Rutledge R, Hunt J P, Lentz C W, Fakhry S M, Meyer A A, Baker C C, Sheldon G F
Department of Surgery, University of North Carolina at Chapel Hill, USA.
Ann Surg. 1995 Sep;222(3):311-22; discussion 322-6. doi: 10.1097/00000658-199509000-00009.
Emergency operative intervention has been one of the cornerstones of the care of the injured patient. Over the past several years, nonoperative management has increasing been recommended for the care of selected blunt abdominal solid organ injuries. The purpose of this study was to utilize a large statewide, population-based data set to perform a time-series analysis of the practice of physicians caring for blunt solid organ injury of the abdomen. The study was designed to assess the changing frequency and the outcomes of operative and nonoperative treatments for blunt hepatic and splenic injuries.
Data were obtained from the state hospital discharge data base, which tracks information on all hospitalized patients from each of the 157 hospitals in the state of North Carolina. All trauma patients who had sustained injury to a solid abdominal organ (kidney, liver, or spleen) were selected for initial analysis.
During the 5 years of the study, 210,256 trauma patients were admitted to the state's hospitals (42,051 +/- 7802 per year). The frequency of nonoperative interventions for hepatic and splenic injuries increased over the period studied. The frequency of nonoperative management of hepatic injuries increased from 55% in 1988 to 79% in 1992 in patients with hepatic injuries and from 34% to 46% in patients with splenic injuries. The rate of nonoperative management of hepatic injuries increased from 54% to 64% in nontrauma centers compared with an increase from 56% to 74% in trauma centers (p = 0.01). In patients with splenic injuries, the rate of nonoperative management increased from 35% to 44% in nontrauma centers compared with an increase from 33% to 49% in trauma centers (p < 0.05). The rate of nonoperative management was associated with the organ injury severity, ranging from 90% for minor injuries to 19%-40% for severe injuries. Finally, in an attempt to compare blood use in operatively and nonoperatively treated patients, the total charges for blood were compared in the two groups. When compared, based on organ injury severity, the total blood used, as measured by charges, was lower for nonoperatively treated patients.
This large, statewide, population-based time-series analysis shows that the management of blunt injury of solid abdominal organs has changed over time. The incidence of nonoperative management for both hepatic and splenic injuries has increased. The study indicates that the rates of nonoperative management vary in relation to the severity of the organ injury. The rates increase in nonoperative management were greater in trauma centers than in nontrauma centers. These findings are consistent with the hypothesis that this newer approach to the care of blunt injury of solid abdominal organs is being led by the state's trauma centers.
急诊手术干预一直是受伤患者治疗的基石之一。在过去几年中，对于某些钝性腹部实性器官损伤的治疗，越来越多地推荐采用非手术治疗方法。本研究的目的是利用一个大型的全州范围、基于人群的数据集，对治疗钝性腹部实性器官损伤的医生的实践进行时间序列分析。该研究旨在评估钝性肝损伤和脾损伤的手术和非手术治疗的变化频率及结果。
数据取自州立医院出院数据库，该数据库跟踪北卡罗来纳州157家医院中所有住院患者的信息。所有腹部实性器官（肾、肝或脾）受伤的创伤患者被选作初始分析对象。
在研究的5年期间，该州医院共收治了210,256名创伤患者（每年42,051±7802名）。在所研究的时间段内，肝损伤和脾损伤的非手术干预频率有所增加。肝损伤患者中，肝损伤非手术治疗的频率从1988年的55%增至1992年的79%，脾损伤患者中则从34%增至46%。非创伤中心肝损伤非手术治疗的比例从54%增至64%，而创伤中心则从56%增至74%（p = 0.01）。对于脾损伤患者，非创伤中心非手术治疗的比例从35%增至44%，创伤中心则从33%增至49%（p < 0.05）。非手术治疗的比例与器官损伤严重程度相关，轻伤患者为90%，重伤患者为19% - 40%。最后，为了比较手术和非手术治疗患者的用血情况，对两组患者的血液总费用进行了比较。按器官损伤严重程度比较时，非手术治疗患者按费用计算的总用血量较低。
这项大型的全州范围、基于人群的时间序列分析表明，钝性腹部实性器官损伤的治疗随时间发生了变化。肝损伤和脾损伤的非手术治疗发生率均有所增加。该研究表明，非手术治疗的比例因器官损伤严重程度而异。创伤中心非手术治疗比例的增加幅度大于非创伤中心。这些发现与以下假设一致，即该州的创伤中心引领了这种治疗钝性腹部实性器官损伤的新方法。
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