J. Owens1,2, A. A. Fokin2, J. Wycech2,3, M. Crawford2, A. Tymchak1,2,3, M. Gomez3, I. Puente1,2,3,4 1Florida Atlantic University,College Of Medicine,Boca Raton, FL, USA 2Delray Medical Center,Trauma Services,Delray Beach, FL, USA 3Broward Health Medical Center,Trauma Services,Fort Lauderdale, FL, USA 4Florida International University,College Of Medicine,Miami, FL, USA
Introduction:
Nonoperative management (NOM) is the standard of care for blunt splenic injuries (BSI) in hemodynamically stable patients. Low-Molecular-Weight Heparin (LMWH) has been shown to be effective in prevention of thromboembolic complications in trauma patients. Reports are scarce regarding safety of early administration of LMWH in patients with BSI. The goal of this study was to investigate safety of early LMWH use in NOM patients with BSI.
Methods:
This IRB approved retrospective cohort study included 135 adult patients with BSI who were delivered to a level 1 trauma center over a 6 year period (2012 to 2017) with attempted NOM. Patients were divided into three groups: Early LMWH (n=12) who received LMWH within 72 hours of admission; Late LMWH (n=21) who received LMWH after 72 hours; and No LMWH (n=102) who did not receive LMWH or received it only after failed NOM and laparotomy. Injury Severity Score (ISS), Spleen organ injury scale (OIS) grade, rate of hemoperitoneum, units of blood transfused, occurrence of Deep Venous Thrombosis/Pulmonary Embolism (DVT/PE) and mortality were compared between the groups. Failure of NOM (FNOM) was defined as undergoing laparotomy after initially attempting NOM. To compare variability between the three groups one way ANOVA was used, followed by Tukey’s post-hoc comparison within the groups. Categorical variables were analyzed using the Kurskall Wallis test.
Results:
Mean ISS was significantly higher in the Late LMWH group compared to the No LMWH group, (19.4 vs 13.5; p=0.02). Mean spleen OIS grade was not different between the three groups (1.7 vs 2.5 vs 2.4; p=0.1). The percent of high grade spleen injuries (OIS 3+) was not statistically different between three groups (16.7% vs 47.6% vs 46.1%; p=0.1). In the Early LMWH group 7 patients (58.3%) had BSI injuries with other abdominal trauma, in the Late LMWH it was 15 patients (71.4%), and in No LMWH group it was 11 patients (10.8%).
Percent of patients with hemoperitoneum diagnosed on computed tomography CT scan was similar in the three groups (49.2% vs 48.3% vs 48.3%; p=0.9). In 135 patients, 17 (12.6%) had FNOM, and all but two failures occurred either before LMWH administration or in patients who never received LMWH. Mean units of blood transfused during hospital stay were statistically different between the three groups (1.2 vs 3.0 vs 1.6 units; p<0.001), with more units transfused in Late LMWH than in Early LMWH (p=0.005), and than in No LMWH (p<0.001). DVT/PE occurred in 4 patients (1 in Early and No LMWH and in 2 patients in Late LMWH) and was not statistically different between the groups (p=0.06). There were no mortalities in any of the groups that received LMWH.
Conclusion:
In patients undergoing NOM for blunt splenic injuries, early administration of LMWH did not increase the failure rate of NOM, units of blood transfused, or mortality and therefore, is safe and recommended.