The Utility of Serial Hemoglobin Monitoring in Non-operative Management of Blunt Splenic Injury

From the 2021 HVPAA National Conference

Nicolas Poupore (University of South Carolina School of Medicine Greenville), Bree Baginski, Nicole Boswell, Katherine Pellizzeri

Background

Serial hemoglobin (Hgb) measurements are frequently used to monitor ongoing hemorrhage in blunt splenic trauma (BST) patients. Serial draws consist of checking the patient’s Hgb every 2 to 12 hours (q2-12h). There is limited evidence that trending serial Hgb levels affect clinical decision making in non-operative management (NOM) of BST. The Eastern Association for the Surgery of Trauma (EAST) states that there is not enough evidence to recommend a particular frequency of measuring Hgb values for NOM.

Objective

This study was performed to compare the usefulness of q2-q12h Hgb values to daily (q24h) Hgb values in NOM of BST patients with the goal of de-implementing serial Hgb measurements from the NOM algorithm of BST.

Methods

We conducted a retrospective chart review of patients with a splenic injury who were brought to Greenville Memorial Hospital between 2013 and 2019. Demographics, comorbidities, lab values, clinical decisions, and outcomes were gathered through a trauma database.

Results

A total of 341 patients who arrived in the trauma bay with a BST underwent NOM. 297 were successful, 37 failed NOM, and 7 died of reasons unrelated to their splenic injuries. Of those that failed NOM, 8 were felt to have a significant decrease in Hgb levels that triggered a change to OM. 5 of the 8 patients (62.5%) were hypotensive first, 2 of the 8 patients (25%) were no longer receiving serial Hgb checks, and 1 of the 8 patients (12.5%) had a repeat CT and was embolized. Patients receiving q24h Hgb levels were not significantly different from q2-12h patients in injury severity, trauma bay vitals, comorbidities, medications, length of stay, largest drop in Hgb, and incidence of failing NOM.

Conclusions

Overall, these results show that trending serial Hgb levels did not seem to independently influence clinical decision making in NOM of BST. There were no identifiable patient-related risk factors in the serial Hgb group to indicate a target population that would benefit from serial Hgb levels. Patients who received q24h Hgb had similar injuries and outcomes compared to patients who received serial Hgb values. These results suggest that daily and serial Hgb levels are comparable in the NOM of BST.

Clinical Implications

These data have two major implications. First, de-implementation of serial Hgb blood draws could reduce the incidence of iatrogenic anemia in hospitalized patients and decrease discomfort or infection risk from multiple blood draws. This theoretically would minimize complications of anemia and reduce their length of stay.

Secondly, patients on average have serial Hgb levels drawn for the first 24-72 hours of hospitalization. This current hospital system charges patients $74.04 for a Hgb value meaning de-implementation of this practice could result in a reduction of $148.08 – $2,665.44 in charges per patient. If this practice were to be implemented for this patient population, this would create a significant cost reduction for patients and ultimately reduce unnecessary testing. The question of utility of serial hemoglobin measurements can also be extended to other patient populations with acute bleeding and potentially reduce its use in groups that find no benefit from this practice.