International Journal of Academic Medicine

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 4  |  Issue : 3  |  Page : 271--277

Non-operative management of blunt hepatic injury: Early return to function, chemical prophylaxis, and elucidation of Grade III injuries


Meghan E Wooster1, M Chance Spalding2, James Andrew Betz3, Sandi Sellers3, Matthew L Moorman3, M Shay O'Mara3,  
1 Indiana University, Indianapolis, Trauma and Critical Care, Indiana, USA
2 Grant Medical Center, Trauma and Acute Care Surgery, Columbus; Ohio University Heritage College of Osteopathic Medicine, Ohio, USA
3 Grant Medical Center, Trauma and Acute Care Surgery, Columbus, Ohio, USA

Correspondence Address:
Dr. M Chance Spalding
Grant Medical Center, OhioHealth, 111 South Grant Avenue, Columbus, Ohio 43215-1898; Ohio University Heritage College of Osteopathic Medicine, Ohio
USA

Abstract

Background: Selective non-operative management of blunt hepatic trauma has shown decreased mortality and iatrogenic injury. Evidence-based recommendations are difficult to obtain regarding management of Grade III hepatic injuries and safe timing to implement return to function measures (enteral intake, chemical deep vein thrombosis [DVT] prophylaxis, and ambulation). Materials and Methods: This is a prospective, observational study of 130 trauma patients with blunt hepatic injuries over 2 years. A guideline was utilized to emphasize early hepatobiliary iminodiacetic acid scan and return to function measures at 24 h after injury. Patients were treated non-operatively with endoscopic retrograde cholangiopancreatography, percutaneous drainage, or embolization per evidence-based guidelines. Results: Fifty-seven patients suffered Grade III–V blunt liver injury. The biliary leak rate was higher for Grade IV and V liver injuries than Grade III (48%, 43%, and 12%, respectively) compared to lower grade injuries (0%). There was no significant difference in complications from initiation of chemical DVT prophylaxis, ambulation, or early enteral intake as a function of grade of hepatic injury. The average time to progression of treatment was 24 h and independent of the grade of liver injury. High-grade liver injuries were associated with lower age, increased injury severity score, and increased Intensive Care Unit length of stay. Conclusions: Trauma providers should consider Grade III liver injuries as low-grade injuries and treat accordingly. However, Grade IV and V injuries fail non-operative management more often than other grade injuries. Early enteral nutrition, chemical DVT prophylaxis, and ambulation are safe regardless of the grade of hepatic injury. The following core competencies are addressed in this article: Medical knowledge, Patient care, Practice-based learning and improvement, Systems-based practice.



How to cite this article:
Wooster ME, Spalding M C, Betz JA, Sellers S, Moorman ML, O'Mara M S. Non-operative management of blunt hepatic injury: Early return to function, chemical prophylaxis, and elucidation of Grade III injuries.Int J Acad Med 2018;4:271-277


How to cite this URL:
Wooster ME, Spalding M C, Betz JA, Sellers S, Moorman ML, O'Mara M S. Non-operative management of blunt hepatic injury: Early return to function, chemical prophylaxis, and elucidation of Grade III injuries. Int J Acad Med [serial online] 2018 [cited 2019 Jun 19 ];4:271-277
Available from: http://www.ijam-web.org/text.asp?2018/4/3/271/248336


Full Text



 Introduction



The liver is the most commonly affected organ in blunt abdominal injury.[1] Non-operative treatment for blunt hepatic injury has become the standard of care in hemodynamically stable adults with high rates of success, whereas, operative management may increase the chance of iatrogenic complications.[2],[3],[4] Non-operative approach to blunt hepatic injury including use of angiographic embolization, endoscopic retrograde cholangiopancreatography (ERCP), or percutaneous drainage has demonstrated decreased morbidity, mortality, and iatrogenic injury. In patients with nonspecific symptoms, use of hepatobiliary iminodiacetic acid (HIDA) scan is nearly 100% sensitive and specific for detection of biliary leaks and once detected, earlier intervention led to shorter hospital stays and less cost than reactive management of biliary complications.[5] Failure of these interventions has been shown to lead to operative intervention 25% of the time.[2],[6] Despite the benefits of non-operative therapy, the biliary and hemorrhagic complications associated with blunt hepatic injury are unchanged.[5],[7],[8],[9],[10]

There is a considerable amount of evidence which demonstrates screening for biliary leaks in Grade I and II hepatic injury is unnecessary, whereas, Grades IV and V frequently require intervention.[5],[7],[8],[9],[10] However, few studies have characterized Grade III hepatic injuries well as several of these studies are underpowered and investigate for biliary complications in Grade III injuries only after symptoms occur.[5],[6],[7],[8],[9]

