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Date: Fri, 26 Jul 1996 16:37:39 -0400From: "Lisa S. Dresner" <71211.2533@compuserve.com>Subject: Re: Nonoperative management of hepatic traumaReply-To: trauma-list@ftech.netWe manage hemodynamically stable patients with blunt liver trauma (and splenic trauma) with non operative techniques.  We define hemodynamically stable as ones who respond to initial resuscitation with 1-2 liters of crystalloid with normalized pulse rate, etc.While some of these patients do require blood transfusions during their hospital stay, as long as they do not appear to have evidence of ongoing blood loss (persistant metabolic acidosis, ongoing volume requirments, etc) we observe them. In the early days we did a lot of angiography on a those with greater than grade 2-3 on CT or with concommittent splenic injury but found that only those liver injuries with evidence of ongoing blood loss every required any intervention.  Lisa Dresner, MDKings County Hospital Center/SUNY BrooklynBrooklyn, New York
Date: Fri, 26 Jul 1996 19:26:23 -0500From: "Dr. Jay Smith" Subject:  Nonoperative management of hepatic trauma -ReplyReply-To: trauma-list@ftech.netWe use a pulse < 120, bp >90, base deficit <3 as criteria for "stability". Of course, stable implies stability over several measurements:  120--120is stable but so is 60--60.  The actual state of perfusion must beaddressed as with the base deficit.We will also use 2 liters of replacement crystalloids to stabilize.  We uselberal amounts of CT scans to determine the severity of injury and willeven watch grade 4 liver injuries nonoperatively if stable.  The grade 4injury of the right lobe extending from the juxtahilar area to the costalmargin often has a bleeding vessel off the right hepatic artery andcoursing posteriorly and laterally that is embolizable via angiography.Embolization will leave an area of posttraumatic cyst, but these seem tobe benign.Consciousness does not affect our decision because we follow thesepatients with blood counts and CT scans as needed.
From: Critical Care Subject: RE: Nonoperative management of hepatic trauma Reply Date: Sat, 27 Jul 96 13:01:00 PDTReply-To: trauma-list@ftech.netThere are many hepatic injuries which are able to be treated non-operatively (or operatively) with little consequence as to final outcome. This is probably the majority of injuries seen on CT. Before CT was used so liberally these were found at lap after positive DPL and were either ignored or had minor haemostatic procedures. Many of these patients have lifethreatening injuries in other body regions - usually the head. In my own view whether or when these patients have surgery is of little consequence - the worst that happens is that they end up with an impressive abdominal scar and a tiny increased risk of adhesive obstruction in the distant future.Conversely there are some patients who are clearly exsanguinating (eg "hypotensive and unchanged despite 2 litres rapid colloid infusion") and the luxury of selective non-operative management is not available. How long you wait before taking these patients to the OR will probably be of great importance in the overall number salvaged. If you wait till they have dilutional coagulopathy, hypothermia, acidosis and intra-abdominal hypertension you have waited too long and when you get in you are not sure which bit to put in the bucket and which bit to try and keep. It is important to bite the bullet early and take these patients to the OR fast. Many will die regardless.Finally and most importantly there are a group (a small group) who have what are often anatomically devastating injuries seen on CT who have a early moderate or even major bleed (>10 unit) and then have a period of stability and in whom operative disturbance would very likely be the difference between life and death. ("If we disturb that clot given that the disruption goes right down to the porta he will probably bleed out"). It is important to recognise this group and make vigourous effort to manage them non-operatively if possible - even if this means quite a substantial period of intensive care and repeated cautious transfusion. They are not the same as the patients who are bleeding to death in front of your eyes and should be distinguished from them by an experienced surgeon (if not an intensivist !). This message brought to you by an intensivist who (almost) never stays the hand of any surgeon prepared to cut anything.IMHO focussing discussion on "what set of numbers makes a patient considered stable or unstable" is a necessary but not sufficient part of the issue. We should also discuss the cognitive stuff too. Comments ?Stephen Streat FRACPIntensivistDepartment of Critical Care MedicineAuckland Hospital, Auckland, New Zealand V +64 9 307 2892F +64 9 307 4927dccm@ahsl.co.nz
