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

Abstract

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.

Management of splenic injury in children and young adults: a survey of surgeons investigating factors responsible for variations in care using the Theoretical Domains Framework

“…(2) Studies have shown a higher use of angioembolisation at adult trauma centres than paediatric trauma centres in the management of paediatric and adolescent splenic injury. (15)(16)(17) It is unclear if this is due to availability or choice, and whether its use increases splenic salvage in children. (15,16,31) This requires further exploration.…”

“…(15)(16)(17) It is unclear if this is due to availability or choice, and whether its use increases splenic salvage in children. (15,16,31) This requires further exploration.…”

“…(9,10) This is evident in the care of children and young adults with splenic injuries: In the United Kingdom, North America, and Australia, hospital type has been correlated with intervention, including operation and angioembolisation. (3,(11)(12)(13)(14)(15)(16)(17)(18)(19) It is unknown what factors may be influencing management decisions in these different settings and age groups.…”

Outcomes of Nonoperative Management of Blunt Splenic Injury—Asian Experience

“…The overall rate of splenic artery angioembolization in our series is 11% (8 out of 88 patients) and this is consistent with the literature. 25 Blood transfusion requirement is a surrogate of hemoglobin and low hematocrit levels, which indicate ongoing bleeding. We have demonstrated that while low hemoglobin and hematocrit does not predict the need for operative intervention, it does predict the failure of NOM.…”

“…Recently, it has been demonstrated that NOM management with low transfusion and low splenic angioembolization rates (0.6%) can lead to high splenic preservation rates with low mortality in dedicated pediatric trauma units. 25 Such results are yet to be duplicated in an adult population. This is a single institutional experience from a busy trauma center.…”