Management of Splenic Trauma - An Historical Perspective

Introduction thank you everybody for showing up um today's topic is pediatric trauma Grand rounds Dr David Wesson who's one of my mentors and actually my boss when I did my pediatric surgery training fellowship at Texas Children's Hospital this is a picture of the Outpatient Center um in Background Houston um I have this 55-page CV and I thought I'd summarize it to the Salient points that are applicable here he's a Canadian he went to medical school at University of Toronto he did the gley course for general surgery residency at UFT he does fellowship at at sick kids also um site we don't have a hookup for uh audio visual we can see you hear you yeah are you able to hear us okay I'll have the pH in the room should I continue yeah okay um research fellowship at Harvard and just recently a certificate of academic Medical Department leadership at University of Texas um he was at the hospital for children for many years where he was associate professor director of the trauma program there chair of the trauma committee for the Department of surgery University of trauma and it was there where um he uh uh was a primary author on the Sentinel paper that suggested non-operative management of splenic trauma it was also there that he was a a Founder for um Safe Kids Canada and many other uh trauma programs um he went to Cornell Medical Center and was chief of pediatric surgery there for a few years and attending at the me Memorial ketering cancer uh Center and since 1997 he's been at Baylor College of Medicine and Texas Children's Hospital in Houston currently he's the associate uh surgeon Chief at Texas Children's he's chief of the department of surgery also uh he's a trauma medical director there he's attended professor of surgery at Baylor College of Medicine this is where um Michael debaki and Kenneth Maddox uh uh have resided and reside currently reside he's a trauma system surveyor for the American College of surgeon and I think again he's going somewhere to another site in in a couple of weeks he's a founder of Safe Kids Canada um he's a founding me member of the international Society of children adolescent injury prevention and still has a lot of ongoing um say both in Canada and the states for trauma and injury prevention but he's been the pr president of the Trauma Association of Canada and he's a reviewer for uh the Pediatrics uh Journal as well as the inj injury prevention Journal needless to say he's had numerous invited lectures as well as uh paper presented over 100 over 100 peer review papers he was primary author on this Sentinel paper back in the early 90s of the ruptur Spen uh went to operate many other papers dozens of books chapters and um he was the first annual Murray ger lecturer at the Trauma Association uh of Canada um conference in Bound of 2011 so with further Ado I'd like to introduce Dr Wesson my mentor and Chief and uh to well thank you very much for the kind introduction um that's not yeah there's there we go it's certainly an honor to be invited to visit with you the last time I was in Vancouver or in Victoria I ended up in the emergency department of this hospital and I must say that I was very well treated and uh saw the best of the Canadian Health Care system which is um was quite gratifying actually for me at the time um and also thank you for the kind introduction I really do appreciate it um I chose to talk about the history of spenic injuries because I think it uh it illustrates a lot of themes that run through surgery in general things like um how surgery changes and evolves over time and what factors contribute to those changes how surgical Dogma develops and how difficult it is to dispel it how relatively small PE people like I was at the time can make some contributions uh assuming you have something to say and some good data so this question of how best to manage injuries has been controversial for over 100 years and I hope to show you what was really behind the controversy and uh you know explain it as and to bring up to date as to what the current management or the best management of spenic injuries really is I have no conflicts of interest to this close and I'll try not to steer you in the wrong direction uh just to show you a little bit of Texas mentality I'll promise not to shoot you either this is the hospital where I work now I started out my career at the hospital for children as Naomi mentioned um I was there on the faculty for 13 years and uh it's where I became interested and got involved in all the controversies about the management of injuries and um but I went to to Houston in 1997 and I've been working at this Hospital ever since uh this is the uh inpatient Tower it's the largest freestanding Hospital in the United States it has uh over 200 ICU beds and six different units um this is the research center which is adjacent to the hospital this is the clinical Care Center which is the outpatient facility where we do all our day surgery or most of our day surgery this is the recently open Pavilion for women which was added uh so that we could care for high-risk pregnancies and uh deal with babies who are expected to be born with major congenital anomalies like uh uh major cardiovascular problems sop gilat treia Donald W defects AC Co geot teratomas and dimatic Heria so all these babies are now actually born