Date: Sat, 27 Jul 1996 22:04:06 +0800From: Sue Taylor Subject: RE: Nonoperative management of hepatic traumaReply-To: trauma-list@ftech.netAt 4:01 AM +0800 7/28/96, Critical Care wrote:>IMHO focussing discussion on "what set of numbers makes a patient considered>stable or unstable" is a necessary but not sufficient part of the issue. We>should also discuss the cognitive stuff too. Comments ?>>Stephen Streat FRACP>Intensivist>Department of Critical Care Medicine>Auckland Hospital, Auckland, New ZealandYes, absolutely, and thank you for your stimulating dissertation.  But Ihaven't seen the discussion which gives us those "Magic Numbers" yet.Admittedly, the rules are made for breaking, and that is what the cognitivestuff is for, but some of us don't know the rules, yet...Surgical-Trainee-to-be.Sue Taylor.Surgical Registrar, SCGHPerth, Western Australia.sue @highway1.com.au
Date: Sat, 27 Jul 1996 20:44:19 +0300From: "Aviel Roy-Shapira, M.D." Subject: Re: Nonoperative management of hepatic traumaReply-To: trauma-list@ftech.netAt 19:59 26-07-96 +0100, Dr. Karim Brohi wrote:Karim raises some interesting points. I too would like to see the results ofthis survey. >A. Patient cardiovascularly normal on arrival>B. Patient cardiovascularly normal after initial crystalloid bolusI consider either A or B as signs of cardiovascular stability. >C. Patient cardiovascularly stable after bolus of crystalloid>       and some blood (how much?)>D. A gut feeling that you'll be able to keep this person alive>       through CT. - ie requiring fluids constantly but>       not dramatically exsanguinating>E. None of the above!>>Secondly, by virtue of our trauma system, patients with isolated>intra-abdominal injuries are taken to the nearest teaching hospital.>Patients with multiple injuries (especially neuro) are brought back>to us by helicopter (excluding our catchment area of course).>As such they often arrive anaesthetised & ventilated (head injuries).>>Can you non-operatively manage safely someone who is unconcious?>How do you exclude the enteric injury (or can you?)These two questions are clearly related. If the only concern were bleeding,head injury would not exclude non-op management, since the hemodynamiceffects of head traua and bleeding are in different directions. The problemis that the signs of enteric injury on CT are subtle, and it is difficult tojudge whether the fluid seen on CT is blood or enteric contents, or amixture of the too. My tendency is therefore to explore these patients. However, it is a matterof judgement. If the CT shows no fluid, except around the liver, with gradeI injury, and the patient is CV normal (not the same as stable, as Karimpoints out), I think that non-op management is justified. Avi>Aviel Roy-Shapira, M.D.  email:avir@bgumail.bgu.ac.ilBen-Gurion University, Beer Sheva, IsraelDept of Surgery A and the Critical Care Unit, Soroka University Hospital. POBox, 151 Beer Sheva, IsraelPhone:972-7-6403390, 972-52-703902. Fax:972-7-6403260 
Date: Sat, 27 Jul 1996 10:57:40 -0400From: "Eric Frykberg  M.D."  Subject:  Nonoperative management of hepatic traumaReply-To: trauma-list@ftech.netWe also watch hepatic injuries nonoperatively based solely onhemodynamic stability, meaning no evidence of ongoing blood lossregardless of how much crystalloid or blood is required toreplete the initial loss, just as Dr. Dresner described.  Sincethis management based solely on the patient's clinical conditionclearly works, what the liver looks like on CT is irrelevant, apoint much of the country (the world?) has yet to realize, muchto the delight of our radiology departments.  Beyond one initialCT to document that it is the liver that is injured, any furtherstudies while the patient remains unchanged are superfluous.  Theliver injury grading system should not be used to make treatmentdecisions, since it is the patient's condition that alonedetermines the necessary course.  If a stable patient has a Grade4 or 5 injury, we will observe, and if a Grade 1 injury isunstable we will operate.  Even the practice of ordering a 2nd CTto document "healing" before discharge of a stable patient hasbeen shown unnecessary (not surprisingly) in a paper by DavidCiraulo and Len Jacobs presented at EAST in Jan. 1996, abstractin Dec 1995 issue of Journal of Trauma.  