Meguid Ahmed A, Bair Holly A, Howells Greg A, Bendick Phillip J, Kerr Hugh H, Villalba Mario R
Division of Trauma Surgery, Department of Surgery, William Beaumont Hospital, Royal Oak, Michigan 48073-2689, USA.
Am Surg. 2003 Mar;69(3):238-42; discussion 242-3.
Recent reports have shown an increased mortality associated with the nonoperative management of blunt splenic injury. We have prospectively applied criteria developed from our previous 15-year experience for the nonoperative management (NOM) of blunt splenic injury. These criteria consist of 1) hemodynamic stability on admission or after initial resuscitation with up to two liters of crystalloid infusion, 2) no physical findings or any associated injuries necessitating laparotomy, and 3) a transfusion requirement attributable to the splenic injury of 2 units or less. From 1994 through 2000 a total of 99 patients presented with blunt splenic injury. Thirty-one patients (31%) underwent splenectomy secondary to hemodynamic instability. During the observation period eight of the 68 patients (12%) who initially met criteria for NOM developed hemodynamic instability and underwent splenectomy. All NOM failures occurred within 72 hours of admission. There was no mortality associated with splenic injury in the NOM (Group I) or in the group failing NOM (Group II), and no associated morbidities from the splenic injury were seen in either group. No significant differences were seen between Groups I and II in terms of age, gender, mechanism of injury, Injury Severity Score, admitting systolic blood pressure, admitting hemoglobin, transfusion requirements, intensive care unit length of stay, or total hospital length of stay (all P > 0.200). We conclude that established criteria for intervention and careful observation in an intensive care setting for at least 72 hours will minimize morbidity or mortality associated with blunt splenic injury in adults.
近期报告显示，钝性脾损伤非手术治疗的死亡率有所上升。我们前瞻性地应用了基于此前15年钝性脾损伤非手术治疗（NOM）经验制定的标准。这些标准包括：1）入院时或经最多两升晶体液输注初始复苏后血流动力学稳定；2）无需要剖腹手术的体格检查发现或任何相关损伤；3）因脾损伤导致的输血量为2个单位或更少。1994年至2000年期间，共有99例患者出现钝性脾损伤。31例患者（31%）因血流动力学不稳定接受了脾切除术。在观察期内，68例最初符合NOM标准的患者中有8例（12%）出现血流动力学不稳定并接受了脾切除术。所有NOM失败均发生在入院72小时内。NOM组（I组）或NOM失败组（II组）中均无与脾损伤相关的死亡病例，两组中均未观察到脾损伤相关的并发症。I组和II组在年龄、性别、损伤机制、损伤严重程度评分、入院收缩压、入院血红蛋白、输血量、重症监护病房住院时间或总住院时间方面均无显著差异（所有P>0.200）。我们得出结论，在重症监护环境中建立干预标准并进行至少72小时的仔细观察，将使成人钝性脾损伤相关的发病率或死亡率降至最低。
