Failures of splenic nonoperative management: is the glass half empty or half full?
BACKGROUND
Published contraindications to nonoperative management (NOM) of blunt splenic injury (BSI) include age > or = 55, Glasgow Coma Scale score < or = 13, admission blood pressure < 100 mm Hg, major (grades 3-5) injuries, and large amounts of hemoperitoneum. Recently reported NOM rates approximate 60%, with failure rates of 10% to 15%. This study evaluated our failures of NOM for BSI relative to these clinical factors.


METHODS
All patients with BSI at a Level I trauma center over a 46-month period ending September 1999 were reviewed. Failures of NOM included patients initially selected for NOM who subsequently required splenectomy/splenorrhaphy.


RESULTS
Five hundred fifty-eight had BSI. Twenty-three percent (128) underwent emergent laparotomy for hemodynamic instability and 77% (430) were observed. The NOM failure rate was only 8%. Univariate analysis identified moderate to large hemoperitoneum (p < 0.03), grades 3 to 5 (p < 0.004), and age > or = 55 (p < 0.0006) as being significantly associated with failure. Multivariate analysis identified age > or = 55 and grades 3 to 5 injuries as independent predictors of failure. The highest failure rates (30-40%) occurred in patients age > or = 55 with major injury for moderate to large hemoperitoneum. Mortality rates for successful NOM were 12%, and 9% for failed NOM.


CONCLUSIONS
Inclusion of all high-risk patients increased the NOM rate while maintaining a low failure rate. Although age > or = 55 and major BSI were independently associated with failure of NOM, approximately 80% of these high-risk patients were successfully managed nonoperatively. There was no increased mortality associated with failure. Although these factors may indeed predict failure, they do not necessarily contraindicate NOM.
Bee
T K
TK
Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
Croce
M A
MA
Miller
P R
PR
Pritchard
F E
FE
Fabian
T C
TC
D000328:Adult; D005260:Female; D015600:Glasgow Coma Scale; D006465:Hemoperitoneum / Q000209:etiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D013154:Spleen / Q000293:injuries*; D017211:Treatment Failure; D014949:Wounds, Nonpenetrating / Q000628:therapy*