2019

FAILURE OF NON-OPERATIVE MANAGEMENT AFTER IR EMBOLIZATION IN A PATIENT WITH GRADE V+ LIVER TRAUMA: A CASE REPORT

Rebecca John, MSN, CPNP, and Dr. Mustafa Kabeer, M.D., FACS, FAAP CHOC Children’s Hospital, Orange, CA

INTRODUCTION§ Trauma is a major cause of injury and death in young

people, particularly when related to blunt objects with high impact or velocity2

§ In pediatrics, the liver and spleen = most commonly injured solid organs following this type of trauma2

§ Often, patients can be managed non-operatively if they remain hemodynamically stable1

§ In severe solid organ injuries interventional radiology (IR) can be utilized to circumvent surgery1

§ Embolization of splenic vascular injury is most common in pediatric cases2

§ Few cases of hepatic procedures have been documented; likely because contrast blush is rare, and only occurs in very high-grade liver injury1

§ This case report will discuss a patient with grade V+ liver laceration, requiring IR embolization and eventual laparoscopic evacuation of abdominal hemorrhage with peritoneal drain placement

HOSPITAL COURSE

DISCUSSIONREFERENCES

OBJECTIVES

§ Using the ATOMAC guideline, the main criteria for failure of NOM in children:

§ This patient continued to exhibit high IAPs, and decreased urine output, making abdominal compartment syndrome the main indication to go to the operating room.

§ Potential complications of IR procedures can include: vascular assess site problems (such as clot formation as with this patient), contrast induced nephropathy, groin or retroperitoneal hematomas, pseudoaneurysm, arterial dissection, or distal embolization1

§ Clinical judgement remains best determinant for need for surgery.

§ More research is needed to establish a comprehensive evidence-based guideline for when to operate.

1. Arbra, C. A., Vogel, A. M., Zhang, J., Mauldin, P. D., Huang, E. Y., Savoie, K. B., ... & Dassinger, M. S. (2017). Acute procedural interventions after pediatric blunt abdominal trauma: A prospective multicenter evaluation. Journal of trauma and acute care surgery, 83(4), 597-602.

2. Notrica, D. M., & Linnaus, M. E. (2017). Nonoperative management of blunt solid organ injury in pediatric surgery. Surgical Clinics, 97(1), 1-20.

3. Notrica, D. M., Eubanks III, J. W., Tuggle, D. W., Maxson, R. T., Letton, R. W., Garcia, N. M., ... & Garcia-Filion, P. (2015). Nonoperative management of blunt liver and spleen injury in children: Evaluation of the ATOMAC guideline using GRADE. Journal of Trauma and Acute Care Surgery, 79(4), 683-693.

3-year-old male run over by a truck at 4-5 mph In the OR:§ Visible bloody clot on the surface of liver along the

lateral aspect on the right side, as well as along the gastro-hepatic ligament extending onto the left diaphragm and near the porta hepatis and falciform ligament.

§ Abdominal washout of 1700 mL blood with JP drain placement.

Post-operative course was uncomplicated and he was discharged on post-op day 25 with close follow-up by:

§ Identify the type of injuries that commonly fail non-operative management (NOM) in trauma patients.

§ Describe potential complications of IR embolization procedures.

§ Discuss possible criteria to determine failure of non-operative management following abdominal trauma.

HOSPITAL COURSE CONT. DISCUSSION CONT.

Primary Pediatrician Hematology Gastroenterology Nutrition

Orthopedic Surgery Physical Therapy Occupational

Therapy Psychology

§ Injuries to liver or spleen > grade IV are known to require embolization and are at higher risk for failure of NOM.

§ Using interventional radiology procedures as a bridge to avoid major surgery can increase the rate of success of NOM.

§ In adults presence of contrast blush is considered predictive of need for surgical intervention3

Transfusion volume ≥ 40mL/kg

Hypovolemic shock

Hemodynamic instability

IR imaging of contrast blush

3

Thanks to: Dr. David Gibbs, M.D., FACS, FAAP, Dr. Mustafa Kabeer, M.D., FACS, FAAP Melisa Hill, MSN, CPNP, Lauren Kanamori, MSN, CPNP, and Jennifer Hayakawa, DNP, PCNS-BC

Acknowledgements: