High-grade Blunt Splenic Injury Research Articles

Level III Trauma Centers Achieve Comparable Outcomes in Blunt Splenic Injury as Level I Centers.

Identifying patients who can be safely managed in lower-level trauma centers is critical to avoid overburdening level I centers. This study examines the transfer patterns and outcomes of blunt splenic injury (BSI) patients cared for at 2 regional level III trauma centers as compared to an associated level I center. A retrospective cohort study was conducted including all trauma patients with BSI admitted to 2 level III trauma centers (TC3) and a level I center (TC1) between 2012 and 2022. Patients were broken into 3 categories: TC1, TC3, and transfer patients (transferred from TC3 to TC1). A total of 1480 patients were admitted to TC1, 208 patients to TC3, and 128 were transferred. 22.7% of transfer patients were children. No difference in splenic injury grade was seen between patients managed at TC1 and TC3. Patients presenting to TC1 had more severe concomitant injuries. Patients underwent urgent splenectomy at similar rates at TC1 and TC3 (15.1 vs 18.7%, P = .1). Successful nonoperative management was achieved at similar rates (81.3 vs 75.5%, P = .1). When controlling for ISS and ED disposition, there was no significant difference in length of stay (LOS), ICU LOS, and inpatient mortality between TC1 and TC3. Level III centers effectively managed BSI achieving comparable outcomes to the level 1 center. Transfers commonly occurred in pediatric and multisystem trauma patients, though high-grade splenic injuries were not predictive of transfer. High-grade BSI can be safely managed at level III centers without need for transfer.

Pre- and post-implementation protocol for non-operative management of grade III-V splenic injuries: An observational study

BackgroundGrade (III–V) blunt splenic injuries (BSI) in hemodynamically stable patients represent clinical challenges for successful non-operative management (NOM). In 2014, Our institution proposed a treatment protocol requiring splenic angiography and embolization for stable, intermediate, and high-grade BSI. It also included a follow-up CT scan for grade III BSI. We sought to assess the success rate of NOM in treating intermediate and high-grade BSI, following a standardized treatment protocol at a level 1 trauma center. MethodsAn observational retrospective study was conducted. Data of patients with BSI from June 2011 to September 2019 were reviewed using the Qatar National Trauma Registry. Patients’ demographics, CT scan and angiographic findings, grade of splenic injuries, and outcomes were analyzed. The pre- and post-implementation of treatment protocol periods were compared. ResultsDuring the study period, a total of 552 hemodynamically stable patients with BSI were admitted, of which 240 had BSI with grade III to V. Eighty-one patients (33.8%) were admitted in the pre-protocol implementation period and 159 (66.2%) in the post-protocol implementation period. The NOM rate increased from 50.6% in the pre-protocol group to 65.6% in the post-protocol group (p = 0.02). In addition, failure of the conservative treatment did not significantly differ in the two periods, while the requirement for blood transfusion dropped from 64.2% to 45.9% (p = 0.007). The frequency of CT scan follow-up (55.3% vs. 16.3%, p = 0.001) and splenic arterial embolization (32.7% vs. 2.5%, p = 0.001) in NOM patients increased significantly in the post-protocol group compared to the pre-protocol group. Overall mortality was similar between the two periods. However, hospital and ICU length of stay and ventilatory days were higher in the post-protocol group. ConclusionsNOM is an effective and safe treatment option for grade III-V BSI patients. Using standardized treatment guidelines for intermediate-to high-grade splenic injuries could increase the success rate for NOM and limit unnecessary laparotomy. Moreover, angioembolization is a crucial adjunct to NOM that could improve the success rate.

Persistent disparities between trauma center types in the management of children with high-grade blunt splenic injuries.

In the early 2000s, substantial variations were reported in the management of pediatric patients with blunt splenic injury (BSI). The purpose of this study was to assess the recent trends and disparities between different types of trauma centers. We hypothesized that there would be persistent disparities despite decreased trends in the rate of splenectomy. This is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database. We included patients (age ≤18years) with high-grade BSI (Abbreviated Injury Scale 3-5) between 2014 and 2021. The patients were divided into three groups based on trauma center types (adult trauma centers [ATCs], mixed trauma centers [MTCs], and pediatric trauma centers [PTCs]). The primary outcome was the splenectomy rate. Logistic regression was performed to evaluate the association between trauma center types and clinical outcomes. Additionally, the trends in the rate of splenectomy at ATCs, MTCs, and PTCs were evaluated. A total of 6601 patients with high-grade BSI were included in the analysis. Overall splenectomy rates were 524 (17.5%), 448 (16.3%), and 32 (3.7%) in the ATC, MTC, and PTC groups, respectively. ATCs and MTCs had significantly higher splenectomy rates compared to PTCs (ATCs: OR=5.72, 95%CI=3.78-8.67, and p<0.001 and MTCs: OR=4.50, 95%CI=2.97-6.81, and p<0.001), while decreased trends in the splenectomy rates were observed in ATCs and MTCs (ATCs: OR=0.92, 95%CI=0.87-0.97, and p=0.003 and MTCs: OR=0.92, 95%CI=0.87-0.98, and p=0.013). This study suggested persistent disparities between different trauma center types in the management of children with high-grade BSI.

National Management Trends in Pediatric Splenic Trauma – Are We There yet?

IntroductionGuidelines recommend nonoperative management of blunt splenic injury (BSI) for hemodynamically stable children. The aim of this study was to determine the contemporary national trends of nonoperative management in pediatric BSI. MethodsA retrospective review was preformed utilizing KIDS database between 2012 and 2019. Pediatric BSI cases age ≤16 years were selected for analysis. Patient demographics, severity, and interventions were compared between hospital types. Results8,296 BSIs were identified, with 74.3% treated at non-pediatric hospitals. Overall, 96.3% of BSI were nonoperative; 2.5% undergoing angioembolization. Rates of splenectomy from 2012 to 2019 remained stable (6.8% versus 7.1% (p = 0.856)). Splenic injuries treated at adult hospitals were more likely to undergo operative management (11.9% versus 4.4%, OR 2.94, p < 0.001) and more likely to undergo angiography (4.8% vs 1.3%, OR 3.133, p < 0.001). On multivariate regression pediatric BSI treated at adult centers were associated with triple the risk of splenectomy (OR 3.50, p < 0.001). Over seven years, high grade BSI treated at children's hospitals increased from 14.6% to 51.7% (p < 0.001) and, splenectomy rates at children's hospitals increased from 1% to 4% (p < 0.001). ConclusionMore than 70% of pediatric splenic injuries are treated at adult hospitals, however, children's hospitals predominately caring for high-grade BSI. After controlling for confounding factors, children treated at adult centers continue to have 3-fold likelihood of splenectomy. Over the last 7 years, pediatric hospitals have seen a significant rise in their overall splenectomy rate, which may suggest a shift in case severity to children's hospitals. Level of evidenceLevel III. Type of studyTreatment study.

A clinical prediction model for non-operative management failure in patients with high-grade blunt splenic injury

BackgroundNonoperative management (NOM) is the standard treatment for hemodynamically stable blunt splenic injury (BSI). However, NOM failure is a significant source of morbidity and mortality. We developed a clinical risk scoring system for NOM failure in BSI. MethodsData from the Japanese Trauma Data Bank from 2008 to 2018 were analyzed. Eligible patients were restricted to those who underwent NOM with high-grade BSI (Organ Injury Scale ≥3). The primary outcome was a predictive score for NOM failure based on risk estimation. ResultsThere were 1651 patients included in this analysis, among whom 110 (6.7%) patients had NOM failure. Multivariate analysis identified seven variables associated with failed NOM: systolic blood pressure, Glasgow coma scale, Injury Severity Score, other concomitant abdominal injury, pelvic injury, high-grade BSI, and angioembolization. An eight-point predictive score was developed with a cut-off of greater than 5 points (specificity, 98.2%; sensitivity, 25.5%) with an area under the curve of 0.81. ConclusionThe clinical predictive score had good ability to predict NOM failure and may help surgeons to make better decisions for BSI.

Recent trends in the management of isolated high-grade splenic injuries: A nationwide analysis.