Difficulties with management of blunt hepatic injury are more complicated than merely the operative versus non-operative decisions. The daily treatment with blunt hepatic injury revolves around safe progression of care. We defined this as safe timing for ambulation, initiation of enteral intake, and chemical DVT prophylaxis. Recently, the Eastern Association for the Surgery of Trauma practice management guideline illustrated a lack of consensus on recommendations involving the timing of these therapies based on current literature.[3]

Summarizing the past literature, it is unclear which subsets of patients benefit from empiric screening for biliary leaks. We hypothesized that biliary leaks in Grade III liver injuries are non-zero and should be treated as a high-grade injury.[11],[12],[13],[14],[15] The primary outcome was the likelihood of biliary leaks in Grade III hepatic injuries. The secondary measures were the effects of grade of hepatic injury on hemorrhage and need for intervention, the safe progression of treatment regarding timing of ambulation, chemical DVT prophylaxis, and enteral intake.

 Materials and Methods



Patients

A prospective observational trial was performed on patients suffering blunt abdominal injury admitted to an urban Level I trauma center over a 2-year period [Figure 1]. The non-operative blunt hepatic injury guidelines focused on empiric HIDA scans at 48 h, early ambulation, chemical DVT prophylaxis, and enteral intake [Figure 2]. These patients were compared to those who were treated with the standard of care for blunt hepatic trauma but not in accordance with the guidelines. Out of over 9000 patients suffering blunt trauma, 196 suffered hepatic injury. 130 patients met inclusion criteria: trauma patients 18 years of age or older who were diagnosed with a liver injury using the American Association for the Surgery of Trauma liver injury scale from a 64-slice helical computed tomography (CT) scan. Sixty-six patients were excluded due to an indication for operative intervention on arrival related to an injury other than the liver. No patients were excluded due to age younger than 18 years, evidence of pre-existing hepatic injury, or known biliary complications prior to admission.{Figure 1}{Figure 2}

Blunt hepatic injury nonoperative management protocol

Early HIDA scan and serial liver function tests were recommended for all Grade III–V injuries [Figure 2]. Biliary leaks and bilomas were evaluated and treated nonoperatively with ERCP or percutaneous drainage per gastroenterology or interventional radiology, respectively, recommendations. Interventional radiology was consulted and angiography recommended when a contrast blush from the liver was found onCT or need for >2 units of packed red blood cells (PRBCs) in 24 h. Early DVT prophylaxis, oral intake, and ambulation were encouraged after serial stable hemoglobin levels [Figure 1] and 24 h after injury. The standard chemical DVT prophylaxis agent at our institution is low-molecular weight heparin (LMWH) 30 mg subcutaneously twice a day unless significant renal dysfunction present then unfractionated heparin 5000 units subcutaneously three times a day were utilized. In patients with a body mass index >40, LMWH 40 mg twice a day was administered. Tolerating a diet was defined as no nausea, vomiting and intake of at least a clear liquid diet or enteral nutrition. Clinically significant biliary injury was defined as identification of biliary leak or biloma on imaging with presence of abdominal pain, nausea, vomiting, or signs of sepsis. Failure of nonoperative intervention included hyperbilirubinemia refractory to nonoperative intervention(s), hemodynamic instability refractory to 2 PRBCs in 24 h or development of peritonitis. The decision to proceed with operative intervention as well as the type of surgery was not dictated by the guideline.

Statistical analysis

The institutional trauma database was utilized to identify eligible patients and each patient's medical record was individually reviewed to assure accuracy. The data were analyzed with the help of trauma statisticians using SAS (Cary, NC) statistical software. Dichotomous or categorical variables were compared between independent patient groups using Chi-square tests. Odds ratios (ORs) were reported where informative. For continuous variables, two-sample t-tests or nonparametric Wilcoxon two-sample tests (or, in the case of five groups, F-tests) were performed.

