Spleen/Liver injury: Grade + 1 = days of bed rest; What is the current status?

Phone conversation with R3 on call:
R3: got a kid down here, has grade 4 splenic lac. Stable
Me: so, what do you want to do?
R3: "take it out"

To be fair, the kid did "collapse" on the way to the bathroom, but probably form a vagal response.

Obviously, very few Pediatric Surgeons would argue that non-operative management is the general strategy in a stable child with blunt liver or splenic trauma. What constitutes non-operative management, on the other hand, is slightly more controversial.

Until recently, we had been treating kids with liver and splenic injury with bed rest, where the days in bed were determined by the grade of the injury. Grade + 1 = days in bed (grade + 2 = weeks of limited activity). In this protocol, as pointed out by St Peter et al. in a paper published in this month's JPS, days of bed rest are considered treatment variables, suggesting that a Grade 3 splenic lac needs 4 days to stabilize. Recent literature on the subject of non-operative management of liver and splenic injury has shifted focus from an absolute grade-defined management algorithm to one determined by hemodynamic stability and physical findings in an attempt to safely truncate what some would concider to be an overkill in terms of hospital stay.

St Peter et al prospectively studies 131 patients with liver and splenic injury from blunt trauma and noted that a protocol for monitoring (not therapy), where stable patients with grades I or II splenic injury are monitored for one night (defined as spending a night in their room regardless of time admission), while those who had a grade III or more, spend two nights in the hospital, is a safe alternative that could shorten hospital stay. Based on their protocol, if a patient needed a transfusion, the clock on observation was re-zero'd.

Using this protocol, the splenic salvage rate was 98.7%, regardless of associated injuries and transfusion requirements (13% required blood transfusion for their splenic and liver injuries). Obviously, and based on this protocol, there was a substantial decrease in hospital stay requirements.

St Peter et al. Prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. Journal of Pediatric Surgery (2011) 46, 173-177

What is the significance of CT-only lung lesions in Wilms' Tumor

The advent of CT imaging of the chest as part of the work up of Wilm's tumor has created substantial controversy. It is natural to assume that lesions of the lung found on CT scan,in the setting of a known primary tumor, represent metastatic disease. False. A study by Ehrlich et al, from the National Wilms' Tumor Study 5 showed that up to a third of lung lesions found on CT only (negative CXR) were not malignant (by pathology). This raises the question of how CT-only lesions should change the management.

Based on COG recommendations, patients who are local stage I or II FH Wilms' tumor should undergo biopsy of CT-only lung lesions to gauge therapy. Patients with Stage III or IV disease, who are enrolled in AREN0533 trial (evaluating response of lung lesions to 3 drug therapy after 6 weeks) are not treated differently in the presence of lung lesions unless these lesions persist after 6 weeks, at which time they would be treated with additional lung radiation, preferably after confirming their malignant nature with biopsy.

Erlich PF. The value of surgery in directing therapy for patients with Wilms’ tumor with pulmonary disease. J Ped Surg (2006) 41, 162-167

"We may need to recannulate this CDH baby!"

That's probably the last thing one wants to hear after answering a page!

Fortunately, the kiddo is doing better and did not require a second ECMO run (near diaphragmatic agenesis). This prompted a search for some literature on the subject of second run ECMO. Took a bit of research but found an article by Meehan et al. that looked at 205 patients from the ELSO neonatal registry who underwent multiple ECMO runs.

My main concern whenever the subject of potential need for recannulation comes up is the issue of recannulating the right CCA and CJV (A scenario encountered in 56% of patients in this study), with the potential for embolic events.

In their review, the authors noted a 20% increase in complication rates, with the largest increase in complication rates being for neurologic (134% increase) and infectious complications (79% increase). The most common type of neurologic complications were clinical seizures and radiologically documented cerebral strokes.

Overall survival after a second run was 38% (32% for CDH).

Journal of Pediatric Surgery, Vol 37, No 6 (June), 2002:pp 845-850