Docstoc

Evaluation management of renal injuries

Document Sample
Evaluation management of renal injuries Powered By Docstoc
					Evaluation & management of
        renal injuries
  Presented by: Dr.Yasser Al-Jehani
            March 2005



               WWW.SMSO.NET
              Introduction

• Trauma is the leading cause of death in
  age group 1-37 yrs
• It also cause a great deal of morbidity
• Significant reduction in these rates is
  expected because of development of
  trauma centers and systems



                   WWW.SMSO.NET
             Renal injuries

• Usually based on single institution series
• Around 4 -10% of trauma cases
• Estimation world wide is 245000/yr
• It a disease of the young (80% < 40yrs)
• Common in males High risk activities
                        • High speed MVA
                        • Contact sports
                        • Violent crimes
                  WWW.SMSO.NET
         Mechanism of injury
• Blunt or penetrating
• The majority are blunt but there is a
  geographical variation     Europe 97%
• Blunt injuries are due to Canada 93%
                               •MVA
• Penetrating injuries are due•Fall
                             USA 82-95%
                                to
            •Stabs           South Africa 25-84%
                               •Assault
            •Gunshots        Rural Turkey 31%
                 Low velocity
                 High velocity
                   WWW.SMSO.NET
      Approach to the injured

• Initially evaluated by ER physician &
  trauma surgeon
• Follows ATLS protocols (ABCDE)
• Keep in mind 10% involves GU system
• Majority of GU injuries involves the kidney
• Obtain Hx (details of injury)


                   WWW.SMSO.NET
• In blunt, any deceleration phenomena,
  suspect         Vascular damage
• In penetrating, stab or gunshot location
                  •Thrombosis
                  •Disruption
• Assessment of gun characteristic (velocity)
                  •Avulsion
• Remember bullet ballistics
   •Speed (1000 ft/sec)
   •High velocity has greater damage
   •Cavities: temporary & permanent
   •Yaw effect
   •Fragmentations
   •Course & destruction (internal path)
                  WWW.SMSO.NET
WWW.SMSO.NET
               Hematuria
• It is the best indicator for GU trauma
• The degree does not correlate with the
  severity
• Either gross orof a vessel (5 RBCS/HPF)
       •Avulsion microscopic no hematuria
• In shock, SBP <(Grade 1)  gross hematuria
       •Contusion 90, hematuria is
  significant & predictor of other organ
  injury
• Always the first aliquot of urine (! Dilution)

                   WWW.SMSO.NET
             Classification

• AAST , OIS
• Grades 1-5
• Grade 1-3 clearly established by studies
• Grade 4/5 areas of overlap exist
• Grade 5 is a multiple grade 4
• Always advance one grade if bilateral
 injury

                   WWW.SMSO.NET
WWW.SMSO.NET
WWW.SMSO.NET
WWW.SMSO.NET
WWW.SMSO.NET
WWW.SMSO.NET
WWW.SMSO.NET
                 Staging
• The use of appropriate imaging to define
 the extent of injuries
      In pediatrics < 16 yrs
Indications for imaging are
       •Shock is late
• Gross hematuria with blunt trauma
       •Increase catecholamines
• Mic.hematuria with shock (SBP < 90)
       •BP decrease if 50% loss
• Penetratingrisk of injuryany degree trauma
       •High
               injury with
                            with blunt
                                       of
  hematuria
• If any suspicion  imaging

                   WWW.SMSO.NET
                Imaging

• Objectives of imaging are
  1.Stage the injury
  2.Recognize pre-existing pathology
  3.Document the function of the other kidney
  4.Identify other organ injury

• Cornerstone is contrast-enhanced CT
 which is highly sensitive and specific

                  WWW.SMSO.NET
                    CT scan
• Findings are:
1. Medial hematoma  vascular injury
2. Medial urinary extravas.  renal pelvis or PUJ
     avulsion
3.   Lack of contrast enhancement in parenchyma
      arterial injury
4.   Define parenchymal laceration/extravas.
5.   Associated injuries & retroperitoneal hematoma



                      WWW.SMSO.NET
               Limitations

• Pt has to be hemodynamically stable
• Inability to define venous injury clearly
• The issue of spiral CT
     is rapid 2-3 min
     but the contrast has less time be
     excreted (10 min is needed)


                   WWW.SMSO.NET
WWW.SMSO.NET
             Ultrasonography
•    Useful for the desirable features
1.   Global availability
2.   Cost-effective
3.   Accessibility to ER dep.
4.   Lack of radiation
5.   Accuracy in detecting free fluid
6.   Confirms the presence of 2 kidneys
7.   With Doppler the function can be assessed
     (flow)



                      WWW.SMSO.NET
           Limitations of US

• Cannot clearly delineate parenchymal
  laceration
• Cannot identify vascular injuries
• Cannot identify collecting system injuries
  clearly




                   WWW.SMSO.NET
           IVP (single shot)

• Used to be the standard in pre CT era
• It is replaced by CT
• Still has a role in trauma, intra-operatively
     Indicated in:
• It •Unstable Pt threatening renal injuries
      exclude life with no CT
• Confirms the existence of contralateral
     •In laparatomy,
     encountering retropritoneal hematoma
  kidney
    If results are abnormal or near normal,
    exploration is indicated
                    WWW.SMSO.NET
• IVP is limited by
  Profound hypotension
  Visceral edema
  Massive fluid resuscitation




                      WWW.SMSO.NET
              Angiography

• Defines arterial injuries
• Indicated if suspicion exists on CT
• It localizes the bleeding vessel
• In the era of interventional radiology,
 embolization/ stenting can be attempted
 in the form of non-operative management



                   WWW.SMSO.NET
            MRI (high field)