in the children's hospital there's a Neurological Institute which is part of the hospital and recently we've opened a West Campus which is about 25 miles to the west of the main campus in one of the growing suburbs in the city so altogether it's uh it's quite a complex organization it's quite a thrill for me to be able to work there I think that when we're talking about spun injuries it's it's important to remember that the most the primary goal in treating them is to prevent sanguina Hemorrhage which is always a risk and uh second goal although important is to save the spleen if possible but it's not the primary purpose I'm going to talk a little bit uh about the uh um function of the spleen I'm not going to say very much about it uh there's really not much that needs to be said at this point in history I think think and talk a little bit about how the management of injuries evolved over time and I'll spend most of my time on that part of it I'm going to summarize what I think is the current state of uh the art right now what the best practices are and uh what DET term is what those are and finally I'll try to say a little bit about what I consider the themes or the lessons in the in that we can glean from this story about the management of injuries the two major themes that uh I want to develop are that um surgery is really shaped by our understanding of human biology as it evolves over time and and the medical technology and the tools that we have at our disposable disposal to care for patients with different medical and surgical problems and that local resources and conditions determine what is practical and what is important there's really no one right way for all times and in all places to manage patients with Clinic injuries and I'm going to tell you a little bit about it why that is in my opinion depends a lot on the people that are available their skills their knowledge and their experience in dealing with children and the facilities including the uh state-of-the-art radiological services available operating rooms icus blood banks and all those things that we take for granted in our leading hospitals nowadays the spleen is at one time was considered to be the seat of the emotions and the word spleen was uh synonymous with a feeling of anger or ill will but it's obviously not that anymore now we understand what it's there for it's a lymphatic organ lies in the upper part of the abdomen you all know a bit about the blood supply and how vascular it is has two main functions one is to serve as a filter for the blood to remove uh old blood cells red blood cells and bacterial and other particulate matter from the blood and also to participate in the immune response it stores of B andt lymphocytes and helps initiate the immune response to foreign antigens this is the sort of state-of-the-art uh 100 years ago when the writing about injuries first developed the anatomy of the Spain was well known but there was no knowledge about what it what its function was there was in fact most people thought it had no no function technology that it was available was really non-existent uh the only way to assess and manage patients with a Sonic injury was based on clinical examination there was no Imaging you couldn't keep an IV up you couldn't um transfuse patients who had ruptured spleen but anesthetic was available and there were skillful surgeons at the time uh and it was possible for any real competent general surgeon to uh do a spinomesencephalic so in other words splenectomy was really the only practical way to deal with the spenic injuries uh to save the life of a patient who was bleeding to death from a ruptured spleen and Cocker who was the first surgeon to receive the Nobel Prize sort of summed it up in a statement that he published in 1911 uh splenic injuries uh injuries of the spleen demand excision of the gland no evil effects follow its removal while the danger of hemorrhage is effectively stopped and that was sort of the prevailing wisdom for at least the next 50 years uh they were di Sonic injuries were diagnosed clinically the sping could be removed fairly easily by any competent surgeon there was no other way to help the patient and there was really no known Downstream consequences of taking out a spleen as far as everybody knew at the time it had no long-term complications then in uh 1932 Mao a British surgeon introduced a new concept uh that also had a major role in the attitudes and the practices of people who are looking after PE patients with rupt spleen the idea of delayed rupture of the spleen he actually published a very short series of cases they weren't well documented and this problem of delayed rupture was rarely seen by other people but it became ingrained in surgical mentality and I remember when I was a resident uh in Toronto General in the 1970s if you touched the plan and saw two red blood cells coming off the surface of it you would took out this spleen if you were doing a gastrectomy or a colectomy or something like that it was really considered to be and and the main reason was that there was this widespread awareness of the risk of uh at least the potential perceived risk of delayed rupture of the spleen and the spleen was sort of like a ticking time bomb that could go off at any time over the next few days or weeks uh remember that the there was no other way to diagnose pinic