Nonoperative Management of Blunt Splenic Trauma in the Elderly: Does Age Play a Role?

2007 ◽  
Vol 73 (6) ◽  
pp. 585-589 ◽  
Author(s):  
Kris Siriratsivawong ◽  
Mazen Zenati ◽  
Gregory A. Watson ◽  
Brian G. Harbrecht
Keyword(s):  
Older Patients ◽  
Injury Severity ◽  
Splenic Injury ◽  
Nonoperative Management ◽  
Age Groups ◽  
Operative Management ◽  
Hospital Length Of Stay ◽  
P Value ◽  
Splenic Trauma ◽  
Blunt Splenic Injury

Nonoperative management (NOM) of blunt splenic injury has become more frequent in the past several decades. Criteria that predict successful NOM remain poorly defined, and one factor that has been studied previously has been patient age. Previous studies have defined older patients as those greater than 55 years of age, but no studies have compared younger patients (55–75 years) with older patients (75+ years) within this age group. A total of 1008 patients ≥55 years of age who sustained blunt splenic injury between 1993 and 2001 were analyzed from the Pennsylvania Trauma Systems Foundation database. Statistical analysis was performed using regression analysis. Data was expressed as mean ± SD, and a P value of ≤ 0.05 was considered significant. Patients were classified as operative management (OM; 39.9%) or NOM (60.1%) according to their initial plan of treatment. Of the patients in the NOM group, 75.3 per cent were successfully managed nonoperatively (SNOM), whereas 24.7 per cent eventually required surgery. The Injury Severity Score of the OM group was highest (34) compared with the SNOM group (22) and failed NOM (FNOM; 27) groups. The mean splenic injury grade for OM, SNOM, and FNOM was 3.5, 2.4, and 3.3, respectively. The number of pre-existing conditions did not differ among the three groups. An upward trend in the failure rate of NOM was observed with increasing age (19.0%, 27.1%, and 28.3%, respectively) for three age groups, 55–64, 65–74, and 75+, but this trend was not statistically significant. Mortality rate was highest in the OM group (35.6%) compared with the successful (16.7%) and failed NOM (17.9%). Hospital length of stay (LOS) and intensive care unit (ICU) LOS were highest among patients who failed NOM (mean hospital LOS = 20.7 days, mean ICU LOS = 13.2 days) compared with OM (17.2 and 10.4, respectively) and successful NOM (12.4 and 6.9, respectively). The majority of patients ≥55 years with blunt splenic injuries can be managed nonoperatively when carefully selected. In the subset of patients older than 55 years of age, increasing age is associated with a trend toward higher failure rates. Mortality was high regardless of management, and failure of NOM in older patients is associated with significantly longer hospital and ICU LOS.

scholarly journals Nonoperative management of splenic injury in closely monitored patients with reduced consciousness is safe and feasible

2019 ◽  
Vol 27 (1) ◽  
Author(s):  
Michel Teuben ◽  
Roy Spijkerman ◽  
Taco Blokhuis ◽  
Roman Pfeifer ◽  
Henrik Teuber ◽  
...  
Keyword(s):  
Mental Status ◽  
Injury Severity ◽  
Splenic Injury ◽  
Nonoperative Management ◽  
Splenic Trauma ◽  
Blunt Splenic Injury ◽  
Icu Stay ◽  
Severity Scores ◽  
Gcs Score ◽  
The Impact

Abstract Background Treatment of blunt splenic injury has changed over the past decades. Nonoperative management (NOM) is the treatment of choice. Adequate patient selection is a prerequisite for successful NOM. Impaired mental status is considered as a relative contra indication for NOM. However, the impact of altered consciousness in well-equipped trauma institutes is unclear. We hypothesized that impaired mental status does not affect outcome in patients with splenic trauma. Methods Our prospectively composed trauma database was used and adult patients with blunt splenic injury were included during a 14-year time period. Treatment guidelines remained unaltered over time. Patients were grouped based on the presence (Group GCS: < 14) or absence (Group GCS: 14–15) of impaired mental status. Outcome was compared. Results A total of 161 patients were included, of whom 82 were selected for NOM. 36% of patients had a GCS-score < 14 (N = 20). The median GCS-score in patients with reduced consciousness was 9 (range 6–12). Groups were comparable except for significantly higher injury severity scores in the impaired mental status group (19 vs. 17, p = 0.007). Length of stay (28 vs. 9 days, p < 0.001) and ICU-stay (8 vs. 0 days, p = 0.005) were longer in patients with decreased GCS-scores. Failure of NOM, total splenectomy rates, complications and mortality did not differ between both study groups. Conclusion This study shows that NOM for blunt splenic trauma is a viable treatment modality in well-equipped institutions, regardless of the patients mental status. However, the presence of neurologic impairment is associated with prolonged ICU-stay and hospitalization. We recommend, in institutions with adequate monitoring facilities, to attempt nonoperative management for blunt splenic injury, in all hemodynamically stable patients without hollow organ injuries, also in the case of reduced consciousness.