The feasibility of nonoperative management for high-grade blunt splenic injuries (BSIs) has been suggested in recent studies. The purpose of this study was to assess nationwide trends in the management of isolated high-grade BSIs. We hypothesized that isolated high-grade BSIs are more frequently being managed nonoperatively. The American College of Surgeons Trauma Quality Improvement Program database was queried to identify patients (16 years or older) with isolated high-grade BSIs (Abbreviated Injury Scale, ≥3) between 2013 and 2019. Patients were divided into two groups based on their hemodynamic status (hemodynamically stable [HS] and hemodynamically unstable [HU]). The primary outcome was the rate of total splenectomy each year, and the secondary outcome was the use of splenic angioembolization (SAE). Multiple regression models were created to estimate annual trends in splenectomy and SAE. A total of 6,747 patients with isolated high-grade BSIs were included: 5,714 (84.7%) and 1,033 (15.3%) in HS and HU groups, respectively. In the HS group, the rate of overall splenectomy was significantly decreased (from 22.9% in 2013 to 12.6% in 2019; odds ratio [OR] for 1-year increment, 0.850; 95% confidence interval [CI], 0.815-0.886; p < 0.001), and the use of SAE was significantly increased (from 12.5% in 2013 to 20.9% in 2019; OR, 1.107; 95% CI, 1.065-1.150; p < 0.001). In the HU group, the overall splenectomy rate was unchanged (from 69.8% in 2013 to 50.8% in 2019; OR, 0.931; 95% CI, 0.865-1.002; p = 0.071), whereas SAE was significantly increased (from 12.7% in 2013 to 28.8% in 2019; OR, 1.176; 95% CI, 1.079-1.284; p < 0.001). We observed significant trends toward more frequent use of nonoperative management in high-grade BSIs with hemodynamic stability. Further studies are warranted to define the role of SAE, especially in patients with hemodynamic instability. Therapeutic/Care Management; Level IV.

WE7.6 Failure of intensive monitoring in high grade blunt splenic injury: an important consideration beyond NOM failure

Abstract Aims Non-operative management (NOM), including intensive monitoring (IM) and angioembolisation (AE), is the standard of care for haemodynamically stable patients with blunt splenic injury to preserve spleen and it's function. Internal review of local Level 1 Trauma Center revealed a NOM failure rate of 4.4%, but an IM failure rate of 16.2% in high grade blunt splenic injury (HGBSI). Age, Injury Severity Score (ISS) and moderate to severe injuries are predictors for NOM failure. However, predictors of IM failure, which can be successfully treated with AE, is not well understood, motivating the current study. Methods Patients with BSI are identified from Trauma Audit and Research Network (TARN) databse from 2015–2020. Clinical, biochemical and radiological data were collated from TARN database and electronic medical records. HGBSI is defined as AAST grade III to V. Results Sixty-eight patients with HGBSI were identified. Seventy-eight percent (n=53) were initially managed with IM, with 21% (n=11) requiring subsequent interventions. Majority who failed IM were involved in road traffic accident compared to other causes (p-value=0.035). In addition, a higher proportion had systole blood pressure&amp;lt;90mmHg (p-value=0.033) and pH&amp;lt;7.2 (p-value=0.038) at presentation. AAST grade, ISS or age did not influence requirement for further intervention. Nine of the eleven patients were treated successfully with AE. Conclusion Understanding predictors of IM failure will enable better selection of patients for AE at initial presentation, leading to potential reduction in duration of IM, length of stay and blood transfusion. Preliminary work using machine learning algorithm to predict IM failure with larger dataset is on-going.

Management of High Grade Splenic Injuries in Rural America.

