Blunt splenic injuries: have we watched long enough?

BACKGROUND

Nonoperative management (NOM) of blunt splenic injuries (BSIs) has been used with increasing frequency in adult patients. There are currently no definitive guidelines established for how long BSI patients should be monitored for failure of NOM after injury.

METHODS

This study was performed to ascertain the length of inpatient observation needed to capture most failures, and to identify factors associated with failure of NOM. We utilized the National Trauma Data Bank to determine time to failure after BSI.

RESULTS

During the 5-year study period, 23,532 patients were identified with BSI, of which 2,366 (10% overall) were taken directly to surgery (within 2 hours of arrival). Of 21,166 patients initially managed nonoperatively, 18,506 were successful (79% of all-comers). Patients with isolated BSI are currently monitored approximately 5 days as inpatients. Of patients failing NOM, 95% failed during the first 72 hours, and monitoring 2 additional days saw only 1.5% more failures. Factors influencing success of NOM included computed tomographic injury grade, severity of patient injury, and American College of Surgeons designation of trauma center. Importantly, patients who failed NOM did not seem to have detrimental outcomes when compared with patients with successful NOM. No statistically significant predictive variables could be identified that would help predict patients who would go on to fail NOM.

CONCLUSIONS

We conclude that at least 80% of BSI can be managed successfully with NOM, and that patients should be monitored as inpatients for failure after BSI for 3 to 5 days.