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Fri Jun 8 15:13:10 BST 2007

No data to support prophylactic Abx post-splenic art embolization. WBC will probably be high post-embolization-I would watch it and follow the temp. 

  Khumar

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Today's Topics:

1. Re: the modern spleen (caesar ursic)
2. RE: the modern spleen (Offner, Patrick)
3. RE: the modern spleen (saad shebrain)
4. Re: the modern spleen (Ronald Gross)
5. RE: the modern spleen (Ronald Gross)
6. Re: the modern spleen (SJASMD at aol.com)
7. Re: the modern spleen (SJASMD at aol.com)
8. RE: the modern spleen (Ronald Gross)
9. Re: the modern spleen (Ronald Simon)
10. Re: the modern spleen (Ronald Simon)
11. RE: the modern spleen (Offner, Patrick)
12. Re: the modern spleen (Ronald Gross)
13. RE: the modern spleen (Ronald Gross)
14. Re: the modern spleen (caesar ursic)
15. RE: trauma-list Digest, Vol 48, Issue 8 (Fiona Fahy)
16. Re: the modern spleen (Ronald Gross)

----------------------------------------------------------------------

Message: 1
Date: Thu, 7 Jun 2007 06:49:06 -0600
From: "caesar ursic" 
Subject: Re: the modern spleen
To: "Trauma &, Critical Care mailing list" 
Message-ID:
<7d3839570706070549j791908d4r6ccfc5ae1a89ed0d at mail.gmail.com>
Content-Type: text/plain; charset=ISO-8859-1; format=flowed

ok, I was thinking as were all of you. There was a large albeit subtle
'blush' on the lateral edge of the injured spleen prior to embolization, so
we were thinking that the whole 'raw' edge of the broken spleen was still
oozing. The radiologists coiled the main splenic artery, as there were no
obvious segmental arterial branches that we could attribute as the main
supply to the bleeding area. He inserted about five coils. Patient remain
hemodynamically normal throughout the whole ordeal.

it is now three hours after presentation to ER, nearly 24 hours since the
injury.

Admitted to ICU with Foley catheter; NPO; I did immunize him with pneumovax
at that point (I'm a pessimist by nature). Serial Hb ordered every six
hours initially, then less frequently. Here's the Hb trend (in g/dL):

admission: 13.9; six hours: 11.9, twelve hours: 11.3 eighteen hours: 10.5
twenty-four hours: 9.5; thirty hours: 9.1 thirty eight hours: 9.3; forty
eight hours: 9.1; morning of day five: 9.2 His BP and heart rate remain
normal all the time. His urine output always at or above 0.5cc/kg/hr.

abdominal exam: slowly improving (slower than I would like): he's quits
asking for narcotics by day two; starts passing flatus again by day three (I
move him out if ICU at that point); hungry again by day four, starts to eat.

other fun stuff: his oxygen saturations are slowly dropping on room air. A
chest x ray on day four shows a significant (maybe one-third) left pleural
effusion. The admission CXR was stone-cold normal, and CT cuts (on
admission) through the lower thorax showed no fluid/consolidation
whatsoever. Reactive pleural effusion? Drain it or let it be and wait for
it to reabsorb? He is now requiring 4 L/min by nasal cannula to maintain
spO2 of 93%. Not really dyspneic, but not really moving around much
either. Elevation at my hospital in Santa Fe is 7,000 feet (2,100
meters).

Oh, and now he's spiking temps to 40 C. WBC count remains slightly elevated
at 14,000 (down from 17,000 on admission). Urinalysis is clean. No IV site
infections. The angiographer had originally insisted that we give him
prophylactic antibiotics prior to the embolization (for one week) to 'cover'
for splenic infarction and splenic abscess formation. I didn't. Should I
have? Should I start antibiotics now? Blood cultures are pending.

Patient knows he won't be playing football this fall (I told him so) but
wants to play basketball starting January.