Rural surgeons face unique challenges when managing patients with high-grade (III-V) blunt splenic injury (BSI) given limited access to interventional radiology and blood products. Patients therefore may require transfer for splenic artery embolization (SAE) when resuscitation may still be ongoing. This study aims to evaluate current resource utilization in a rural trauma population with limited access to SAE and blood products. Retrospective analysis of adult patients with high-grade BSI at one Level 1 trauma center and two Level 2 trauma centers was performed. Patients were evaluated for resources used after transfer to the regional trauma center. Primary outcomes measured were SAE, operative management (OM), and blood product utilization. Secondary outcomes measured included injury severity score (ISS) and mortality. Final analysis included 134 transferred patients. 16% underwent SAE, 16% underwent OM, and 69% were treated successfully with nonoperative and non-procedural management (NOM). 52% of the SAE patients had sustained a grade III splenic injury, 38% grade IV, and 10% grade V. 84% of patients required <3 units of packed red blood cells (PRBC) and 57% of patients required none. 80% of transferred patients required <3 total units of all combined blood products. The majority of patients with BSI transferred to a tertiary trauma center from a rural facility were successfully managed without SAE and required minimal transfusion of blood products. In the absence of other injuries necessitating transfer to a tertiary trauma center, rural surgeons should consider management of high grade splenic injuries at their home institution.

Cost Utility of Splenic Artery Angioembolization for High-Grade Splenic Injury

Abstract Background: Management of blunt spleen injuries has evolved from mandatory splenectomy to non-operative man-agement (NOM) allowing for splenic salvage, Splenic artery embolization (SAE) has been shown to be an effective treat-ment for hemodynamically stable patients with high-grade blunt splenic injury. However, there are no local estimates of how much treatment costs. Aim of Study: The aim of this study was to evaluate the cost of providing SAE to patients in the setting of blunt abdominal trauma with splenic injury and to determine if the costs of an added, preventative procedure (SAE) early in management of blunt splenic injury would be offset by added utility by avoiding splenectomy. Patients and Methods: This study was a retrospective cohort study from a tertiary institution (50 patients in King Khaled Hospital Trauma Center, Hail, KSA and 9 patients in Al Hussein University Hospital, Cairo, Egypt). A total of 59 patients were treated with embolization in this period for blunt trauma, and however 39 cases were excluded given the presence of multiple concomitant injuries. Isolated splenic injury treated with SAE were identified in 20 patients and included for final analysis. Of these 10 patients, none required subsequent splenectomy following SAE. Results: The mean total angiography costs were 1837.94±  405.368 $, the costs of post-procedure management of patients including all hospital costs prior to discharge with associated length of stay. Conclusion: Splenic embolization is a low-cost procedure for management of blunt splenic injury. The cost to provide SAE at our center was much lower than previously modelled data from overseas studies. Further research is advised to directly compare the cost of SAE and splenectomy in other countries.

Experience with clinical pathway for management of high grade blunt splenic injuries: a prospective study in adults at two tertiary trauma centers

Background: There is ambiguity regarding anatomical site of embolization, frequency of follow-up scans and splenic function following angioembolisation in the management of high grade blunt splenic injury. A splenic salvage pathway in patients who are hemodynamically stable or resuscitated to stability was introduced across two trauma centres. The aims of this project were: to develop a clinical pathway to manage hemodynamically stable blunt splenic injury patients and to determine rates of splenic salvage for patients with high grade splenic injury, assess complications and splenic function following completion of the pathway.Methods: Prospective study over a period of 24 months. Data was collected to evaluate rates of splenic salvage, complications and function of the spleen following angioembolisation.Results: Thirty-three patients, predominantly males (n=29) between the ages of 14-85 years, were included in the study. Three (9%) with grade V injury, underwent angioembolization on admission but required splenectomy as an inpatient. On day 14, all patients (n=30) with splenic salvage underwent blood tests, with 3 patients (9%) receiving vaccination for altered red cell morphology. The introduction of clinical pathway led to an increase in our splenic salvage rate to 91%.Conclusions: We believe that introduction of proposed clinical pathway may result in increased rates of splenic salvage with preservation of function following angioembolisation. 

The management and outcome of paediatric splenic injuries in the Netherlands

BackgroundNon-operative management (NOM) is generally accepted as a treatment method of traumatic paediatric splenic rupture. However, considerable variations in management exist. This study analyses local trends in aetiology and management of paediatric splenic injuries and evaluates the implementation of the guidelines proposed by the American Paediatric Surgical Association (APSA) in a level 1 trauma centre.MethodsThe charts of paediatric patients with blunt splenic injury (BSI) who were admitted or transferred to a level 1 trauma centre between 2003 and 2020 were retrospectively assessed. Information pertaining to demographics, mechanism of injury, injury description, associated injuries, intervention and outcomes were analysed and compared to international literature.ResultsThere were 130 patients with BSI identified (63.1% male), with a mean age of 11.3 ± 4.0 and a mean Injury Severity Score (ISS) of 21.6 ± 13.7. Bicycle accidents were the most common trauma mechanism (23.1%). Sixty-four percent were multi-trauma patients, 25% received blood transfusions, and 31% were haemodynamically unstable. Mean injury grade was 3.0, with 30% of patients having a high-grade injury. In total, 75% of patients underwent NOM with a 100% efficacy rate. Total splenectomy rate was 6.2%. Four patients died due to brain damage.Patients with a high-grade BSI (grades IV–V) had a significantly higher ISS and longer bedrest and more often presented with an active blush on computed tomography (CT) scans than patients with a low-grade BSI (grades I–III). Non-operative management was mainly the choice of treatment in both groups (76.6% and 79.5%, respectively). Haemodynamic instability was a predictor for operative management (OM) (p = 0.001). Predictors for a longer length of stay (LOS) included concomitant injuries, haemodynamic instability and OM (all p < 0.02). Interobserver agreement in the grading of BSI is moderate, with a Cohens Kappa coefficient of 0.493.ConclusionNon-operative management has proven to be a realistic management approach in both low- and high-grade splenic injuries. Consideration for operative management should be based on haemodynamic instability. Compared to the anticipated length of bedrest and hospital stay outlined in the APSA guidelines, the Netherlands can reduce the length of bedrest and hospital stay through their non-operative management.Level of evidenceTherapeutic study, level III

The cost to perform splenic artery embolisation following blunt trauma: Analysis from a level 1 Australian trauma centre

IntroductionSplenic artery embolisation (SAE) has been shown to be an effective treatment for haemodynamically stable patients with high-grade blunt splenic injury. However, there are no local estimates of how much treatment costs. The purpose of this study was to evaluate the cost of providing SAE to patients in the setting of blunt abdominal trauma at an Australian level 1 trauma centre. MethodsThis was a single-centre retrospective review of 10 patients who underwent splenic embolisation from December 2017 to December 2018 for the treatment of isolated blunt splenic injury, including cost of procedure and the entire admission. Costs included angiography costs including equipment, machine, staff, and post-procedural costs including pharmacy, general ward costs, orderlies, ward nursing, allied health, and further imaging. ResultsDuring the study period, patients remained an inpatient for a mean of 4.8 days and the rate of splenic salvage was 100%. The mean total cost of splenic embolisation at our centre was AUD$10,523 and median cost AUD$9959.6 (range of $4826-$16,836). The use of a plug as embolic material was associated with increased cost than for coils. Overall cost of patients requiring ICU was mean AUD$11,894 and median AUD$11,435.8. Overall cost for those not requiring ICU was mean AUD$7325 and median AUD$8309.8. ConclusionSplenic embolisation is a low-cost procedure for management of blunt splenic injury. The cost to provide SAE at our centre was much lower than previously modelled data from overseas studies. From a cost perspective, the use of ICU for monitoring after the procedure significantly increased cost and necessity may be considered on a case-by-case basis. Further research is advised to directly compare the cost of SAE and splenectomy in an Australian setting.

Predictors of surgical management of high grade blunt splenic injuries in adult trauma patients: a 5-year retrospective cohort study from an academic level I trauma center