Assessment of Nonoperative Management of Blunt Spleen and Liver Trauma

2005 ◽  
Vol 71 (5) ◽  
pp. 379-386 ◽  
Author(s):  
Om P. Sharma ◽  
Michael F. Oswanski ◽  
Daniel Singer ◽  
Shekhar S. Raj ◽  
Yahya A.H. Daoud
Keyword(s):  
Older Adults ◽  
Injury Severity ◽  
Nonoperative Management ◽  
Operative Management ◽  
Liver Trauma ◽  
P Value ◽  
Splenic Trauma ◽  
Success Rates ◽  
Younger Adults ◽  
Trauma Ct

An 8-year analysis of nonoperative management (NOM) of spleen and liver trauma was done in a level 1 trauma center. Spleen and liver trauma was diagnosed in 279 patients: 93 children (<18), 137 younger adults (18–54), and 49 older adults (≥ 55). Nineteen patients who failed resuscitations died within 0–60 minutes of arrival and were excluded from treatment analysis. Operative management (OM) was done in 39 (15%) and NOM in 221 (85%) patients with failure (NOMF) in 11 (5%). NOM and NOMF was 82 per cent and 5.6 per cent in spleen, 74 per cent and 14.3 per cent in combined spleen/liver, and 96 per cent and 1.5 per cent in liver trauma ( P value <0.001). NOM was done in 99 per cent of children, 81 per cent of younger adults, and 68 per cent of older adults with 0 per cent, 8 per cent, and 10 per cent NOMF. Higher grades of splenic trauma and CT fluid had higher OM rate. NOM success rates were 93.8 per cent in grade 3 and 90.3 per cent in higher grades of spleen trauma. There was no NOMF in higher grades of liver trauma. CT fluid grade had no impact on NOMF. Female patients had higher mean injury severity score, age, and mortality compared to cohorts. NOM should be attempted in hemodynamically stable patients. Age over 55, higher grades of injury, and large hemoperitoneum were not predictors of failure of NOM.

scholarly journals Splenic Artery Embolization for Patients with High-Grade Splenic Trauma: Indications, Techniques, and Clinical Outcomes

2021 ◽  
Vol 38 (01) ◽  
pp. 105-112
Author(s):  
Majd Habash ◽  
Darrel Ceballos ◽  
Andrew J. Gunn
Keyword(s):  
Clinical Outcomes ◽  
Splenic Artery ◽  
Splenic Injury ◽  
Nonoperative Management ◽  
Operative Management ◽  
Splenic Trauma ◽  
Trauma Patients ◽  
High Grade ◽  
Artery Embolization ◽  
Splenic Artery Embolization

AbstractThe spleen is the most commonly injured organ in blunt abdominal trauma. Patients who are hemodynamically unstable due to splenic trauma undergo definitive operative management. Interventional radiology plays an important role in the multidisciplinary management of the hemodynamically stable trauma patient with splenic injury. Hemodynamically stable patients selected for nonoperative management have improved clinical outcomes when splenic artery embolization is utilized. The purpose of this article is to review the indications, technical aspects, and clinical outcomes of splenic artery embolization for patients with high-grade splenic injuries.

scholarly journals Laparoscopic surgery for splenic injuries in the era of non-operative management: current status and future perspectives

Surgery Today ◽  
2020 ◽  
Author(s):  
Luigi Romeo ◽  
Francesco Bagolini ◽  
Silvia Ferro ◽  
Matteo Chiozza ◽  
Serafino Marino ◽  
...  
Keyword(s):  
Laparoscopic Surgery ◽  
Splenic Injury ◽  
Nonoperative Management ◽  
Current Knowledge ◽  
Operative Management ◽  
Current Status ◽  
Splenic Trauma ◽  
Future Perspectives ◽  
Encapsulated Bacteria ◽  
Non Operative Management