 Results



Patient characteristics and degree of injury

During the 2-year study period, 130 patients met criteria for nonoperative management of blunt hepatic injury [Figure 2]. Grade III, IV, and V injuries were younger (28.2 years vs. 35.6 years, P = 0.0001) with higher injury severity score, 30.7 versus 19.1 (P < 0.0001), and longer Intensive Care Unit length of stay (LOS), 2.4 versus 4.5 (P < 0.02) [Table 1]. For ease of understanding, our results are divided into three sections referencing primary and secondary outcomes of the research: biliary leaks, hepatic hemorrhage, and progression of treatment (enteral intake, chemical DVT prophylaxis and ambulation).{Table 1}

Biliary leaks

Seventy-four patients (57%) suffered Grade I and II hepatic injuries with zero biliary leaks. Grade III injuries had a significantly lower leak rate than Grade IV and V, 11% versus 47% (P = 0.028) [Table 2]. Fifty-six patients (43%) were found to have Grade III to IV injuries, 37 patients underwent HIDA scan and 30% had a bile leak. There was no significant difference in the number of biliary leaks when comparing Grade III to Grades IV and V. There was one biliary leak in Grade III (12%), six in Grade IV (48%), and three in Grade V (43%) hepatic injury. The one patient with a Grade III hepatic injury and a biliary leak underwent successful ERCP. Of patients with Grade IV injury and biliary leak, four of these patients underwent ERCP, one bile leak was subclinical and the patient underwent expectant management. One patient had a missed injury that underwent operative intervention. In Grade V, hepatic injuries, two patients had a successful ERCP and one of these patients underwent percutaneous drainage of a biloma. A third patient underwent an ERCP that failed due to inability to place a biliary stent and progressed to operative intervention [Figure 2].{Table 2}

Analysis of early liver function tests did not correlate with presence of biliary leak or biloma regardless of the grade of injury. There was no difference in the timing to identification of Grade III versus Grade IV and V biliary leaks, respectively (2 vs. 2.27 days). Patients with Grade IV and V injuries had longer ICU LOS (3.5 vs. 1.6 days) compared to Grade III (P = 0.0005). Overall, a total of 11 non-operative interventions were performed on 10 patients with Grade III–V biliary leaks and (2/11, 17%) failed non-operative management.

Hepatic hemorrhage

Eleven patients underwent angiography. Ten patients met criteria with a contrast blush on 64 slice CT angiogram of the abdomen and pelvis at admission. One patient underwent angiography due to suspicion of intra-abdominal hemorrhage based on the presence of intra-abdominal hematoma on CT angiography. Two (2/11, 18.2%) patients underwent embolization, one Grade III, and one Grade IV There were no operative interventions performed for hemorrhage control [Figure 2].

Progression of treatment

Progression of treatment was defined as initiation of ambulation, chemical DVT prophylaxis, and initiation of enteral intake. We implemented all three treatments after 24 h (hours) regardless the grade of liver injury [Table 3].{Table 3}

Overall, 67.7% of patients with blunt hepatic injury where ambulating with minimal assistance after 24 h. The other 23.3% suffered orthopedic injuries that limited their mobility. There was no significant association between grade of liver injury and likelihood of tolerating early ambulation. There were no complications associated with early ambulation.

At 24 h, 60% (78/130) of patients were administered chemical DVT prophylaxis. Nearly 22% (28) were administered DVT prophylaxis after 24 h due to concern for ongoing coagulopathy or intracranial injury. About 18% (24) were discharged before administration of DVT prophylaxis or <24 h. 77% (57/74) of Grade I and II injuries, 39% (12/31) of Grade III injuries, 44% (8/18) of Grade IV injuries, and 14% (1/7) of Grade V injuries received DVT prophylaxis within 24 h. The average DVT prophylaxis was initiated later in Grade V injuries compared to Grade III and IV (3.14 days vs. 1.84 days, P = 0.00393). [Table 4] There were no complications including change in PRBC transfusion, drop in hemoglobin >2 g/dL, need for angiography or operative intervention associated with early initiation of chemical DVT prophylaxis. Of all patients, three percent[4] had complications due to venous thromboembolic events (VTE). In patients with Grade III injury, one patient had a pulmonary embolus (PE), one a DVT, of patients with Grade IV, one patient had a PE and DVT, and of patients with Grade V there was one patient with a DVT. The average hospital day of initiation of DVT prophylaxis in the patients with complications due to VTE was 3 days. There was no statistically significant difference between the groups.{Table 4}

Enteral nutrition was initiated on all patients irrespective of injury at 24 h after admission unless surgical intervention on the aerodigestive tract was planned. Overall, 72% of patients tolerated enteral nutrition at 24 h. 77% of patients with Grade I and II injuries tolerated enteral nutrition after 24 h. 84% of patients with Grade III injury tolerated enteral nutrition at 24 h; however, Grade IV and V injuries (58%) were significantly less likely to tolerate early enteral nutrition (OR = 3.8, P = 0.029) [Table 3].

Overall, there was no increased morbidity or mortality with non-operative management of blunt hepatic injuries including biliary leak, hepatic hemorrhage or with progression of treatment including ambulation, chemical DVT prophylaxis or enteral intake after 24 h.

