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Evidence-Based Management and Controversies in Blunt Splenic Trauma.

ABSTRACT: The study aims to describe the evidence-based management and controversies in blunt splenic trauma.A shift from operative management to non-operative management (NOM) has occurred over the past decades where NOM has now become the standard of care in haemodynamically stable patients with blunt splenic injury. Splenic artery embolisation (SAE) is generally believed to increase the success rate of NOM. Not all the available evidence is that optimistic about SAE however. A morbidity specifically related to SAE of up to 47% has been reported. Although high-grade splenic injury is a prognostic factor for failure of NOM, an American research group has published a study in which NOM is performed in over half of haemodynamically stable patients with grade IV or V splenic injury without leading to an increased morbidity (in terms of complications) or mortality. Another area of current investigation in the literature is the exact indication for SAE. Although the generally accepted indication is the presence of vascular injury, a topic of current investigation is whether there might be a role for pre-emptive embolisation in patients with high-grade splenic injury. On the other hand, evidence is also emerging that not all blushes require an intervention (small blushes <1 or 1.5 cm do not). Lastly, the available evidence shows that splenic function is preserved after embolisation, and therefore, the routine administration of vaccinations seems not to be necessary. There might be a difference between proximal and distal embolisations; however, with regard to splenic function, in favour of distal embolisation.Nowadays, NOM is the standard of care in haemodynamically stable patients with blunt splenic injury. The available evidence (although with a relatively small number of patients) shows that splenic function is preserved after NOM, a major advantage compared to splenectomy. SAE is used as an adjunct to observation in order to increase the success rate of NOM. Operative management should be applied in case of haemodynamic instability or if associated intra-abdominal injuries requiring surgical treatment are present. Patient selection (which patient can be safely treated non-operatively, does every blush needs to be embolised?, which patients might be better off with direct operative intervention given the patient and injury characteristics) is an ongoing subject of further research. Future studies should also focus on long-term outcomes of patients treated with embolisation (e.g. total number of lifetime infectious episodes requiring antibiotic treatment or hospital admission, quality of life).

SUBMITTER: Olthof DC

PROVIDER: S-EPMC5332509 | biostudies-other | 2017

REPOSITORIES: biostudies-other

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Evidence-Based Management and Controversies in Blunt Splenic Trauma.

Olthof D C DC van der Vlies C H CH Goslings J C JC

Current trauma reports 20170209 1

<h4>Purpose of review</h4>The study aims to describe the evidence-based management and controversies in blunt splenic trauma.<h4>Recent findings</h4>A shift from operative management to non-operative management (NOM) has occurred over the past decades where NOM has now become the standard of care in haemodynamically stable patients with blunt splenic injury. Splenic artery embolisation (SAE) is generally believed to increase the success rate of NOM. Not all the available evidence is that optimis ...[more]

PMID: 28303214

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Project description:INTRODUCTION: The goal of non-operative management (NOM) for blunt splenic trauma (BST) is to preserve the spleen. The advantages of NOM for minor splenic trauma have been extensively reported, whereas its value for the more severe splenic injuries is still debated. The aim of this systematic review was to evaluate the available published evidence on NOM in patients with splenic trauma and to compare it with the operative management (OM) in terms of mortality, morbidity and duration of hospital stay. METHODS: For this systematic review we followed the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" statement. A systematic search was performed on PubMed for studies published from January 2000 to December 2011, without language restrictions, which compared NOM vs. OM for splenic trauma injuries and which at least 10 patients with BST. RESULTS: We identified 21 non randomized studies: 1 Clinical Controlled Trial and 20 retrospective cohort studies analyzing a total of 16,940 patients with BST. NOM represents the gold standard treatment for minor splenic trauma and is associated with decreased mortality in severe splenic trauma (4.78% vs. 13.5% in NOM and OM, respectively), according to the literature. Of note, in BST treated operatively, concurrent injuries accounted for the higher mortality. In addition, it was not possible to determine post-treatment morbidity in major splenic trauma. The definition of hemodynamic stability varied greatly in the literature depending on the surgeon and the trauma team, representing a further bias. Moreover, data on the remaining analyzed outcomes (hospital stay, number of blood transfusions, abdominal abscesses, overwhelming post-splenectomy infection) were not reported in all included studies or were not comparable, precluding the possibility to perform a meaningful cumulative analysis and comparison. CONCLUSIONS: NOM of BST, preserving the spleen, is the treatment of choice for the American Association for the Surgery of Trauma grades I and II. Conclusions are more difficult to outline for higher grades of splenic injury, because of the substantial heterogeneity of expertise among different hospitals, and potentially inappropriate comparison groups.