AbstractThe spleen is one of the organs most commonly injured by blunt abdominal trauma. It plays an important role in immune response to infections, especially those sustained by encapsulated bacteria. Nonoperative management (NOM), comprising clinical and radiological observation with or without angioembolization, is the treatment of choice for traumatic splenic injury in patients who are hemodynamically stable. However, this strategy carries a risk of failure, especially for high-grade injuries. No clear predictors of failure have been identified, but minimally invasive surgery for splenic injury is gaining popularity. Laparoscopic surgery has been proposed as an alternative to open surgery for hemodynamically stable patients who require surgery, such as after failed NOM. We reviewed research articles on laparoscopic surgery for hemodynamically stable patients with splenic trauma to explore the current knowledge about this topic. After presenting an overview of the treatments for splenic trauma and the immunological function of the spleen, we try to identify the future indications for laparoscopic surgery in the era of NOM.

scholarly journals Recent Changes in the Management of Blunt Splenic Injury: Effect on Splenic Trauma Patients and Hospital Implications

2008 ◽  
Vol 90 (2) ◽  
pp. 109-112 ◽  
Author(s):  
S Sinha ◽  
SVV Raja ◽  
MH Lewis
Keyword(s):  
Blood Transfusion ◽  
Hospital Stay ◽  
Splenic Injury ◽  
Transfusion Requirement ◽  
Operative Management ◽  
Splenic Trauma ◽  
Trauma Patients ◽  
Blunt Splenic Injury ◽  
Non Operative Management

INTRODUCTION Management of blunt splenic injury has been controversial with an increasing trend towards splenic conservation. A retrospective study was performed to identify the effect of this changed policy on splenic trauma patients and its implications. PATIENTS AND METHODS Data regarding patient demography, mode of splenic injury, CT grading, blood transfusion requirement, operative findings hospital stay and follow-up were collected. Statistical analysis of the data was performed using non-parametric Mann–Whitney tests RESULTS Over an 8-year period, only 21 patients were admitted with blunt splenic injury. Ten patients were managed operatively and 11 non-operatively. Non-operative management failed in one patient due to continued bleeding. Using Buntain's CT grading, the majority of grades I and II splenic injuries were managed non-operatively and grades III and IV were managed operatively (P = 0.008). Blood transfusion requirement was significantly higher among the operative group (P = 0.004) but the non-operative group had a significantly longer hospital stay (P = 0.029). Among those managed non-operatively (median age, 24.5 years), a number of patients were followed up with CT scans with significant radiation exposure and unknown long-term consequences. CONCLUSIONS Non-operative management of blunt splenic trauma in adults can be performed with an acceptable outcome. Although CT is classed as the ‘gold standard’, initial imaging for detection and evaluation of blunt splenic injury, ultrasound can play a major role in follow-up imaging and potentially avoids major radiation exposure.

scholarly journals Non operative management of isolated traumatic splenic injury

2021 ◽  
Vol 8 (4) ◽  
pp. 1101
Author(s):  
Shiwani Thakur ◽  
Naseer Ahmed Awan ◽  
Umer Mushtaq ◽  
Shaukat Jeelani ◽  
M. R. Attri ◽  
...  
Keyword(s):  
Standard Treatment ◽  
Splenic Injury ◽  
Statistical Significance ◽  
Operative Management ◽  
Successful Outcome ◽  
Blunt Injury ◽  
P Value ◽  
Splenic Trauma ◽  
High Dependency ◽  
Non Operative Management

Background: Road traffic accidents, sports injuries, assaults, and falls from height, are among most common causes of blunt splenic trauma. In 1970s, postsplenectomy complications were published by some authors, revealing the high mortality and morbidity related to overwhelming postsplenectomy infection (OPSI). Therefore, conservative management for splenic trauma was accepted as treatment of choice in all the patients to decrease mortality due to OPSI. Therefore, NOM of traumatic splenic injury has now been accepted as standard treatment of choice for all AAST grade I, II and III, whereas this was not found safe in higher grades of splenic trauma.  Methods: This is a hospital based prospective observational study, done on 45 hemodynamically stable patients of splenic trauma. Results: Out of all studied parameters grade of injury, contrast blush on CT scan, grade of hemoperitoneum showed statistical significance with p value<0.001, however gender, age, mode of injury, showed no statistical significance. In our study, out of 45 patients, 38 (84.44%) patients had successful NOM of splenic trauma.  Conclusions: Non-operative management (NOM) of blunt injury to the spleen in adults has become the standard of care in hemodynamically stable patients. This modality of treatment in paediatric patients is also highly successful and is standard treatment of choice in both adults and children. Success of NOM of isolated splenic injury depends on multiple factors such as availability of ICUs, high dependency units for strict monitoring, blood banks and availability of multidisciplinary team efforts encompassing anesthetics, trauma surgeons, radiologists, for successful outcome. 