 Discussion



The liver is the most commonly injured organ in blunt abdominal trauma.[1] Management of the high-grade hepatic injury involves a multidisciplinary non-operative treatment approach to decrease morbidity. Evidence is lacking concerning the timing to safe ambulation, start of chemical DVT prophylaxis, and initiation of enteral intake after hepatic injuries. Our primary goal was to determine if surveillance for bile leaks through HIDA scan resulted in detection of a higher number of Grade III biliary leaks than previously reported. This particular complication is notorious for having a delayed presentation and the early recognition and treatment leads to decreased morbidity.[8],[13],[16] Our secondary goal was to evaluate the safe timing to initiation of ambulation, chemical DVT prophylaxis, and enteral intake. Ambulation itself has not been demonstrated to increase complication rates of blunt hepatic injuries, but hesitation still exists concerning the appropriate timing. Safe timing for initiation of chemical DVT prophylaxis and enteral intake in blunt hepatic injuries is still unclear.[17],[18]

HIDA scan is reported to be 100% sensitive and specific for the detection of bile leaks.[5] With empiric HIDA scans for Grade III–V injuries, we found a lower incidence of clinically significant biliary leaks in Grade III injuries than previously reported.[2],[3],[5],[6],[8],[9] Unfortunately, this did not reach statistical significance. This suggests that Grade III liver injuries should be treated as “low grade.” After identification of a bile leak, the clinical management can be both operative and non-operative. We achieved a 100% (2/2) successful non-operative management of low-grade liver injuries and 83% (9/11) successful non-operative management of high-grade liver injuries. Only two patients (17%) failed non-operative management due to delayed diagnosis and failure of non-operative intervention, respectively. The success rate of non-operative management of liver injuries in our study was similar to what has been previously reported.[4],[5],[6],[8]-,-[15],[19]

Non-operative management of hepatic hemorrhage has demonstrated low morbidity and mortality in hemodynamically stable or transiently responsive patients.[3],[6],[8],[13],[16],[20] We demonstrated 100% (10/10) successful non-operative intervention with angiography compared to reported success rates of 79%–92%.[14],[15],[19],[20] Our higher success rate of 100% (10/10) may be secondary to our institutional bias toward early angiography after identification of a contrast blush on CT regardless of the patient's hemodynamics or the size of the blush. This, along with the responsiveness of our interventional radiology team, may have led to the higher success rate than previously published.

Recommendations for safe progression of treatment including initiation of enteral intake, ambulation, and chemical DVT prophylaxis when treating blunt hepatic are not clearly defined by current evidence. Similar to the previous studies, we found no increased morbidity with ambulation at 24 h.[17],[21] Early initiation of chemical DVT prophylaxis has been demonstrated to be safe in splenic but not hepatic injuries.[18] We demonstrated this is indeed safe within 48 h for Grade III and IV and 72 h in Grade V. This principle may be broadened to all blunt hepatic trauma, regardless the grade of injury. Nearly 3% of our patients suffered complications due to coagulopathy similar to other documented outcomes.[22],[23] Average day of initiation of DVT prophylaxis was no longer than those without complications. Minimizing other risk factors for DVT and PE are necessary. Safe timing for initiation of enteral intake remains largely unknown. We demonstrate that allowing patients with blunt hepatic injury to have enteral intake at 24 h is safe regardless the grade of injury.

Our study was limited by lack of empiric HIDA scans on all grades of liver injuries. This may create a potential bias to detect more clinically insignificant leaks in higher grade injuries. Protocol compliance was a challenge as it was a new practice and timing of laboratory and imaging was somewhat inconsistent. Although this study population is large on a scale of blunt hepatic injury studies, the population size may not be large enough to understand the complications associated with early ambulation, enteral intake, and chemical DVT prophylaxis.

 Conclusions



Non-operative management for blunt hepatic injury has increased in popularity over the previous decades to now become the standard of care. Grade III blunt hepatic injuries, contrary to our hypothesis, have a low biliary leak and biloma rate. Surveillance with a HIDA scan is beneficial for Grade III liver injuries with clinical signs of bile leak and biloma and on a routine basis in higher blunt hepatic injuries allowing for early diagnosis and treatment. Early progression of treatment including early ambulation, enteral intake, and DVT prophylaxis is safe regardless of the grade of liver injury.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Ethical conduct of research

The study “Non-operative management of blunt hepatic injury: Early return to function, chemical prophylaxis, and elucidation of Grade III injuries” has been approved by the Ohiohealth Institutional Review Board, #15-0012.

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