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

Abstract

BackgroundTreatment 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.MethodsOur 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.ResultsA 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.ConclusionThis 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.

Trauma Team Activation: Which Surgical Capability Is Immediately Required in Polytrauma? A Retrospective, Monocentric Analysis of Emergency Procedures Performed on 751 Severely Injured Patients

“…Current medical advancements encourage minimal invasive procedures to control hemorrhage [ 35 ]. An increasing number of traumatic hepatic and splenic injuries are treated non-operatively [ 36 , 37 ] or with the support of interventional radiology (e.g., coiling) [ 38 , 39 ]. With evolving minimally invasive techniques or the non-operative treatment of solid organ lesions, there might be a higher threshold for the indication to perform damage-control laparotomy [ 40 , 41 ].…”

Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document

“…NOM was demonstrated to be feasible also in patients with altered consciousness: Teuben et al reported their retrospective experience with NOM in 20 patients with GCS < 14. All the patients were admitted to a monitored intermediate care unit or ICU and underwent frequent examinations of vital signs and physical examinations (including hemoglobin level measurements) [ 79 ]. Recently, Kumar et al published a randomized trial where patients treated with NOM for blunt spleen and liver trauma were randomized to early (3 days) or late (5 days) discharge.…”

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

“…A total of 90 could be treated by NOM. There were 7 patients (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15), p = 0.019) and a higher lactate (2.1 (1.7-3.6) vs. 4.1(2.7-5.4), p = 0.016) than patients with high grade injuries treated by spleen preserving treatment. All of the patients with a high grade splenic injury in the splenectomy group were hemodynamically unstable, this was visible by significant more transfusion requirements of ECs (p = 0.005), FFP's (p < 0.014) and thrombocytes (p < 0.013).…”

“…However, Spleen preservation is not always an option since it can lead to life-threatening hemorrhages [11]. The most important prerequisite for successful NOM is adequate patient selection [12][13][14][15]. Hence, it is of utmost importance to choose the right management for the right patient.…”

“…However no consensus exists about the management of high grade splenic injuries (> grade 3) in hemodynamically stable patients. In some institutions, splenectomy is the preferred treatment option, whereas in other institutes all of these patients are treated by spleen preserving treatment options [12,14,18,19]. Preferably, when a blush is seen on contrast enhanced computed tomography (CT)-scan, either central or partial angio-embolization(AE) is performed [20][21][22].…”