injuries except for the clinical diagnosis and it was a pretty easy operation to do and there were no long-term consequences as I said so this was sort of the context and the prevailing wisdom uh as the middle of the 20th century approached and that was about to change and um as far back as 1919 there was some uh evidence that the spleen had an important role in in immune function but the most important and seminal paper that really changed people's attitudes was uh the publication in the analy of surgery by King and Schumacher of 5K cases of overwhelming sepsis in children who had had a splenectomy for spherocytosis two of which died and there have been many many other advances in our understanding of the function of the spleen since then but really this is the overarching or overwhelming primary consideration that it's an important and essential uh component of our immune system and taking the spleen out is not without its consequences so unlike what Coker said that the spleen has no evil effects the in fact the opposite is true and if if any of you had a patient to die of Sonic postsplenectomy infection as I have you'll understand what I mean it's a devastating problem and it occurs in the space of 24 hours now um to get into the history History again um this man Tim wansboro was the uh the right man at the right place at the right time to sort of try to change this accepted dog and to look at spenic injuries from a different perspective he was the chief of general surgery at the hospital for sick children and uh late 1940s and early 1950s um his son and my dad actually were fraternity Brothers at the University of Toronto and lifelong friends so I had a slight connection to him and in late 1940s he had a patient who was admitted to the hospital with what he thought was a spenic injury and he decided not to operate on him and that unfortunate kid was run over by a street car later and at the time of autopsy the pathologist really made an observation that this Spen had been ruptured before and had healed there was scar in it and he so wbor said well maybe maybe we don't have to operate on every kid with a ruptured Spen and he began to practice that and to influence his colleagues at the hospital and the people he taught and the successors of at the depart at the uh hospital for sick children but it was never published or mentioned outside the SI kids hospital the first publication appeared in 1968 and the primary author was Jimmy Simpson who was a very very fast and skillful surgeon the slickest surgeon at the hospital during my time as a resident there he reported a series of 52 cases of ruptured what he called ruptured spleen 10 of them died of associated injuries nothing to do with the spleen 30 had a splenectomy and 12 were treated non-operatively and uh so this this was the first time that any publication appeared uh in surgical literature on non-operative management of injuries I first met Dr Simpson on it and Summer Afternoon in 1968 which is same year this publication was presented when my little brother Tom we were at the summer Cottage up in Lake Simco and he developed abdominal pain and we took him into the city to the hospital and I was a Premed student at the time so my my parents took me along because I thought I might learn something from the experience and I remember two guys in white suits coming in and examining my brother taking blood and they actually went to the little lab in the emergency room where they did the Whit out count themselves and called Dr Simpson and he came in and before the sun had Set uh Dr Simpson had taken out his spleen there was no ultrasound there was no CT scan there was nothing fancy U and uh and I was really impressed and about 15 years later when Dr Simpson retired he gave me all his uh his library and his slides and I still value his the books that he lent me because a lot of them are contain information about thoracic surgery kids that's not not available anywhere else but nobody outside Toronto believed him uh they basically people said oh they there's no way that this is possible we all know that when you injure the spleen it's going to bleed and it's going to keep bleeding until you either take it out or the patient dies and um after all because Dr Simpson's diagnosis was all based on clinical examination of the patient there was no objective way to support him and many people said probably there were these kids that he had successfully treated nonoperatively never had spenic injuries in the first place and that's where like technology entered into the scene and um beginning in the late 1960s early 1970s the liver spleen scans were available on a 247 basis at s kids hospital and it was for the at then at that time when we were first able to document objectively the presence or absence of a injury and this is the kind of scan you would get that um you can see it looks as if the spleen is broken into two pieces uh in a child who had a blunt abdominal injury so these scans were available at the hospital just like CT scans are today and became the the basis of our management of of of these patients and it allowed us for the first time to kind of prove that non-operative management was possible this is where I sort of came in from a medical point of view I was just finishing my fellowship when they asked me to update the experience with injuries at the hospital and we did a review of a consecutive series of cases um all of them were confirmed by operation or scan so this was the first publication that uh really had objective evidence that some of these kids had really had spenic injuries that were uh treated successfully without operation um only 30% of them had an operation and the indications for operation were basically surgeons judgment clinical assessment there were no U standard criteria or guidelines that we use at the time in order to select patients for surgery versus non-operative therapy and of the 19 that were operated on uh 15 had splenectomy and you'll see that as time goes by the the proportion of patients who even needed an operation had a splenectomy goes down and down until you can almost save 100% of the of the splenic injury patients of the patients that were treated nonoperative nonoperatively there were no deaths they were all admitted to the ICU so there's a Long Hospital stay at that time we still had this notion in the back of our minds that there was a possibility of delayed rupture 16 of the 44 required a blood transfusion and the volume of blood given was 31 Ms per kilo on average in those days unlike um well we used either whole blood or reconstituted whole blood and it seems we've almost come full a circle in that in the in the 21st century and all of the operations occurred within 16 hours of admission there was no case of delayed rupture in this whole series of 44 non-operative cases so people said oh I don't believe you the those patients that you're showing they had um congenital anomalies of a spleen and that really wasn't a splin injury so even even though we had pretty good evidence people still denied the uh the the evidence that we were trying to show them but um this is a scan of the same child that I just showed you because we always used to get um uh follow-up scans six or eight weeks later and this is the same patient showing that the scen had completely healed so um you know we could dispel dispense with that argument that we were only dealing with spenic uh uh malformations not true spenic injuries so um to say that this paper was not well received is kind of an understatement um we were basically vilified by the entire surgical Community around North America including all the pediatric surgeons and the general surgeons that uh had experienced with trauma I don't know if you've ever heard of Bill blaz Dell but he was the one of the big surgeons at San Francisco General he said if you believe this was a a quote from a p a presentation he made at an ACS meeting in the in Florida back in 1986 which was sometime after our publication if you believe serger aggravates bleeding and you shouldn't even be in surgery we probably have more experiencing managing kids than any pediatric surgeon will ever see because they don't see that much so um now even if you haven't heard of blaz Dell you've probably heard of Don trunk this is what Dr trunky had to say about our paper and our idea they gave all those children that they managed conservatively 30 MS per kilo body weight of blood which was not true the second thing is that their operative mortality from bleeding from the spleen was 5% which is not true I just don't see any rationale for their approach at the time they would say things like oh we operate on day they come in they go home in four days and we never see them again everything is fine and of course anybody who's a surgeon knows that there's a very over simpli simplification of what really happens now fortunately the uh the guy who wrote this article which had all these quotes in it um contacted me and although I was a young guy I was like three or four years out of my fellowship and fairly inexperienced uh this is what I had to say and all all of these quotes were published in the same uh publication from the College of Surgeons that appeared after this meeting and really we were able to refute everything that they said none of the patients had any complications and all subsequently recovered without surgery they walked out and are now perfectly normal individuals so what was really the problem uh I think the problem was that our diagnostic uh tools had become much better we were much more able to establish the diagnosis of spenic injury these the CT scan and the radi nuclei Imaging scans were much more sensitive than clinical examination prior to to the availability of these scans the uh diagnosis of spenic rupture was made in a patient who had a blun injury but who had shown signs of hemorrhage basically those patients were in hemorrhagic shock and uh with the Advent of CT and radionucleide imaging we began to realized that we had only been seeing the tip of this sort of injury uh spenic injury Iceberg you know there was a lot of patients that were never clinically recognized and although we weren't aware of it uh we had always been treating uh patients selectively U because we weren't able to diagnose those oul splin injuries that we can see nowadays so in those days a ruptured splin prior to to these scans a ruptured spleen was a basically a patient had shock from a blunt abdominal injury now a ruptured spleen is is usually just a patient who's had a blun injury that to the abdomen who may or may not even have any signs or symptoms and possibly doesn't have any evidence of blood loss but we get these scans anyway and