------------------------------

Message: 2
Date: Thu, 7 Jun 2007 08:49:04 -0600
From: "Offner, Patrick" 

Subject: RE: the modern spleen
To: "Trauma & Critical Care mailing list" 
Message-ID:
<3CCC1415C1512240A1D4BA60DCB5704D388075 at EVS01.corp.centura.org>
Content-Type: text/plain; charset="US-ASCII"

Reactive pleural effusions and fever are very common with this scenario.
I would continue to watch very closely. Missed bowel injury has to be in
the back of your mind. In my experience, splenic infarction is unusual
with main splenic artery embo(but have seen several--including
abscess--after distal embo). Don't believe in prophylactic antibiotics
in this situation--no data.

pat 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of caesar ursic
Sent: Thursday, June 07, 2007 6:49 AM
To: Trauma &, Critical Care mailing list
Subject: Re: the modern spleen

ok, I was thinking as were all of you. There was a large albeit subtle
'blush' on the lateral edge of the injured spleen prior to embolization,
so we were thinking that the whole 'raw' edge of the broken spleen was
still oozing. The radiologists coiled the main splenic artery, as there
were no obvious segmental arterial branches that we could attribute as
the main
supply to the bleeding area. He inserted about five coils. Patient
remain
hemodynamically normal throughout the whole ordeal.

it is now three hours after presentation to ER, nearly 24 hours since
the injury.

Admitted to ICU with Foley catheter; NPO; I did immunize him with
pneumovax at that point (I'm a pessimist by nature). Serial Hb ordered
every six hours initially, then less frequently. Here's the Hb trend
(in g/dL):

admission: 13.9; six hours: 11.9, twelve hours: 11.3 eighteen hours:
10.5 twenty-four hours: 9.5; thirty hours: 9.1 thirty eight hours: 9.3;
forty eight hours: 9.1; morning of day five: 9.2 His BP and heart rate
remain normal all the time. His urine output always at or above
0.5cc/kg/hr.

abdominal exam: slowly improving (slower than I would like): he's quits
asking for narcotics by day two; starts passing flatus again by day
three (I move him out if ICU at that point); hungry again by day four,
starts to eat.

other fun stuff: his oxygen saturations are slowly dropping on room
air. A chest x ray on day four shows a significant (maybe one-third)
left pleural effusion. The admission CXR was stone-cold normal, and CT
cuts (on
admission) through the lower thorax showed no fluid/consolidation
whatsoever. Reactive pleural effusion? Drain it or let it be and wait
for
it to reabsorb? He is now requiring 4 L/min by nasal cannula to
maintain
spO2 of 93%. Not really dyspneic, but not really moving around much
either. Elevation at my hospital in Santa Fe is 7,000 feet (2,100
meters).

Oh, and now he's spiking temps to 40 C. WBC count remains slightly
elevated at 14,000 (down from 17,000 on admission). Urinalysis is
clean. No IV site infections. The angiographer had originally insisted
that we give him prophylactic antibiotics prior to the embolization (for
one week) to 'cover'
for splenic infarction and splenic abscess formation. I didn't. Should
I have? Should I start antibiotics now? Blood cultures are pending.

Patient knows he won't be playing football this fall (I told him so) but
wants to play basketball starting January.
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/

*****************************************************************************
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contain information that is privileged and confidential. If you are not the 
intended recipient of this communication, any disclosure, copying, further 
distribution or use thereof is prohibited. If you have received this 
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------------------------------

Message: 3
Date: Thu, 7 Jun 2007 08:00:17 -0700 (PDT)
From: saad shebrain 
Subject: RE: the modern spleen
To: "Trauma &, Critical Care mailing list" 
Message-ID: <239530.38915.qm at web32615.mail.mud.yahoo.com>
Content-Type: text/plain; charset=iso-8859-1

the sympathetic left sided pleural effusion is less likely to be the source of WBC elevation unless very early empyema is going on. secondary effects of large pleural effusion could explained his hypoxia (compression collapse).
But I think with embolization of the main splenic artery, splenic abscess is likely to be evolving.The HEADQUARTERS of the immune system is attacked.He will need splenectomy. the sooner is the better.we have a similar case, where embolization of splenic artery lead to infarction and abscess formation.the hope to improve with Abx, ended with mortality case.

"Offner, Patrick" 
wrote:
Reactive pleural effusions and fever are very common with this scenario.
I would continue to watch very closely. Missed bowel injury has to be in
the back of your mind. In my experience, splenic infarction is unusual
with main splenic artery embo(but have seen several--including
abscess--after distal embo). Don't believe in prophylactic antibiotics
in this situation--no data.

pat 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of caesar ursic
Sent: Thursday, June 07, 2007 6:49 AM
To: Trauma &, Critical Care mailing list
Subject: Re: the modern spleen

ok, I was thinking as were all of you. There was a large albeit subtle
'blush' on the lateral edge of the injured spleen prior to embolization,
so we were thinking that the whole 'raw' edge of the broken spleen was
still oozing. The radiologists coiled the main splenic artery, as there
were no obvious segmental arterial branches that we could attribute as
the main
supply to the bleeding area. He inserted about five coils. Patient
remain
hemodynamically normal throughout the whole ordeal.

it is now three hours after presentation to ER, nearly 24 hours since
the injury.

