Quantity of hemoperitoneum is associated with need for intervention in patients with stable blunt splenic injury

Abstract

Background In patients with hemodynamically stable blunt splenic injury (BSI), there is no consensus on whether quantity of hemoperitoneum (HP) is a predictor for intervention with splenic artery embolization (SAE) or failing nonoperative management (fNOM). We sought to analyze whether the quantity of HP was associated with need for intervention. Methods This retrospective cohort study included adult trauma patients with hemodynamically stable BSI admitted to six trauma centers between 2014 and 2016. Quantity of HP was defined as small (perisplenic blood or blood in Morrison's pouch), moderate (blood in one or both pericolic gutters), or large (additional finding of free blood in the pelvis). Multivariate logistic regression was performed to identify predictors of intervention with SAE or fNOM versus successful observation. Results There were 360 patients: hemoperitoneum was noted in 214 (59%) patients, of which the quantity was small in 92 (43%), moderate in 76 (35.5%), and large in 46 (21.5%). Definitive management was as follows: 272 (76%) were observed and 88 (24%) had intervention (83 SAE, 5 fNOM). The rate of intervention was univariately associated with quantity of HP, even after stratification by American Association for the Surgery of Trauma (AAST) grade. After adjustment, larger quantities of HP significantly increased odds of intervention (p=0.01). Compared with no HP, the odds of intervention were significantly increased for moderate HP (OR=3.51 (1.49 to 8.26)) and large HP (OR=2.89 (1.03 to 8.06)), with similar odds for small HP (OR=1.21 (0.46 to 2.76)). Other independent predictors of intervention were higher AAST grade, older age, and presence of splenic vascular injury. Conclusion Greater quantity of HP was associated with increased odds of intervention, with no difference in risk for moderate versus large HP. These findings suggest quantity of HP should be incorporated in the management algorithm of BSI as a consideration for angiography and/or embolization to maximize splenic preservation and reduce the risk of splenic rupture. Level of evidence III, retrospective epidemiological study.

Predictors of transfer from a remote trauma facility to an urban level I trauma center for blunt splenic injuries: a retrospective observational multicenter study

“…Overall, most patients were male (n = 58), were a median age of 26 (21-42) years old, most (n = 62) had no comorbidities, and 47 had been injured from a ski/snowboarding accident. Compared to admitted patients, significantly more females were transferred, (13/38 vs. 3/36, p = 0.007, Table 1), more had an abbreviated injury scale score (AIS) ≥ 3 (vs < 3) of the chest (31/38 vs. 7/35, p = 0.002) and had a higher injury severity score (16 (16-22) vs. 13 (9)(10)(11)(12)(13)(14)(15)(16), p = 0.008), in comparison to admitted patients.…”

“…The patient was initially stable in the interventional radiology suite but went straight to surgery after blood pressure plummeted. Other studies have indicated failure rates between 6-20%, and they mostly depend on age, ISS, splenic injury grade, and appropriateness of patient selection for NOM [15,[24][25][26][27][28][29]. This patient appears to have been appropriately triaged for SAE, because the patient was young (26 years old), had an ISS of 16, a splenic injury grade of 4, bordering on 5 upon admission, and had a moderate amount of hemoperitoneum, yet was initially stable.…”

“…Thus, lower-level trauma centers with limited resources must expeditiously decide who can be immediately transferred to a higher level of care for SAE and who can be safely admitted for either surgery (exploratory laparotomy and splenectomy) or observation. Although there are a proliferation of studies examining the triage of splenic injuries [3,[6][7][8][9][10][11][12][13][14][15], there are a paucity of studies on management of patients with blunt splenic injuries in remote settings and of the few that exist, most report very small numbers and are not current [16,17]. There continues to be great variability in the processes of care for splenic injury patients, with sparse data reported across Level III or IV trauma centers.…”