BackgroundsSplenic injury accounts for 40% of all injuries after blunt abdominal trauma. Blunt splenic injury in hemodynamically unstable patients is preferably treated by splenectomy. Nowadays hemodynamically stable patients with low grade splenic injuries are mostly treated by non-operative management (NOM). However no consensus exists about the management of high grade splenic injuries in hemodynamically stable patients. Therefore the aim of this study was to analyze patients with high grade splenic injuries in our institution.MethodsWe retrospectively included all patients with a splenic injury presented to our level I trauma center during the 5-year period from January 1, 2012, until December 31, 2017. Baseline characteristics, data regarding complications and mortality were collected from the electronic patient registry. Patients were grouped based on splenic injury and the treatment they received.ResultsA total of 123 patients were included, of which 93 (75.6%) were male with a median age of 31 (24–52) and a median injury severity score of 27 (17–34). High grade injuries (n = 28) consisted of 20 Grade IV injuries and 8 grade V injuries. Splenectomy was required in 15/28 (53.6%) patients, of whom all remained hemodynamically unstable after resuscitation, including all grade V injuries. A total of 13 patients with high grade injuries were treated with spleen preserving therapy. Seven of these patients received angio-embolization. One patient went for laparotomy and the spleen was treated with a hemostatic agent. Secondary hemorrhage was present in 3 of these patients (initial treatment: 1 embolization/ 2 observational), resulting in a success rate of 76.9%. There is no mortality seen in patient with high grade splenic injuries.ConclusionNon-operative treatment in high grade splenic injuries is a safe treatment modality in hemodynamically stable patients. Hemodynamic status and peroperative bleeding, not injury severity or splenic injury grade were the drivers for surgical management by splenectomy. This selected cohort of patients must be closely monitored to prevent adverse outcomes from secondary delayed bleeding in case of non-operative management.

Age is a predictor for mortality after blunt splenic injury

BackgroundWhile the incidence of geriatric trauma continues to increase, the management of high-grade blunt splenic injury (BSI) in the elderly remains controversial. Among this population, data evaluating survival rates following non-operative and operative management are inconsistent. We analyzed mortality risk in geriatric patients with high-grade BSI based on operative vs. non-operative management. MethodsA retrospective analysis of the National Trauma Database identified patients with isolated, high-grade (AIS ≥ 3) BSI from 2014 to 2015. Patients were stratified into three groups: non-elderly (<65 years), elderly (65–79 years), and advanced age (80 years and older). Each age group was stratified into three management groups: non-operative (including embolization), initial operative management (OR within 24 h), and failed non-operative management. Patient characteristics and outcomes were compared. Multivariable logistic regression estimated association with mortality. Results5560 patients with isolated, high-grade BSI were identified. In the group that failed NOM, mortality was 2% in non-elderly patients, versus 22.2% in elderly patients and 50% in patients of advanced age (p < .01). In this group, patients over 80 years old spent an average of 6.5 days longer in the ICU vs. non-elderly patients (median 10.5 days, IQR [6.75, 19.5] vs. 4 days, IQR [3,6], p = 0.02). In patients with isolated, high grade BSI, age was independently associated with mortality (AOR 1.02; p < 0.01). Elderly patients who required surgery were over three times more likely to die (AOR 3.39; p < 0.01). Advanced age patients who required surgery were over eight times more likely to die (AOR 8.1; p < 0.01). ConclusionsFor patients with BSI, age is independently associated with death in both operative and non-operative cases.

Early Venous Thromboembolism Prophylaxis for Isolated High-Grade Blunt Splenic Injury

BackgroundNonoperative management (NOM) has become more common in hemodynamically stable patients with high-grade blunt splenic injury. However, there are no widely accepted guidelines for an optimal and safe timeframe for the initiation of venous thromboembolism (VTE) prophylaxis. The purpose of this study was to explore the association between the timing of VTE prophylaxis initiation and NOM failure rate in isolated high-grade blunt splenic injury. MethodsWe utilized the American College of Surgeons Trauma Quality Improvement Program database (2013-2014) to identify adult patients who underwent NOM for isolated high-grade blunt splenic injuries (grades 3-5). The incidence of NOM failure after the initiation of VTE prophylaxis was compared between two groups: VTE prophylaxis <48 h after admission (early prophylaxis group), and ≥48 h (late prophylaxis group). ResultsA total of 816 patients met the inclusion criteria. Of those, VTE prophylaxis was not administered in 525 patients (64.3%), whereas VTE prophylaxis was given <48 h and ≥48 h after admission in 144 and 147 patients, respectively. There was no significant difference in the NOM failure rate after the initiation of VTE prophylaxis between the early and late prophylaxis groups (3.5% versus 3.4%, P = 1.00). In the multiple logistic regression analysis, early initiation of VTE prophylaxis was not significantly associated with NOM failure (OR: 1.32, 95% CI 0.35-4.93, P = 0.68). ConclusionsThe results of our study suggest that early initiation of VTE prophylaxis (<48 h) does not increase the risk of NOM failure in patients with isolated high-grade blunt splenic injury.