Project description:BackgroundsSplenic injury accounts for 40% of all injuries after blunt abdominal trauma. Blunt splenic injury in hemodynamically unstable patients is preferably treated by splenectomy. Nowadays hemodynamically stable patients with low grade splenic injuries are mostly treated by non-operative management (NOM). However no consensus exists about the management of high grade splenic injuries in hemodynamically stable patients. Therefore the aim of this study was to analyze patients with high grade splenic injuries in our institution.MethodsWe retrospectively included all patients with a splenic injury presented to our level I trauma center during the 5-year period from January 1, 2012, until December 31, 2017. Baseline characteristics, data regarding complications and mortality were collected from the electronic patient registry. Patients were grouped based on splenic injury and the treatment they received.ResultsA total of 123 patients were included, of which 93 (75.6%) were male with a median age of 31 (24-52) and a median injury severity score of 27 (17-34). High grade injuries (n = 28) consisted of 20 Grade IV injuries and 8 grade V injuries. Splenectomy was required in 15/28 (53.6%) patients, of whom all remained hemodynamically unstable after resuscitation, including all grade V injuries. A total of 13 patients with high grade injuries were treated with spleen preserving therapy. Seven of these patients received angio-embolization. One patient went for laparotomy and the spleen was treated with a hemostatic agent. Secondary hemorrhage was present in 3 of these patients (initial treatment: 1 embolization/ 2 observational), resulting in a success rate of 76.9%. There is no mortality seen in patient with high grade splenic injuries.ConclusionNon-operative treatment in high grade splenic injuries is a safe treatment modality in hemodynamically stable patients. Hemodynamic status and peroperative bleeding, not injury severity or splenic injury grade were the drivers for surgical management by splenectomy. This selected cohort of patients must be closely monitored to prevent adverse outcomes from secondary delayed bleeding in case of non-operative management.

Project description:PurposeAsplenic patients are at increased risk for the development of overwhelming postsplenectomy infection (OPSI) syndrome. It is believed that adequate immunization, antimicrobial prophylaxis, as well as appropriate education concerning risks on severe infection lead to the decreased incidence of OPSI. The aim of this study was to analyze the methods used to prevent OPSI in trauma patients splenectomized before the age of 18.Patients and methodsA retrospective, single-center study of all pediatric patients sustaining blunt splenic injury (BSI) managed at our level 1 trauma center from January 1979 to March 2012 was performed. A questionnaire was sent to all the included patients to determine the level of knowledge concerning infection risks, the use of antibiotics, and compliance to vaccination recommendations. Furthermore, we investigated whether the implementation of guidelines in 2003 and 2011 resulted in higher vaccination rates.ResultsWe included 116 children with BSI. A total of 93 completed interviews were eligible for analysis, resulting in a total response rate of 80% and 1,116 patient years. Twenty-seven patients were splenectomized, and 66 patients were treated by a spleen preserving therapy (including embolization). Only two out of 27 splenectomized patients were adequately vaccinated, five patients without a spleen used prophylactic antibiotics, and about half of the asplenic patients had adequate knowledge of the risk that asplenia entails. A total of 22/27 splenectomized patients were neither adequately vaccinated nor received prophylactic antibiotics. There was no OPSI seen in our study population during the 1,116 follow-up years.ConclusionThe vaccination status, the level of knowledge concerning prevention of an OPSI, and the use of prophylactic antibiotics are suboptimal in pediatric patients treated for BSI. Therefore, we created a new follow-up treatment guideline to have adequate preventive coverage to current standards for these patients.

Dataset Information

Evidence-Based Management and Controversies in Blunt Splenic Trauma.

Publications

Evidence-Based Management and Controversies in Blunt Splenic Trauma.

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