Admitted to ICU with Foley catheter; NPO; I did immunize him with
pneumovax at that point (I'm a pessimist by nature). Serial Hb ordered
every six hours initially, then less frequently. Here's the Hb trend
(in g/dL):

admission: 13.9; six hours: 11.9, twelve hours: 11.3 eighteen hours:
10.5 twenty-four hours: 9.5; thirty hours: 9.1 thirty eight hours: 9.3;
forty eight hours: 9.1; morning of day five: 9.2 His BP and heart rate
remain normal all the time. His urine output always at or above
0.5cc/kg/hr.

abdominal exam: slowly improving (slower than I would like): he's quits
asking for narcotics by day two; starts passing flatus again by day
three (I move him out if ICU at that point); hungry again by day four,
starts to eat.

other fun stuff: his oxygen saturations are slowly dropping on room
air. A chest x ray on day four shows a significant (maybe one-third)
left pleural effusion. The admission CXR was stone-cold normal, and CT
cuts (on
admission) through the lower thorax showed no fluid/consolidation
whatsoever. Reactive pleural effusion? Drain it or let it be and wait
for
it to reabsorb? He is now requiring 4 L/min by nasal cannula to
maintain
spO2 of 93%. Not really dyspneic, but not really moving around much
either. Elevation at my hospital in Santa Fe is 7,000 feet (2,100
meters).

Oh, and now he's spiking temps to 40 C. WBC count remains slightly
elevated at 14,000 (down from 17,000 on admission). Urinalysis is
clean. No IV site infections. The angiographer had originally insisted
that we give him prophylactic antibiotics prior to the embolization (for
one week) to 'cover'
for splenic infarction and splenic abscess formation. I didn't. Should
I have? Should I start antibiotics now? Blood cultures are pending.

Patient knows he won't be playing football this fall (I told him so) but
wants to play basketball starting January.
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/

*****************************************************************************
This communication is for the use of the intended recipient only. It may 
contain information that is privileged and confidential. If you are not the 
intended recipient of this communication, any disclosure, copying, further 
distribution or use thereof is prohibited. If you have received this 
communication in error, please advise me by return e-mail or by telephone and 
delete/destroy it.
*****************************************************************************
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------------------------------

Message: 4
Date: Thu, 07 Jun 2007 11:00:10 -0400
From: "Ronald Gross" 
Subject: Re: the modern spleen
To: "Critical Care mailing list Trauma &" 
Message-ID: <4667E53A.7FF1.00B9.0 at harthosp.org>
Content-Type: text/plain; charset=US-ASCII

Ceasar,

I do not believe in prophylactic ABX for a presumably sterile procedure (embolization) either. I would tap the sympathetic pleural effusion and remove the source of the (unseen) atelectasis of the left lung and watch him improve his oxygenation rapidly, would not transfuse (a no-brainer for this group), and would mobilize.

Ok, now on post #3, so I am up to my 3 cents! ;-)

Ron

>>> "caesar ursic" 6/7/2007 8:49 AM >>>
ok, I was thinking as were all of you. There was a large albeit subtle
'blush' on the lateral edge of the injured spleen prior to embolization, so
we were thinking that the whole 'raw' edge of the broken spleen was still
oozing. The radiologists coiled the main splenic artery, as there were no
obvious segmental arterial branches that we could attribute as the main
supply to the bleeding area. He inserted about five coils. Patient remain
hemodynamically normal throughout the whole ordeal.

it is now three hours after presentation to ER, nearly 24 hours since the
injury.

Admitted to ICU with Foley catheter; NPO; I did immunize him with pneumovax
at that point (I'm a pessimist by nature). Serial Hb ordered every six
hours initially, then less frequently. Here's the Hb trend (in g/dL):

admission: 13.9; six hours: 11.9, twelve hours: 11.3 eighteen hours: 10.5
twenty-four hours: 9.5; thirty hours: 9.1 thirty eight hours: 9.3; forty
eight hours: 9.1; morning of day five: 9.2 His BP and heart rate remain
normal all the time. His urine output always at or above 0.5cc/kg/hr.

abdominal exam: slowly improving (slower than I would like): he's quits
asking for narcotics by day two; starts passing flatus again by day three (I
move him out if ICU at that point); hungry again by day four, starts to eat.

other fun stuff: his oxygen saturations are slowly dropping on room air. A
chest x ray on day four shows a significant (maybe one-third) left pleural
effusion. The admission CXR was stone-cold normal, and CT cuts (on
admission) through the lower thorax showed no fluid/consolidation
whatsoever. Reactive pleural effusion? Drain it or let it be and wait for
it to reabsorb? He is now requiring 4 L/min by nasal cannula to maintain
spO2 of 93%. Not really dyspneic, but not really moving around much
either. Elevation at my hospital in Santa Fe is 7,000 feet (2,100
meters).