now we see all these injuries that otherwise we would never have known about now uh couple of years later we published another paper which is a followup and and there were two reasons behind this paper one was to um confirm that the non-operative patients have required very little blood and second to uh show what our experience was after we instituted this policy of only doing a laparotomy for kids who require more than 40 Ms per kilogram of blood you remember in the first paper the all the patients that were successfully treated non-operatively either didn't need any blood or on average needed about 30 m per kilo which is a little bit less than half a blood volume on average so that we started to use that as our main Criterion for selecting patients for surgery and frankly I don't think there's been any better Criterion for the decision to make an to do an operation or any kind of intervention uh since then you'll see that in the first paper the 15 of the 19 that we had to operate on had a splenectomy in this paper only three of the 10 that were operated on needed a splenectomy the others were patched up in some way so that the spleen was saved so the overall spenic salvage rate was 96% and this is the sort of what happened to the patients who were treated nonoperatively all survived only 15 of 65 required a blood transfusion and the average was 22 Ms per kilo and most of these had other injuries only 20 were admitted to the ICU you can see that we gradually r r ratcheted down the length of time in the hospital overall and the length of time in the operting Standardization room so the next sort of chapter in the story was kind of the r uh the standardization of non-operative or selective non-operative management of injuries and uh a more rational use of resources uh to essentially reduce the use of blood products reduce the I ICU stay and the total length of stay and the reduce the use of scans Etc and this was all worked out and uh by the uh committee at the American pediat surgical Association led by Steven sanos who's a surgeon who's currently practicing in New York City and these are the guidelines that Dr sanos committee came up with you can Guidelines see that the the um cases are classified according to CCT grading of the severity of the injury grade one grade two grade three grade four none of them except for the ones with grade four injury required admission to the ICU the number of Hospital days is basically the grade plus one so for grade one injuries is a two day hospital grade two is the three days in hospital Etc uh and there was agreement that no pre-discharge or post discharge scanning of any kind was necessary so once the diagnosis had been established it was recommended that no further Imaging be done and uh selano subsequently published a paper that was a multicenter uh report of the impact of these guidelines on uh the use of resources and the management of patients with injuries and the bottom line is that overall there was a major reduction in the ICU days the length of State the use of Imaging and activity restriction uh as a result of the implication of of these guidelines now um it hasn't really saved lives but it Controversy certainly reduced the use of resources and non-operative Care succeeds in more than 90% of cases um and U but there was still a big controversy between the pediatric surgery world and the general uh surgery world of the trauma surgery world around North America and this is important because about 80% of according to discharge data that you can you can get um 80% of kids with sponic injuries in the US are treated in general hospitals not in children's hospitals but uh this a number of reports have documented that the risk of operation and of splenectomy is much higher uh in for patients that are treated in general hospitals uh by general surgeons uh so the risk of trauma of operation is higher when the patient's treated by general surgeon or a trauma surgeon at a Trauma Center or General Hospital versus a children's hospital and at a non-teaching National Trauma Database hospital uh over time these differences of opinion have kind of faded away and according to the National trauma database which is a big database that collects data from all across North America uh there's a even for adults there's now 76% of patients who are treated in hospital for eruption spleen or sponic injuries are treated non-operatively so this is finally um been accepted by the adult trauma world the current guidelines which the best version of the current uh Current Guidelines recommended best practices are published by the Eastern Association for the surgery of trauma and they're easily available on their website and they basically divide patients with injured sple into two groups those with unstable Vital Signs and those with stable Vital Signs they recommend immediate operation for patients who are hemodynamically unstable and uh for those who are not hemodynamically unstable they recommend non-operative therapy or non-operative management but that requires frequent monitoring by surgeon uh frequent Vital Signs monitoring the availability of an operat in room immediately and the availability of blood uh for blood transfusion if required there's really no evidence that there's any way to classify patients according to their risk or the need for operation based on their CT findings