Maintaining Low Transfusion and Angioembolization Rates in the Age of Nonoperative Management of Pediatric Blunt Splenic Injury

2014 ◽  
Vol 80 (11) ◽  
pp. 1159-1163 ◽  
Author(s):  
Vincent P. Duron ◽  
Kristopher M. Day ◽  
Shaun A. Steigman ◽  
Jeremy T. Aidlen ◽  
Francois I. Luks
Keyword(s):  
Blood Transfusion ◽  
Injury Severity ◽  
Splenic Injury ◽  
Nonoperative Management ◽  
Vital Signs ◽  
Transfusion Rate ◽  
Blunt Splenic Injury ◽  
Pediatric Hospitals ◽  
Revised Trauma Score ◽  
Trauma Score

Nonoperative management of hemodynamically stable blunt splenic injury (BSI) is the gold standard in children. Recent studies from nonpediatric surgery-specialized trauma centers have demonstrated a rise in transfusion and angioembolization associated with decreased splenectomy rates. We investigate the rate of splenectomy and nonsurgical interventions (angioembolization, blood transfusion) for BSI in a pediatric surgery-specialized trauma center. We conducted a retrospective review of children (0 to 18 years) treated between September 2001 and September 2011 at a children's hospital. Analyzed data included presenting vital signs, nadir hemoglobin, splenic injury grade, Revised Trauma Score, and Injury Severity Score (ISS). Measured outcomes included transfusion, angioembolization, and splenectomy rates. The study period was divided into three time periods to identify possible trends and compared with national averages. There were 180 patients, 91 with multiple injuries (50.6%) and 89 (49.4%) with isolated BSI. Seventy-six per cent of patients were male, average age was 12.8 years, and average ISS was 14.7. The overall splenectomy rate was 1.7 per cent (1.1% for isolated splenic injury). Our angioembolization rate was 0.6 per cent compared with 7.4 to 16 per cent nationally. Our transfusion rate was 14.4 per cent overall and 5.6 per cent for isolated splenic injury compared with 9.5 to 24.9 per cent nationally. Intervention rates remained unchanged over the study period. Splenectomy rates have remained low at our institution without an increase in angioembolization or transfusion. Children with splenic injuries treated at dedicated pediatric hospitals can be successfully managed nonoperatively without angioembolization or blood transfusion.

Penetrating Renal Trauma: Nonoperative Management is Safe in Selected Patients

2019 ◽  
Vol 85 (3) ◽  
pp. 266-272
Author(s):  
Thomas R. Resch ◽  
Joseph A. Kufera ◽  
William Chiu ◽  
Thomas M. Scalea
Keyword(s):  
Injury Severity Score ◽  
Severity Score ◽  
Gunshot Wound ◽  
Injury Severity ◽  
Nonoperative Management ◽  
Operative Management ◽  
Hospital Length Of Stay ◽  
Organ Injury ◽  
Renal Trauma ◽  
Median Hospital

Present literature seems to support the nonoperative management of penetrating renal trauma although data remain limited. We conducted a nine-year retrospective review of nonoperative versus operative management and mechanism of injury [stab wound (SW) versus gunshot wound (GSW)] among patients admitted with penetrating renal trauma. Of 203 patients, the median age was 24 years, with the majority being male and having GSW injuries. More than half (52.2%) were treated nonoperatively (69.9% of SW and 40% of GSW injured patients). When compared with all operative patients combined, nonoperative patients had a lower median Injury Severity Score (17 vs 26, P < 0.001), lower transfusion requirement (27.4% vs 77.3%, P < 0.001), shorter median hospital stay (4.7 vs 12.6 days, P < 0.001), and lower mortality (1.9% vs 13.4%, P = 0.002). Gunshot wound patients had a higher median Injury Severity Score (26 vs 14, P < 0.001), higher median American Association for the Surgery of Trauma-Organ Injury Score (3 vs 2, P = 0.001), greater need for transfusion (69.2% vs 29.3%, P < 0.001), longer median hospital length of stay (12.1 vs 3.9 days, P < 0.001), and greater mortality (12.5% vs 0%, P < 0.001) than SW patients. Nonoperative management of penetrating renal injury is safe in selected patients. In addition, renal GSW injuries are associated with a greater morbidity and mortality.

