血管栓塞治疗伴血流动力学不稳定的孤立性严重钝性脾损伤：倾向评分匹配分析。
Angioembolization for Isolated Severe Blunt Splenic Injuries with Hemodynamic Instability: A Propensity Score Matched Analysis.
机构信息
Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, 371-0811, Japan.
Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan.
出版信息
World J Surg. 2023 Nov;47(11):2644-2650. doi: 10.1007/s00268-023-07156-5. Epub 2023 Sep 7.
BACKGROUND
This study aimed to compare patient outcomes after splenic angioembolization (SAE) or splenectomy for isolated severe blunt splenic injury (BSI) with hemodynamic instability, and to identify potential candidates for SAE.
METHODS
Adult patients with isolated severe BSI (Abbreviated Injury Scale [AIS] 3-5) and hemodynamic instability between 2013 and 2019 were identified from the American College of Surgeons Trauma Quality Improvement (ACS TQIP) database. Hemodynamic instability was defined as an initial systolic blood pressure (SBP) <90 mmHg, heart rate (HR) >120 bpm, or lowest SBP <90 mmHg within 1 h after admission, with ≥1 unit of blood transfused within 4 h after admission. In-hospital mortality was compared between splenectomy and SAE groups using 2:1 propensity-score matching. The characteristics of unmatched and matched splenectomy patients were also compared.
RESULTS
A total of 478 patients met our inclusion criteria (332 splenectomy, 146 SAE). After propensity-score matching, 166 splenectomy and 83 SAE patients were compared. Approximately 85% of propensity-score matched patients sustained AIS 3/4 injuries, and 50% presented with normal SBP and HR before becoming hemodynamically unstable. The median time to intervention (splenectomy or SAE) was 137 min (interquartile range 94-183). In-hospital mortality between splenectomy and SAE groups was not significantly different (5.4% vs. 4.8%, p = 1.000). More than half of unmatched patients in the splenectomy group sustained AIS 5 injuries and presented with initially unstable hemodynamics. The median time to splenectomy in such patients was significantly shorter than in matched splenectomy patients (67 vs. 132 min, p < 0.001).
CONCLUSION
Splenectomy remains the mainstay of treatment for patients with AIS 5 BSI who present to hospital with hemodynamic instability. However, SAE might be a feasible alternative for patients with AIS 3/4 injuries.
背景
本研究旨在比较脾动脉栓塞术（SAE）与脾切除术治疗伴有血流动力学不稳定的孤立性严重钝性脾损伤（BSI）的患者结局，并确定 SAE 的潜在候选者。
方法
从美国外科医师学会创伤质量改进计划（ACS TQIP）数据库中确定 2013 年至 2019 年期间伴有孤立性严重 BSI（损伤严重程度评分 [AIS] 3-5 级）和血流动力学不稳定的成年患者。血流动力学不稳定定义为初始收缩压（SBP）<90mmHg、心率（HR）>120bpm 或入院后 1 小时内最低 SBP<90mmHg，且入院后 4 小时内输注≥1 个单位的血液。使用 2:1 倾向评分匹配比较脾切除术和 SAE 组的院内死亡率。还比较了未匹配和匹配的脾切除术患者的特征。
结果
共有 478 例患者符合纳入标准（脾切除术 332 例，SAE 146 例）。经过倾向评分匹配后，比较了 166 例脾切除术和 83 例 SAE 患者。大约 85%的倾向评分匹配患者有 AIS 3/4 级损伤，且 50%在出现血流动力学不稳定之前具有正常的 SBP 和 HR。干预（脾切除术或 SAE）的中位时间为 137 分钟（四分位距 94-183）。脾切除术和 SAE 组的院内死亡率无显著差异（5.4%比 4.8%，p=1.000）。脾切除术组中超过一半的未匹配患者有 AIS 5 级损伤，且初始血流动力学不稳定。这些患者行脾切除术的中位时间明显短于匹配的脾切除术患者（67 分钟比 132 分钟，p<0.001）。
结论
对于因血流动力学不稳定而就诊的 AIS 5 BSI 患者，脾切除术仍然是主要的治疗方法。然而，对于 AIS 3/4 级损伤的患者，SAE 可能是一种可行的替代方法。
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