whether it's a grade four injury or a grade two injury doesn't seem to make any difference and the amount of hop paratum that you can see on the scan doesn't seem to be a useful Criterion for deciding whether to operate it's mainly the hemodynamic stability that's uh it's uh important the whole business of embolization versus uh open open surgery with sporify or splenectomy um is still up up in the air I think it really depends on the local expertise but certainly ambul embolization uh is definitely an adjunct in patients who are hemodynamically stable who require a lot of blood so it it took a lot of time but I don't think there's anybody who would question the potential benefits of non-operative management of Sonic injuries um it's pretty widely accepted now uh among general surgeons trauma surgeons and pediatric surgeons that this is the wise thing and if you look back on the whole history of what happened over the 19 the period from the 1960s to the current I think you can see several stages the first stage was um basically well your patients didn't even have sponic injuries which you might call that denial second stage was well um you pediatric surgeon don't even know how to care for injured children which was kind of an angry response and the third stage was um well it may work for kids but it doesn't work for adults which is sort of a bargaining thing in the final stage was um well now we don't even get to operate anymore and we can't teach our P our residents how to do an exploratory laparotomy because of what you guys have done and that's sort of like a depress depression kind of the final stage has really been acceptance of the reality of this uh now on the understanding the resources to Monitor and care for a patient if Hemorrhage and bleeding uh Hemorrhage develops and an inter intervention as necessary are always Barriers available now there's still some barriers to this non-operative management of spenic injury um there's no question that U the risk of operative intervention seems to be higher in general hospitals it's higher in for-profit hospitals which is not such a big thing here in Canada but certainly many for-profit hospitals in the US and the data that you can get from the discharge abstracts indicate that for-profit hospitals have a much higher upward rate whether it's a Trauma Center or non-t trauma center shouldn't matter but U the risk of surgery is actually higher still in on Trauma Center hospitals and in rural versus Urban hospitals and the same for general surgeons and trauma surgeons versus pediatric surgeons there's still a higher in incidents of surgical intervention for injury when controlling for all the other parameters like age and um CT grade Etc but I think that the the last three on this list lack of experience with pediatri trauma inability to monitor continuously or lack of immediate or availability are legitimate uh reasons to maybe intervene in some way either primarily with surgical intervention uh if you don't have those tools to continuously Monitor and intervene if if uh the patient's condition changes so there are some circumstances where I think that an operation might be indicated if all the tools that we have available at our T tertiary hospitals and our major children's hospitals are not available there's still a number of Unsolved Questions Unsolved questions um I mentioned earlier that we use the 40 Ms per kilogram or half a blood volume as the Criterion for deciding to operate on uh the patient there's never been anything published subsequently that is a valid guide to decide when to intervene same goes for the need for transfusion the indications for how much blood the patient should get whether contrast extravasation is an indication for intervention but I think that uh lack of resources lack of experienced Personnel blood banking ICU o availability are certainly legitimate indications to to operate if you're particularly in a remote area now this is a slide from a patient of mine recently who had a spenic injury resulting from a actually Brandon to another kid on the soccer field and you can see there's some extravasation of contrast here and a fairly massive hop paratum and you know I think this child was successfully treated non-operatively he received one transfusion and subsequently recovered without any further problems but I think the scanning that we have now is a little bit more sensitive so that uh while extravasation of died 25 years ago meant more massive bleeding than we are able to pick up nowadays so I don't think that uh extravasation is really a valid indication to intervene either with embolization or with surgery so I think in the end this whole um controversy over the management of Conclusion stic injuries was not was not settled by argument it was settled by U our better understanding of the need of for the spleen to be saved if possible because of its essential role in the immune system also the context in which we practice because we're much more able to make a diagnosis of injury so the incidence has gone up considerably we now have reliable IV access with benefits of intensive care unit and safe blood transfusion so that we can uh afford to watch some of these patients after they've been admitted and we do have alternate treatment options including imization available at the most advanced hospitals so in summary I would say that