• It provides an excellent details
• BUT: no clear advantage over CT
• Time consuming & not rapidly available
• Lesser ability to detect urinary extravas.
• Rarely indicated in sever contrast allergy



                   WWW.SMSO.NET
     Retrograde pyelography

• Very limited use
• For selected cases in which CT cannot
 exclude renal collecting system injury or
 PUJ avulsion when no opacification is seen
 in distal uerter




                  WWW.SMSO.NET
            Follow up imaging
• Usually in cases treated conservatively
• Usually done in 48-36 hrs
• But if Pt’s condition is not improving, imaging
    might be indicated earlier
•   Watch for            Pain
                         Fever
                         Bleeding



                       WWW.SMSO.NET
    Non-operative management
•In penetrating trauma (stab or gunshot)
 • Pt is of renal well staged  non-operatively
•If 98% stable & injuries are managed non-
    operatively
•In 55% of stab Pt / 24% of gunshots Pt
 • Significant injuries grade 2-5 are managed
    non-operatively
 • Grade 4/5 usually  require exploration
 • Usually, hemodynamically stable Pt who is
    well staged by CT  no exploration
 • Admission, bed rest & follow up
                   WWW.SMSO.NET
WWW.SMSO.NET
Operative management




       WWW.SMSO.NET
              Renal exploration
•   Transabdoninal approach (other organs)
•   Early vessel occlusion (control of bleeding)
•   Before opening Gerota’s fascia
•   Trans.colon is lifted superiorly
•   Small bowel lifted superiorly to other side, this
    Exposes the mid retroteritonium
•   Incision is made over the aorta medial to the
    inferior mesenteric vein




                        WWW.SMSO.NET
WWW.SMSO.NET
• The incision is extended superiorly to the
 Early vessel isolation:
 ligament of Treitz
 Is it necessary ?
• As the aortic surface is exposed, the left
 renal vein is renal loss
 •It decreasesfollowed as it crosses the
 •Nephrectomy rate reduced 56% 18%
 aorta
• The kidney is exposed by incision in the
  peritonium lateral to the colon
• Gerota’s fascia is opened


                   WWW.SMSO.NET
WWW.SMSO.NET
WWW.SMSO.NET
       Renal reconstruction
•Complete renal exposure
•Debridment of nonviable tissues
•Hemostasis by ligature of bleeding vessel
•Watertight closure of collecting system
•Coverage & approximation of parenchymal
 defect
•Renorrhaphy: repair of parenchymal laceration
•If polar injury cannot be repaired  partial
Nephrectomy  pedicle flap  drains

                 WWW.SMSO.NET
WWW.SMSO.NET
         Renovascular injuries

• Arterial injuries from deceleration
• Mobility stretch intemal disruption (low
    elasticity)  thrombosis  ischemia
•   Should not be delayed (< 2 hrs)
•   Hypertension is common after repair
•   Auto-graft has better results
    (hypogastric/sleepnic arteries) ischemia
                            •Causes
•   Segmental artery        •If > 20%  explore
•   Main vein  repair , segmental vein  ligate

                      WWW.SMSO.NET
   Indications for nephrectomy
• Ability to reconstruct the kidney depend
  on many factors       •Pt’s stability
• Option: damage control by packing the
                        •Coagulation profile
  wound  correct Pt’s condition
• Plan to return for corrective surgery (in
  24hrs)
• But nephrectomy is done if life is
  threatened

                   WWW.SMSO.NET
              Complications
• Persistent urinary leak
• Causes urinoma  perirenal infection
• Majority resolve spontaneously
• If it persist  internal ureteral stenting




                     WWW.SMSO.NET
WWW.SMSO.NET
      Delayed renal bleeding

• Within 21 days
• Managed by bed rest & hydration
• If it persists  angiography/embolization




                  WWW.SMSO.NET
WWW.SMSO.NET
        Perinephric abscess

• Rare, urinoma is a precursor
• Percutaneous drainage/ surgically




                  WWW.SMSO.NET
             Hypertension

• Vessel injury  stenosis/ occlusion
• Compression of renal parenchyma
  by urinoma or hematoma
• Post traumatic arteriovenous fistula
• Renin-angiotensin axis activation (partial
  renal ischemia)


                   WWW.SMSO.NET
         Renal insufficiency

• Data is lacking
• Mainly with grade 4-5 (6%)
• Post angiographic embolization (10%)




                 WWW.SMSO.NET
Renal trauma & pre-existing kidney
           lesion
• Increases vulnerability
• Higher in children (low fat/ weak muscle)
• According to frequency
        Hyronephrosis (PUJ, stones or reflux)
        Cyst
        Tumors
        Abnormal position

                  WWW.SMSO.NET
WWW.SMSO.NET
In summary

    WWW.SMSO.NET
WWW.SMSO.NET
WWW.SMSO.NET
              Conclusion
• The approach to the diagnosis and
  management of renal trauma continues to
  evolve.
• In the setting of significant hemodynamic
  instability, operative exploration remains
  the diagnostic and therapeutic modality of
  choice.
• In patients with blunt trauma and in
  certain cases of penetrating trauma, a
  progressive trend is towards nonoperative
  management of renal trauma.
                  WWW.SMSO.NET
• Continued change in the approach to renal
  trauma is almost a certainty.
• Interventional radiology and endourologic
  manipulation have increased the ability to
  successfully treat patients without surgery
  and to address common complications of
  renal trauma.
• Numerous diagnostic options exist in the
  setting of a stable patient.
• With awareness of these modalities, the
  clinician can provide each patient with
  optimal treatment.
                  WWW.SMSO.NET
Thanks

  WWW.SMSO.NET

				
DOCUMENT INFO
Shared By:
Tags:
Stats:
views:15
posted:1/9/2013
language:
pages:55