patients. CONCLUSION: In our study non-operative management (NOM) of high grade splenic injuries including SAE, was followed by an increase in total leukocyte and platelet counts. Normal levels of immunoglobulins and memory B cells, absence of H-J bodies and preserved splenic size and intraparenchymal blood flow suggest that SAE has only minor impact on splenic function and that immunisation probably is unnecessary.