there's really no right way for all times and all places and just in 2013 just as in was true in 1913 the best way to manage these kids depends on our sort of understanding of the biology of the spleen and of uh the functions of the spleen the resources that are available or needed to support a patient uh and to uh be able to monitor patient and have a surgeon available to operate if necessary so uh I think that uh I'll end at that point um I think all the controversy about sponic trauma is understandable and if you understand the context in which it developed and uh how the our knowledge about the spleen and our technology and our ability to support a patient particularly if bleeding happens has uh developed over the last 100 years I think it's um much more easy easy to understand and I know um I have deliberately left a lot of time for uh questions so I'm sure you guys have some questions if you want to uh ask them I'd be happy to do Technology that go ahead I'm going to try the technology here uh and if you hit the little thing while your just this is so that we can uh people at the remote sites will be able to hear what we're talking Embolization vs splenectomy about anybody want to ask a question PES a button guy who has the green but you're I got green now okay so um can you tell me a little bit more about the dichotomy the decision making between embolization and splenectomy because I think that's something we face now when to do either and how are you guys approaching that there's no we we use embolization there's no evidencebased basis on which to make that decision I think um the where it's available and you have uh the opportunity to get embolization done on a short-term basis you know 24/7 I think that uh that's certainly a legitimate way of dealing with these with these patients and I don't think you can say in a given patient that this patient is suitable for embolization or this patient is not suitable for embolization I think that if there's ongoing blood loss hemodynamic instability I think that um depending on how un stable the patient is um you know embolization I think is is a valid consideration not every hospital has it available obviously there are many hospitals that don't have IR and many more remote uh rural hospitals uh that that you know need to depend on surgery to deal with the problem I think sometimes we see unstable patients getting embolization I don't know well they really shouldn't be unstable when they're in the radiology department I mean I guess it depends a little bit on what you mean by unstable um most of the patients like the child that I showed you with the extravasation um respond to single transfusion that's sort of my rule of thumb if the patient can be stabilized after one transfusion and uh then I would not operate on them but if they continue to require blood and even if they do respond to repeated uh transfusions those are the kinds of patients that I think would you consider embolization there is the rare case that comes into the emergency room with low blood pressure shock obvious and you give blood and they still don't stabilize those patients I think probably should go to the operating room in my opinion uh think I do next just talk oh yeah hit it's right by the disc where the microphone is so go ahead I I did hit next try okay all Permissive hypotension right good so I'm just I'm curious to figure out how to balance this because in some mostly penetrating trauma we're using some permissive hypotension now yeah and you know when we identify this guy obviously needs to go to the O Let's just minimize what we give him and get get them to surgery and uh so I'm just trying to balance how you figure out who you keep an emerge and try to transfuse to see if they stabilize and is there any or is there any way to predict like who's not going to respond and should just go straight to surgery because he said that the CT doesn't really correlate with who needs I I don't think that um you know Dr Ken Maddox who's one of the uh other surgeons in our department started this whole controversy 20 years ago or so and when they published a paper that um tried to show that patients did better trauma patients with penetrating injuries did better if you didn't try to resuscitate them with large volumes of fluid and blood before you took them to the operating room and that was a paper that was a study that was patients were randomly allocated but it was based on the day that they were treated it wasn't a true R randomization and it wasn't really there was no real way to prove that um in fact everything else was controlled adequately but that's still the practice in in Houston uh that they avoid giving lot volumes uh blood or fluids before taking a patient to the operating room with penetrating injuries and I think that's a different category we we don't really have I personally don't have very much experience at all with with penetrating trauma in children there we do get the odd case but it's usually uh you know clear that you need to take the patient to the operating room you don't necessarily have to do any scanning or anything like that but um I don't think that I or any of the other pediatric surgeons that I know would recommend permissive hypotension in a patient with a blunt injury I think that we try to resuscitate them adequately and restore their blood volume and