scholarly journals Outcomes Following Blunt Traumatic Splenic Injury Treated with Conservative or Operative Management

2019 ◽  
Vol 12 (3) ◽  
pp. 83-88
Author(s):  
Sarah Corn ◽  
Jared Reyes ◽  
Stephen D Helmer ◽  
James M Haan
Keyword(s):  
Mechanical Ventilation ◽  
Length Of Stay ◽  
Injury Severity ◽  
Splenic Injury ◽  
Hospital Length Of Stay ◽  
Continuous Variables ◽  
Blunt Splenic Injury ◽  
Injury Management ◽  
Icu Admission ◽  
Complications And Mortality

Introduction Laparotomy, embolization, and observation are described for blunt splenic injury management. This study evaluated outcomes of blunt splenic injury management based on baseline factors, splenic injury severity, and associated injuries. Methods A nine-year retrospective review was conducted of adult patients with blunt splenic injury. Collected data included demographics, injury characteristics, treatment modality, complications, and outcomes (mechanical ventilation, days on mechanical ventilation, intensive care unit [ICU] admission and length of stay, hospital length of stay, and in-hospital mortality). Categorical and continuous variables were analyzed using χ2 analysis and one-way analysis of variance for normally distributed variables and a non-parametric test of medians for variables that did not meet the assumption of normality, respectively. Results Splenic injury grade was similar between operative and embolization groups, but severe hemoperitoneum was more common in the operative group. Complications and mortality were highest in the operative group (50.7% and 26.3%, respectively) and lowest in the embolization group (5.3% and 2.6%, respectively). Operative patients required more advanced interventions (ICU admission, mechanical ventilation). There were no differences between those treated with proximal versus distal embolization. Observation carried a failure rate of 11.2%, with no failures of embolization. Conclusions Embolization patients had the lowest rates of complications and mortality, with comparable splenic injury grades to those treated operatively. Further prospective research is warranted to identify patients that may benefit from early embolization and avoidance of major abdominal surgery.

The Utility of Serial Hemoglobin Monitoring in Non-Operative Management of Blunt Splenic Injury

2021 ◽  
pp. 000313482110488
Author(s):  
Nicolas S. Poupore ◽  
Nicole D. Boswell ◽  
Bryana Baginski ◽  
John Cull ◽  
Katherine F. Pellizzeri
Keyword(s):  
Chart Review ◽  
Clinical Decision Making ◽  
Injury Severity ◽  
Splenic Injury ◽  
Retrospective Chart Review ◽  
Clinical Decision ◽  
Operative Management ◽  
Blunt Splenic Injury ◽  
Non Operative Management ◽  
Trauma Bay

Background The Eastern Association for the Surgery of Trauma (EAST) states there is not enough evidence to recommend a particular frequency of measuring Hgb values for non-operative management (NOM) of blunt splenic injury (BSI). This study was performed to compare the utility of serial Hgb (SHgb) to daily Hgb (DHgb) in this population. Methods We conducted a retrospective chart review of patients with BSI between 2013 and 2019. Demographics, comorbidities, lab values, clinical decisions, and outcomes were gathered through a trauma database. Results A total of 562 patients arrive in the trauma bay with BSI. In the NOM group, 297 were successful and 37 failed NOM. Of those that failed NOM, 8 (21.6%) changed to OM due to a drop in Hgb. 5 (62.5%) were hypotensive first, 2 (25%) were no longer receiving SHgb, and 1 (12.5%) had a repeat CT scan and was embolized. DHgb patients were not significantly different from SHgb patients in injury severity, length of stay, the largest drop in Hgb, and incidence of failing NOM. Patients taking aspirin were more likely to fall below 7 g/dl at 48 and 72 hours into admission. Conclusions These results suggest that that trending SHgb may not influence clinical decision-making in NOM of BSI. Besides taking aspirin, risk factors for who would benefit from SHgb were not identified. Patients who received DHgb had similar injuries and outcomes than patients who received SHgb. Prospective studies are needed to evaluate the clinical utility of SHgb compared to DHgb.

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