Overall Splenectomy Rates Stable Despite Increasing Usage of Angiography in the Management of High-grade Blunt Splenic Injury.

The purpose of this study was to understand the contemporary trends of splenectomy in blunt splenic injury (BSI) and to determine if angiography and embolization (ANGIO) may be impacting the splenectomy rate. The approach to BSI has shifted to increasing use of nonoperative management, with a greater reliance on ANGIO. However, the impact ANGIO has on splenic salvage remains unclear with little contemporary data. The National Trauma Data Bank was used to identify patients 18 years and older with high-grade BSI (Abbreviated Injury Scale >II) treated at Level I or II trauma centers between 2008 and 2014. Primary outcomes included yearly rates of splenectomy, which was defined as early if performed within 6 hours of ED admission and delayed if greater than 6 hours, ANGIO, and mortality. Trends were studied over time with hierarchical regression models. There were 53,689 patients who had high-grade BSI over the study period. There was no significant difference in the adjusted rate of overall splenectomy over time (24.3% in 2008, 24.3% in 2014, P value = 0.20). The use of ANGIO rapidly increased from 5.3% in 2008 to 13.5% in 2014 (P value < 0.001). Mortality was similar overtime (8.7% in 2008, 9.0% in 2014, P value = 0.33). Over the last 7 years, the rate of angiography has been steadily rising while the overall rate of splenectomy has been stable. The lack of improved overall splenic salvage, despite increased ANGIO, calls into question the role of ANGIO in splenic salvage on high-grade BSI at a national level.

Nonoperative Management Is as Effective as Immediate Splenectomy for Adult Patients with High-Grade Blunt Splenic Injury

The comparative effectiveness of nonoperative management (NOM) vs immediate splenectomy (IS) for hemodynamically stable adult patients with grade IV or V blunt splenic injury (BSI) has not been clearly established in the literature. We performed a retrospective analysis of adult patients, from the 2013 to 2014 American College of Surgeons Trauma Quality Improvement Program (TQIP) Participant Use Data Files, who sustained grade IV or V BSI. Outcomes after IS vs attempted NOM were compared using propensity score analysis in order to adjust for patient- and injury-related variables. Nonoperative management was attempted in 1,489 (52.2%) of 2,746 patients who sustained grade IV or V BSI. Propensity matching techniques resulted in a cohort of 758 IS and NOM patients who were well matched for all known patient- and injury-related variables. In-hospital mortality was not different between the IS and NOM patients (11.5% vs 10.0%, p= 0.33), although IS patients had a higher incidence of infectious complications (21.4% vs 16.9%, p= 0.02). The rate of NOM failure in our sample was 20.1%. Independent predictors of failed NOM included the presence of a bleeding disorder, early blood transfusion requirement, and grade V injury. Splenic artery embolization was associated with a decreased risk of NOM failure. Patients who had failed NOM had a lower in-hospital mortality rate than IS patients (6.4% vs 16.4%, p= 0.004), but required longer hospitalization. Nonoperative management is as effective as IS for hemodynamically stable adult patients with grade IV or V BSI. The delay in operative intervention that results from failed attempts at NOM does not adversely affect the outcomes of patients who ultimately require splenectomy.

Nonoperative management of splenic injuries: significance of age

BackgroundIn the nonoperative management (NOM) of blunt splenic injuries (BSI), the clinical relevance of age as a risk factor has not been well studied. MethodsUsing the 2011 National Trauma Data Bank data set, age was analyzed both as a continuous variable and a categorical variable (group 1 [13–54 y], group 2 [55–74 y], and group 3 [≥75 y]). BSI severity was stratified by abbreviated injury scale (AIS): group 1 (AIS ≤2), group 2 (AIS 3), and group 3 (AIS ≥4). A semiparametric proportional odds model was used to model NOM outcomes and effects due to age and BSI severity. ResultsOf 15,113 subjects, 15.3% failed NOM. The odds of failure increased by a factor of 1.014 for each year of age, or factor of 1.5 for groups 2 and 3 each. BSI severity groups 2 and 3 had increases in the odds of failure by factors of 3.9 and 13, respectively, compared with those of group 1. Most failures occurred by 48 h irrespective of age. The effect of age was most pronounced in age groups 2 and 3 with the most severe BSI, where a NOM failure rate of >50% was seen. Both age and failure of NOM were independent predictors of mortality. ConclusionsAge is associated with failure of NOM but its effect seems more clinically relevant only in high-grade BSI. Factors that could influence NOM success in elderly patients with high-grade injuries deserve further study.

