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Nonoperative Management of Splenic Injuries
Have We Gone Too Far?
George C. Velmahos, MD, PhD;
Linda S. Chan, PhD;
Eman Kamel, MD;
James A. Murray, MD;
Nabil Yassa, MD;
Deborah Kahaku, RN;
Thomas V. Berne, MD;
Demetrios Demetriades, MD, PhD
Arch Surg. 2000;135:674-681.
Hypothesis Patients with severe blunt injuries to the spleen have a high likelihood of failing nonoperative management of splenic injuries (NOMSI).
Design Review of medical records, helical computed tomographic imaging data, and trauma registry data.
Setting Academic level I trauma center at a large county hospital.
Patients A total of 105 patients with blunt trauma to the spleen, admitted between January 1995 and December 1998, who survived more than 48 hours and had complete records. Of these patients, 53 (56%) were selected for NOMSI. The splenic injury was graded by the Organ Injury Scale of the American Association for the Surgery of Trauma (grades I to V, with grade V being the worst possible injury).
Main Outcome Measures Failure of NOMSI, defined as the need for operation to the spleen after a period of nonoperative management.
Results Compared with patients who had successful NOMSI, the 29 patients (52%) in whom NOMSI failed were older and more severely injured. They also required extra-abdominal operations more frequently, underwent transfusion with more units of blood while being managed nonoperatively, and had higher grades of splenic injury. Splenic injury grade III or higher and transfusion of more than 1 U of blood were identified as independent risk factors for failure of NOMSI. The existence of both risk factors predicted failure in 97% of cases. The grading by computed tomography correlated well with the actual injury to the spleen as seen at operation.
Conclusions In patients with high-grade splenic injuries who require a transfusion of more than 1 U of blood, NOMSI is very likely to fail. Decreasing the threshold for operation or intensifying the monitoring is highly recommended for such patients.
From the Division of Trauma and Critical Care, Department of Surgery (Drs Velmahos, Kamel, Murray, Berne, and Demetriades and Ms Kahaku), Division of Biostatistics and Outcomes Research (Dr Chan), and Department of Radiology (Dr Yassa), University of Southern California and the Los Angeles County/University of Southern California Medical Center, Los Angeles.
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