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The splenic injury outcomes trial

An American Association for the Surgery of Trauma multi-institutional study

Zarzaur, Ben L. MD, MPH; Kozar, Rosemary MD, PhD; Myers, John G. MD; Claridge, Jeffrey A. MD, MS; Scalea, Thomas M. MD; Neideen, Todd A. MD; Maung, Adrian A. MD; Alarcon, Louis MD; Corcos, Alain MD; Kerwin, Andrew MD; Coimbra, Raul MD, PhD

Journal of Trauma and Acute Care Surgery: September 2015 - Volume 79 - Issue 3 - p 335–342
doi: 10.1097/TA.0000000000000782
AAST 2014 Plenary Papers
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BACKGROUND Delayed splenic hemorrhage after nonoperative management (NOM) of blunt splenic injury (BSI) is a feared complication, particularly in the outpatient setting. Significant resources, including angiography (ANGIO), are used in an effort to prevent delayed splenectomy (DS). No prospective, long-term data exist to determine the actual risk of splenectomy. The purposes of this trial were to ascertain the 180-day risk of splenectomy after 24 hours of NOM of BSI and to determine factors related to splenectomy.

METHODS Eleven Level I trauma centers participated in this prospective observational study. Adult patients achieving 24 hours of NOM of their BSI were eligible. Patients were followed up for 180 days. Demographic, physiologic, radiographic, injury-related information, and spleen-related interventions were recorded. Bivariate and multivariable analyses were used to determine factors associated with DS.

RESULTS A total of 383 patients were enrolled. Twelve patients (3.1%) underwent in-hospital splenectomy between 24 hours and 9 days after injury. Of 366 discharged with a spleen, 1 (0.27%) required readmission for DS on postinjury Day 12. No Grade I injuries experienced DS. The splenectomy rate after 24 hours of NOM was 1.5 per 1,000 patient-days. Only extravasation from the spleen at time of admission (ADMIT-BLUSH) was associated with splenectomy (odds ratio, 3.6; 95% confidence interval, 1.4–12.4). Of patients with ADMIT-BLUSH (n = 49), 17 (34.7%) did not have ANGIO with embolization (EMBO), and 2 of those (11.8%) underwent splenectomy; 32 (65.3%) underwent ANGIO with EMBO, and 2 of those (6.3%, p = 0.6020 compared with no ANGIO with EMBO) required splenectomy.

CONCLUSION Splenectomy after 24 hours of NOM is rare. After the initial 24 hours, no additional interventions are warranted for patients with Grade I injuries. For Grades II to V, close observation as an inpatient or outpatient is indicated for 10 days to 14 days. ADMIT-BLUSH is a strong predictor of DS and should lead to close observation or earlier surgical intervention.

LEVEL OF EVIDENCE Prognostic/epidemiological study, level III; therapeutic study, level IV.

From the AAST Multi-Institutional Trials Committee (B.L.B., R.K., J.G.M., J.A.C., T.M.S., T.A.N., A.A.M., L.A., A.C., A.K., R.X.); University of Tennessee Health Science Center (B.L.Z.), Memphis, Tennessee; Indiana University School of Medicine (B.L.Z.), Indianapolis, Indiana; University of Texas Health Science Center Houston (R.K.), Houston; and University of Texas Health Science Center San Antonio (J.G.M.), San Antonio, Texas; Case Western Reserve University School of Medicine (J.A.C.), Cleveland, Ohio; University of Maryland School of Medicine (T.M.S.), Baltimore, Maryland; Medical College of Wisconsin (T.A.N.), Milwaukee, Wisconsin; Yale University School of Medicine (A.A.M.), New Haven, Connecticut; University of Pennsylvania Medical Center–Presbyterian (L.A.); and University of Pennsylvania Medical Center–Mercy (A.C.), Philadelphia, Pennsylvania; University of Florida College of Medicine–Jacksonville (A.K.), Jacksonville, Florida; and University Of California San Diego Health Sciences (R.C.), San Diego, California.

Submitted: September 8, 2014, Revised: March 17, 2015, Accepted: March 18, 2015.

This study was presented at the 73rd annual meeting of the American Association for the Surgery of Trauma September 10–13, 2014, in Philadelphia, Pennsylvania.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

Address for reprints: Ben L. Zarzaur, MD, MPH, Department of Surgery, Indiana University School of Medicine, 702 Rotary Circle Suite, 022B Indianapolis, IN 46204; email: bzarzaur@iupui.edu.

© 2015 Lippincott Williams & Wilkins, Inc.