their Metacritic Mite there any other questions conf comments sir next after okay It Go Green yeah did oh good you're on thanks very much for the Interview presentation Dr won really enjoyed it uh do you want to comment I'm a sege you want to comment a bit about your Techni of saving salvaging sple in the op yeah well I used to be kind of sarcastic about this in the sense that the the ones that you're easy able easily able to salvage in the operating room are the ones that probably didn't need operating in the first place uh when the spleen is completely P pulverized um then there's really not much you can do but I think I would divide the patients that you're talking about into two groups the ones that have multiple intraabdominal injuries in which case I don't think it's I think the most expedient thing to do is to rapidly take out the spleen if there's a liver injury or bowel injuries or other problems that you have to pancreas injuries that you have to deal with at the time uh packing and suturing um are you know um options that you can use it's been a long time since I've operated on hisonic injury I do remember a very interesting case one time we had a baby it was only it was a birth trauma actually that had a ruptured spleen that we were operating on and we were particularly concerned about saving the spleen because um of the age of the child and um one of the scrub nurses we we got those little chest tubes the 12 French chest tubes that come with the big tro car in them look just like knitting needles well we took a couple of long spools of uh deex on ligature and she knitted a little net little hair net that we put around the planen and and we were packing it in the meanwhile she took her about 10 minutes to do she was Scottish very interesting sort of ironic that um she was an RNA what they call I don't know if you have rnas here but they were nursing assistants that didn't have a bachelor's degree in nursing and she was subsequently Let Go by the hospital because she wasn't well qualified sort seems ridiculous and Rich but you can get those little meshes now I don't know whether you stalk them in the operating room but the the people that might make viol and uh you know produ them I I I don't have any magic and I don't have any great experience I've done quite a few splin or surg surgical procedures on the spleen electively for cysts and other things and it's amazing how much surgery you can do on the spleen uh and still control the bleeding successfully U many of the my colleagues I don't personally do this but are doing hemis splenectomies now for the various eological disorders that we see like cocytus in order to preserve some spenic function and uh as long as you're careful you use a lot of Coty uh you can usually transect the spleen uh along its uh um crosswise and uh uh I would I don't have any uh other magic Solutions all right try again does um oh did you go green somebody else turn well speak up and I'll repeat the question well I don't think we know the answer to that question there have been a number of animal experiments that try to assess the function of the spleen after partial splenectomy and the rule that I kind of carry in my mind is that if you can Preserve at least a third of a spleen with its intact blood supply it will function normally little bits of spleen I don't think are um you know effective in that sense um one of my teachers used to always liate the splenic artery in doing pancreatectomies and babies for you know ideopathic hypo or hyperinsulinemia and leaving the short gastrics intact and the spleen seem to function normally by scan and also by looking at the blood smear you you don't see these hour how will Jolly body if you do that so I would presume if as long as you're embolizing the spleen uh you know the splenic artery uh if you embolize every single branch of the splenic artery and the spleen completely infarcts I think it's probably not going to function but I think that you know you could make a strong case that um that's better than having a laparotomy uh and having a your spleen taking out um I think that it's easy to fun to test the function of the spleen at least uh according to looking at by looking at the blood smear uh in a patient who's had that kind of procedure and I certainly would recommend that and I had a case a couple years ago I think we presented at trauma rounds at one point and we completely or Radiology completely embolized the spleen we couldn't see any blush I mean you couldn't see it I mean it was there but you know it had been fully uniz no blood flow to it and two years later she had a normal scen based on function and and an Ultras Sun it was just amazing we didn't expect it so we again what Dr W Comments said any other questions comments thoughts um what what do the general surgeons feel about the role of this approach in adults is there any still a controversy or is it pretty much settled I think you're um it's one of the the blessings of being in a big General Hospital environment you have a lot of these other resources available in the radiology department that not all all children's hospitals our our Interventional Radiology Services um relatively new they don't uh and I'm sure that the that you you're fortunate to have that here well thank you all very much for your attention and for inviting me here it's been a pleasure yeah