B. Lin1, K. Matsushima1, L. De Leon1, G. Recinos1, A. Piccinini1, E. Benjamin1, K. Inaba1, D. Demetriades1 1University Of Southern California,Acute Care Surgery,Los Angeles, CALIFORNIA, USA
Introduction:
Non-operative management (NOM) has become the standard of care in hemodynamically stable patients with blunt splenic injury. Due to the potential risk of bleeding, there are no widely accepted guidelines for an optimal and safe timeframe for the initiation of venous thromboembolism (VTE) prophylaxis in patients undergoing NOM. The purpose of this study was to explore the association between the timing of VTE prophylaxis initiation and NOM failure rate in isolated blunt splenic injury.
Methods:
After approval by the institutional review board, we utilized the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) database (2013-2014) to identify adult patients (≥18 years) who underwent NOM for isolated blunt splenic injuries (Grade III/IV/V). Patients were excluded if they expired within 24 hours of admission or required surgical management of splenic injury within 12 hours after admission. Failure of NOM was defined as any splenic surgeries after 12 hours of admission. The incidence of overall NOM failure was compared between two groups: 1) VTE prophylaxis <48 hours after admission (early prophylaxis group), and 2) VTE prophylaxis ≥48 hours (late prophylaxis group). Similarly, we compared the incidence of NOM failure after the initiation of VTE prophylaxis between the early and late prophylaxis group. Multiple logistic regression analysis was performed for NOM failure adjusting for clinically important covariates including the timing of VTE prophylaxis initiation.
Results:
A total of 816 patients met the inclusion criteria; median age: 34 years (IQR 23-52), 67% male gender, median ISS: 13 (IQR 10-17), 679 patients (83.2%) with severe splenic injury (Grade IV/V). Of the patients who met the inclusion criteria, VTE prophylaxis was not administered in 525 patients (64.3%), whereas VTE prophylaxis was given < 48 hours and ≥48 hours after admission in 144 and 147 patients, respectively. Among patients who received VTE prophylaxis, angioembolization of the spleen was performed in 30 patients (10.3%). Overall NOM failure rate was 13.4% (39/291). While overall NOM failure rate was significantly lower in the early group compared to late prophylaxis group (4.9% vs. 21.8%, p<0.001), there was no significant difference in the NOM failure rate after the initiation of VTE prophylaxis between two groups (3.5% vs. 3.4%, p=1.00). In the multiple logistic regression analysis, early initiation of VTE prophylaxis was not significantly associated with NOM failure (OR: 1.19, 95% CI 0.31-4.51, p=0.80).
Conclusion:
Our results suggest that early initiation of VTE prophylaxis (<48 hours) does not increase the risk of NOM failure in patients with isolated splenic injury. Further prospective study to validate the safety of early VTE prophylaxis is warranted.