Trauma center angiography use in high-grade blunt splenic injuries: Timing is everything.

The use of angiography (ANGIO) in the management of high-grade (Abbreviated Injury Scale [AIS] score > 2) blunt splenic injury (BSI) remains controversial. We aimed to compare patient characteristics of those treated at high and low ANGIO centers, to compare the characteristics of the patients undergoing ANGIO at high and low ANGIO centers, and to determine the relationship among hospital ANGIO use, the timing of angiography, and splenectomy after angiography. The National Trauma Data Bank was used to identify patients 18 years and older with BSI (AIS score > 2) treated at Level I or II trauma centers that admitted at least 10 patients with high-grade BSI from 2007 to 2010. Timing of ANGIO and splenectomy was determined. Hospitals were stratified based on ANGIO use rates into three groups: 0% (no ANGIO); 1% to 19.9% (low ANGIO); and more than 20% (high ANGIO). Hierarchical logistic regression was used to control for patient clustering at the hospital level and to determine factors associated with splenectomy. Cox regression with ANGIO as a time-varying covariate was also used. A total of 10,405 met inclusion criteria. After adjusting for hospital case mix, low ANGIO (odds ratio, 1.02; 95% confidence interval [CI], 0.70-1.48) and no ANGIO (odds ratio, 0.88; 95% CI, 0.59-1.31) centers showed no difference with regard to splenectomy compared with high ANGIO centers. ANGIO (Hazard Ratio = 0.52; 95% CI, 0.41-0.65) was protective of splenectomy on Cox regression analysis, taking into account ANGIO timing relative to splenectomy. There were no differences in splenectomy rates after adjusting for case mix at high and low ANGIO centers. Early ANGIO, irrespective of hospital ANGIO use, is associated with splenic salvage. Therapeutic study, level III.

Prospective Trial of Angiography and Embolization for All Grade III to V Blunt Splenic Injuries: Nonoperative Management Success Rate Is Significantly Improved

Nonoperative management (NOM) of blunt splenic injury is well accepted. Substantial failure rates in higher injury grades remain common, with one large study reporting rates of 19.6%, 33.3%, and 75% for grades III, IV, and V, respectively. Retrospective data show angiography and embolization can increase salvage rates in these severe injuries. We developed a protocol requiring referral of all blunt splenic injuries, grades III to V, without indication for immediate operation for angiography and embolization. We hypothesized that angiography and embolization of high-grade blunt splenic injury would reduce NOM failure rates in this population. This was a prospective study at our Level I trauma center as part of a performance-improvement project. Demographics, injury characteristics, and outcomes were compared with historic controls. The protocol required all stable patients with grade III to V splenic injuries be referred for angiography and embolization. In historic controls, referral was based on surgeon preference. From January 1, 2010 to December 31, 2012, there were 168 patients with grades III to V spleen injuries admitted; NOM was undertaken in 113 (67%) patients. The protocol was followed in 97 patients, with a failure rate of 5%. Failure rate in the 16 protocol deviations was 25% (p = 0.02). Historic controls from January 1, 2007 to December 31, 2009 were compared with the protocol group. One hundred and fifty-three patients with grade III to V injuries were admitted during this period, 80 (52%) patients underwent attempted NOM. Failure rate was significantly higher than for the protocol group (15%, p = 0.04). Use of a protocol requiring angiography and embolization for all high-grade spleen injuries slated for NOM leads to a significantly decreased failure rate. We recommend angiography and embolization as an adjunct to NOM for all grade III to V splenic injuries.