the modern spleen

[Ronald Gross]

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" <cmursic at gmail.com> 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.
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