I am also unaware of anydata in which decompensation requiring surgery in an initiallystable patient being observed has any correlation with the gradeof liver injury, even though that appears to be the presumptionbehind the practice of multiple CT's described by Dr. Smith. Even if such a correlation exists, however, the patient, and notthe CT, will still dictate the treatment, and we should stilltreat patients, and not shadows on a piece of celluloid.I wholly agree with Dr. Streat's comments on nonoperativeobservation of liver injuries, but caution him that virtually allthe surgeons participating in this net ARE "intensivists", andmay not understand the distinction implied in his statement.Eric Frykberg, M.D.Jacksonville, Fl
From: KMATTOX@aol.comDate: Sat, 27 Jul 1996 21:24:20 -0400Subject: Re: Nonoperative management of hepatic trReply-To: trauma-list@ftech.netA word of caution.  A STRONG word of caution.  Be careful.  The data wegenerate in the large teaching hospitals with many house staff, monitors andother assistive systems is totally different from the lone surgeon in a15,000 population community with a 25 bed hospital.  If a single majorcomplication occurs, including hepatitis C following blood transfusions, hisgonads in that community are worthless.  In that environment, the most"conservative" approach may be to operate and the aggressive approach is towatch.k
Date: Sun, 28 Jul 1996 11:31:05 +0100From: "Dr. Karim Brohi" To: trauma-list@ftech.netSubject: Re: Nonoperative management of hepatic traumaReply-To: trauma-list@ftech.netDr. MattoxI don't think anyone is suggesting that these patients are managed nonoperatively outside a setting where there is adequate supervisionin terms of monitoring, nursing and medical staff and radiologybackup.I'm interested to hear in the criteria you use for 'haemodynamicallystable' and also how (if at all) you apply nonoperative management to the unconscious patient, being one of the leading proponents of thistechnique.Dr. Karim Brohi BSc FRCSTrauma & Critical Care Unit, Royal London HospitalMailto:karim@trauma.orghttp://www.trauma.org/
From: SHERIDAN@HELIX.MGH.HARVARD.EDUDate: Sun, 28 Jul 1996 12:44:36 -0500 (EST)Subject: Re: Nonoperative management of hepatic traumaReply-To: trauma-list@ftech.netamen to Eric Frykberg's comments on nonoperative management of liver injuriesRob SheridanBoston, MA
Date: Mon, 29 Jul 1996 18:50:00 +1200 (NZST)From: dave adams Subject: Re: Nonoperative management of hepatic traumaReply-To: trauma-list@ftech.netKarimIn this context our idea of stable is haemodynamically stable after initialfluid challenge of 1,500 to 2,000ml of crystalloid or colloid and onlyrequiring maintenance fluids thereafter.CT is not as sensitive for bleeding, for gut injury, and probably forpancreatic injury as DPL, so we do a DPL first as a screening measure. Thenif we are going to be conservative we do CT to further document what it isthat we are sitting on. ie DPL tells us whether there is an injury, but notwhat it is. We get about 6 significant liver injuries per year, and haven'thad to operate on one for three years. Haven't had any complication of thisapproach.CheersDave>Dave Adams FRACSGeneral & Vascular SurgeonMiddlemore HospitalAuckland, NEW ZEALANDemail dcrad@ihug.co.nzPh ++64 21 986614
Date: Mon, 29 Jul 1996 08:16:09 -0500From: "Dr. Jay Smith" Subject:  Nonoperative management of hepatic traumaReply-To: trauma-list@ftech.netActually, we do not use liberal amounts of CT scans, but use the CTscanner liberally.  Most patients only get 2 scans at most.  We have beendoing a study to document the development of cysts after embolization.>>> Dr. Jay Smith  07/26/96 07:26pm >>>We use a pulse < 120, bp >90, base deficit <3 as criteria for "stability". Of course, stable implies stability over several measurements:  120--120is stable but so is 60--60.  The actual state of perfusion must beaddressed as with the base deficit.We will also use 2 liters of replacement crystalloids to stabilize.  We uselberal amounts of CT scans to determine the severity of injury and willeven watch grade 4 liver injuries nonoperatively if stable.  The grade 4injury of the right lobe extending from the juxtahilar area to the costalmargin often has a bleeding vessel off the right hepatic artery andcoursing posteriorly and laterally that is embolizable via angiography.Embolization will leave an area of posttraumatic cyst, but these seem tobe benign.Consciousness does not affect our decision because we follow thesepatients with blood counts and CT scans as needed.