Sir,
The standard treatment of choice for hemodynamically stable patients with blunt splenic trauma is currently, nonoperative management (NOM), thanks to the development in intensive care units and the improvement of computed tomography and angioembolization technique.[1] However, the indications and criteria for successful (NOM) remain controversial. The study is aimed to evaluate the feasibility of conservative treatment and to identify the main predictor factors of NOM to choose the most appropriate therapeutic attitude.
A retrospective multivariate regression analysis was carried out of 100 patients with injury to the spleen between 2013 and 2018. A total of 100 patients were identified (80 men and 20 women) with a median age of 36 ± 15.75 years. In 59 cases, spleen lesions were associated with other intra-abdominal involvement mainly in the liver (57.6%) and kidneys (50.8%). Nine patients were admitted for penetrating splenic trauma, among which three had an attempt of NOM, which was successful in two-thirds of the cases. Ninety-one patients were admitted for blunt splenic trauma with an attempt of NOM in 81.3% of cases and a success rate of 86.5%. Our analytical study [Table 1] found that predictors of NOM failure were age ≥55 years (P = 0.011), SBP at admission <100 mmHg (P = 0.000071), or shock on admission (P = 0.028), a transfusion of three units or more of packed red cells (PRC) (P = 0.0029), as well as associated pancreatic injury (P = 0.00018) or intra-abdominal hollow organ injury (P = 0.01). As a result of the multivariate logistic regression analysis [Table 2], SBP <100 mmHg (odds ratio [OR] = 1.293; 95% confidence interval [CI] = 1.045–1.601; P = 0.018) and blood transfusion >3 PRC (OR = 2.739; 95% CI = 1.140–6.581; P = 0.024) were determined to be independent predictive factors for the failure of NOM.
Table 1.
Univariate analysis of patient and trauma characteristics
| Variable | Successful NOM | Failed NOM | P |
|---|---|---|---|
| Age | 34.94±15 | 47.6±20.6 | 0.011 |
| Accident mechanism | |||
| Road accidents | 59.37 | 80 | 0.21 |
| Assaults | 9.37 | 0 | 0.31 |
| GCS | 6.25 | 20 | 0.13 |
| SBP 100 mmHg | 3.12 | 40 | 0.000071 |
| Pulse rate >100 | 21.87 | 50 | 0.081 |
| Shock | 3.12 | 20. | 0.028 |
| Hb <10 | 7.8 | 10 | 0.81 |
| Transfusion >3 CG | 6.67 | 70 | 0.0029 |
| AAST >III | 23.44 | 30 | 0.65 |
| Associated lesions | |||
| Liver | 34.37 | 40 | 0.73 |
| Pancreas | 0 | 20 | 0.00018 |
| Kidney | 26.56 | 50 | 0.13 |
| Hollow organ | 0 | 10 | 0.01 |
| ISS >25 | 46.87 | 30 | 0.32 |
NOM: Nonoperative management, GCS: Glasgow Coma Scale, SBP: Systolic blood pressure, Hb: Hemoglobin, AAST: American Association for the Surgery of Trauma, ISS: Injury severity score
Table 2.
Results of the multivariate logistic regression analysis
| Variables | OR | 95% Confidence Interval (Lower-Upper) | P |
|---|---|---|---|
| Age | 1.043 | 0.065-17.004 | 0.976 |
| SBP <100 mmHg | 1.294 | 1.046-1.599 | 0.018 |
| Shock | 0.854 | 0.379-1.898 | 0.699 |
| Transfusion >3 CG | 2.81 | 1.150-6.589 | 0.025 |
| Associated lesions | |||
| Pancreas | 0.951 | 0.851-1.064 | 0.387 |
| Hollow organ | 0.875 | 0.428-1.803 | 0.254 |
OR: Odds ratio, CI: Confidence interval, SBP: Systolic blood pressure
NOM means surgical observation with a serial physical examination, serial computed tomography, or angiographic embolization. The overall success rate reported in the literature ranged from 78% to 98%.[2] In our study, the success rate was 86.5%. Several studies determined a correlation between failed NOM and statistically significantly lower SBP in admission.[3,4] and higher requirement in blood transfusion in the first 24 h.[5] Special attention should be paid to these patients when they are treated with NOM approaches.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
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