Oh, and now he's spiking temps to 40 C. WBC count remains slightly elevated
at 14,000 (down from 17,000 on admission). Urinalysis is clean. No IV site
infections. The angiographer had originally insisted that we give him
prophylactic antibiotics prior to the embolization (for one week) to 'cover'
for splenic infarction and splenic abscess formation. I didn't. Should I
have? Should I start antibiotics now? Blood cultures are pending.

Patient knows he won't be playing football this fall (I told him so) but
wants to play basketball starting January.
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/

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------------------------------

Message: 5
Date: Thu, 07 Jun 2007 11:17:09 -0400
From: "Ronald Gross" 
Subject: RE: the modern spleen
To: "Trauma & Critical Care mailing list" 
Message-ID: <4667E935.7FF1.00B9.0 at harthosp.org>
Content-Type: text/plain; charset=US-ASCII

Agree re: effusion and infarction, but given the time frame and kid's physical exam I think that a missed bowel injury is highly unlikely....

I have no doubt that Ceasar (not time) will tell!

>>> "Offner, Patrick" 
6/7/2007 10:49 AM >>>
Reactive pleural effusions and fever are very common with this scenario.
I would continue to watch very closely. Missed bowel injury has to be in
the back of your mind. In my experience, splenic infarction is unusual
with main splenic artery embo(but have seen several--including
abscess--after distal embo). Don't believe in prophylactic antibiotics
in this situation--no data.

pat 

-----Original Message-----
From: trauma-list-bounces at trauma.org 
[mailto:trauma-list-bounces at trauma.org] On Behalf Of caesar ursic
Sent: Thursday, June 07, 2007 6:49 AM
To: Trauma &, Critical Care mailing list
Subject: Re: the modern spleen

ok, I was thinking as were all of you. There was a large albeit subtle
'blush' on the lateral edge of the injured spleen prior to embolization,
so we were thinking that the whole 'raw' edge of the broken spleen was
still oozing. The radiologists coiled the main splenic artery, as there
were no obvious segmental arterial branches that we could attribute as
the main
supply to the bleeding area. He inserted about five coils. Patient
remain
hemodynamically normal throughout the whole ordeal.

it is now three hours after presentation to ER, nearly 24 hours since
the injury.

Admitted to ICU with Foley catheter; NPO; I did immunize him with
pneumovax at that point (I'm a pessimist by nature). Serial Hb ordered
every six hours initially, then less frequently. Here's the Hb trend
(in g/dL):

admission: 13.9; six hours: 11.9, twelve hours: 11.3 eighteen hours:
10.5 twenty-four hours: 9.5; thirty hours: 9.1 thirty eight hours: 9.3;
forty eight hours: 9.1; morning of day five: 9.2 His BP and heart rate
remain normal all the time. His urine output always at or above
0.5cc/kg/hr.

abdominal exam: slowly improving (slower than I would like): he's quits
asking for narcotics by day two; starts passing flatus again by day
three (I move him out if ICU at that point); hungry again by day four,
starts to eat.

other fun stuff: his oxygen saturations are slowly dropping on room
air. A chest x ray on day four shows a significant (maybe one-third)
left pleural effusion. The admission CXR was stone-cold normal, and CT
cuts (on
admission) through the lower thorax showed no fluid/consolidation
whatsoever. Reactive pleural effusion? Drain it or let it be and wait
for
it to reabsorb? He is now requiring 4 L/min by nasal cannula to
maintain
spO2 of 93%. Not really dyspneic, but not really moving around much
either. Elevation at my hospital in Santa Fe is 7,000 feet (2,100
meters).

Oh, and now he's spiking temps to 40 C. WBC count remains slightly
elevated at 14,000 (down from 17,000 on admission). Urinalysis is
clean. No IV site infections. The angiographer had originally insisted
that we give him prophylactic antibiotics prior to the embolization (for
one week) to 'cover'

=== message truncated ===

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