J. Wycech1,2, J. Owens2,3, M. Gomez1, A. Tymchak1,2,3, M. Crawford2, A. A. Fokin2, I. Puente1,2,3,4 1Broward Health Medical Center,Trauma Services,Fort Lauderdale, FL, USA 2Delray Medical Center,Trauma Services,Delray Beach, FL, USA 3Florida Atlantic University,College Of Medicine,Boca Raton, FL, USA 4Florida International University,College Of Medicine,Miami, FL, USA
Introduction:
Non-operative management (NOM) is the standard of care for blunt splenic injuries (BSI) in hemodynamically stable patients. Traditionally, use of NOM is debatable when solid organ injury scale (OIS) Grade is III or higher with a tendency to expand the use of NOM to Grade IV injuries of liver, pancreas and kidneys. The goal of this study was to investigate whether NOM should be extended to higher grade spleen injuries, and to examine failure of NOM in isolated blunt splenic injuries (IBSI) in relation to the severity of spleen injury.
Methods:
This IRB approved retrospective cohort study included 133 adult patients with IBSI who were delivered to a level I trauma center between 2012 and 2017 and had attempted NOM of abdominal trauma. Patients were grouped by their OIS Grades and their management approach and outcomes, such as failure of NOM (FNOM), were compared. Furthermore, age, Injury Severity Score (ISS), comorbidities, packed red blood cells transfused within 24 hours (PRBC24), rate of hemoperitoneum, angiography, embolization, repeat abdominal computed tomography (CT), hospital length of stay (HLOS) and mortality were compared in OIS Grade III and IV groups. FNOM was defined as laparotomy after initially attempting NOM.
Results:
The average Spleen OIS was 2.4 (range I-V) with overall FNOM of 11.5% (n=12) and 1.9% (n=2) mortality. There were 33 patients with OIS I, 24 with OIS II, 32 with OIS III, 35 with OIS IV, 7 with OIS V. 2 patients did not have an assigned OIS Grade, because of the lack of precise radiological description of their spleen injury. Rate of attempted NOM in each OIS Grade group was as follows: OIS I 100.0%, OIS II 95.8%, OIS III 71.9%, OIS IV 65.7%, OIS V 28.6%. FNOM was 0% for OIS Grades I and II with no mortalities. In OIS Grades III and IV, FNOM rates were the same (21.7% vs 21.7%; p=1.0) with 1 mortality in patients with OIS Grade III. All patients with OIS Grade V, who had attempted NOM (n=2) failed NOM and underwent laparotomy.
Between OIS Grade III and IV, mean ISS (13.6 vs 19.4; p=0.001) and hemoperitoneum rate (69.6% vs 95.7%; p=0.02) were significantly higher in OIS Grade IV patients. Age (40.2 vs 41.1), comorbidities (65.2% vs 65.2%), PRBC24 (34.8% vs 34.8%), rates of angiography (52.2% vs 65.2%), embolization (30.4% vs 26.1%), repeat CT (30.4% vs 39.1%), HLOS (6.8 vs 9.4 days) and mortality (4.3% vs 0.0%) were not statistically different between patients with OIS Grades III and IV (all p>0.1).
Conclusion:
The rate of FNOM in patients with OIS Grade III and IV was the same, despite a significantly higher ISS and hemoperitoneum rate in Grade IV patients. Expansion of NOM to higher grade splenic injuries is cautiously recommended.