|Year : 2015 | Volume
| Issue : 2 | Page : 101-105
Feasibility of nonoperative management of grade III and IV splenic injury in hemodynamically stable patients in limited ICU settings: A prospective study
M Wani1, SA Mir1, YZ Watali1, JA Bhat2, MY Bhat3, HA Moheen4
1 Department of Surgery, Government Medical College, Srinagar, Jammu and Kashmir, India
2 Department of Radiodiagonosis, Government Medical College, Srinagar, Jammu and Kashmir, India
3 Department of Pharmacology, Government Medical College, Srinagar, Jammu and Kashmir, India
4 Postgraduate Student, BS, University of Kashmir, Kashmir, Jammu and Kashmir, India
|Date of Web Publication||16-Jun-2015|
Dr. S A Mir
Department of Surgery, Government Medical College, Srinagar - 190 001, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background: The management of splenic injuries has evolved over the years. The objective of this study was to evaluate the feasibility of nonoperative management (NOM) of higher grades (grade III and IV) of splenic trauma in limited intensive care unit (ICU) settings.
Patients and Methods: This prospective study was carried out in the Department of Surgery Government Medical College, Srinagar over a period of 1.5 year from January 2012 to June 2013. The study included 50 hemodynamically stable patients with computed tomography (CT) documented grade III or IV splenic trauma (30 patients with grade III and 20 patients with grade IV). Vigorous monitoring was done in general surgical ward setup during first 2-3 days of trauma consisting of hourly monitoring by the resident doctor on the 1 st day and 3-hourly monitoring thereafter.
Results: Most common mode of trauma was road traffic accident (20, 40%) followed by fall from height (15, 30%), human violence (10, 20%), and others including animal assault (5, 10%). Ninety-four percent of our patients were managed nonoperatively without any mortality. Fourteen patients from group A (grade III) and 17 patientsfrom group B (grade IV) required blood transfusions. Ninety-three percent of the patients from group A and 45% of patients from group B were managed in the ward setting without any need for ICU setup. Children with grade III laceration showed complete resolution on CT after an average of 5.2 months and those with grade IV laceration on CT after an average of 9.3 months.
Conclusion: NOM of higher grades of splenic trauma appears to be feasible in centers with limited ICU facilities, though it demands strict and continuous monitoring during initial 2-3 days.
Keywords: Blunt abdominal trauma, diagnostic imaging, ICU limited settings, nonoperativemanagement, resuscitation, splenic trauma
|How to cite this article:|
Wani M, Mir S A, Watali Y Z, Bhat J A, Bhat M Y, Moheen H A. Feasibility of nonoperative management of grade III and IV splenic injury in hemodynamically stable patients in limited ICU settings: A prospective study. Arch Int Surg 2015;5:101-5
|How to cite this URL:|
Wani M, Mir S A, Watali Y Z, Bhat J A, Bhat M Y, Moheen H A. Feasibility of nonoperative management of grade III and IV splenic injury in hemodynamically stable patients in limited ICU settings: A prospective study. Arch Int Surg [serial online] 2015 [cited 2020 Oct 22];5:101-5. Available from: https://www.archintsurg.org/text.asp?2015/5/2/101/153652
| Introduction|| |
The management of splenic injuries has evolved since the 1940s when Wansborough, from the hospital for sick children in Toronto, reviewed the necropsy of a child with a suspected previous splenic injury, and noted a well-healed complete transection of the spleen into two segments on two separate pedicles.  He suggested that splenectomy was not always necessary for hemodynamically stable patients with splenic injuries.  The protocol of nonoperative management (NOM) in adults was broken after the observation of the management of spleen trauma in children. , Billroth suggested over 100 years ago that the injured spleen has the ability of self-healing.  When it comes to visceral injuries following abdominal trauma, there is nothing as radical as the NOM of hepatic and splenic injuries.  In 1882, Gross indicated NOM for splenic injuries and recommends bed rest and mild diet for minor injuries and lead acetate, ergot, and opium for severe lesions; surgery will be performed only if necessary.  The treatment for blunt abdominal trauma has significantly changed thanks to new diagnostic methods and the accurate assessment of organ damage. Traditionally splenectomy was done in almost all patients with splenic trauma. Splenectomy is associated with many complications. Many clinical studies indicated that splenectomy increases risk of infection susceptibility with its most deadly manifestation, overwhelming post splenectomy infection (OPSI), which appears in 0.5% of trauma patients and in over 20% of elective splenectomies for hematologic disorders.  OPSI is most frequent during the first 2 years of asplenia, but there is a permanent risk of infection with a mortality of over 80%. It is currently considered that traumatic splenic injury is no longer an absolute indication for splenectomy, thus a proper review of indications for emergency surgery in traumatic hemoperitoneum is needed. It has proven to have advantages, such as low hospital costs, avoidance of nontherapeutic laparotomies, low rates of intra-abdominal complications, low rate of blood transfusions, and low mortality rate. NOM is currently not recommended in institutions other than those with full capabilities, including multislice computed tomography (CT) scan, trauma intensive care unit (TICU) staff, and in-house surgery team.  NOM is not 100% safe and is deemed to fail in 2-33% of cases. ,, The presence of multiple splenic lesions, large amount of free fluid, age greater than 55 years, and high injury severity score (ISS) are important risk factors associated with treatment failure. ,, NOM has emerged as treatment of choice for American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) grade I, II and III, while grade IV remains the point of discussion yet. The purpose of the present study was to evaluate the feasibility of NOM for grade III and IV splenic trauma in a tertiary care hospital of northern India with limited ICU facility. The only absolute indication for emergency laparotomy is hemodynamic instability. 
| Patients and Methods|| |
This prospective study was carried out in the Department of Surgery, Government Medical College, Srinagar over a period of 1.5 year from January 2012 to June 2013. Shri Maharaja Hari Singh (SMHS) Hospital is an associated hospital of Government Medical College (GMC), Srinagar. It is an 800-bedded hospital with a limited ICU facility. Its ICU has a capacity of seven beds. This ICU is meant not only for the SMHS Hospital but also other associated hospitals of GMC Srinagar and other peripheral hospitals of Kashmir valley. CT angiography is available in SMHS Hospital, although none of our patients had splenic blush on contrast-enhanced computed tomography (CECT). About 700 patients of blunt abdominal trauma are admitted to the surgical causality department of SMHS Hospital, Srinagar annually.
The study included 50 hemodynamically stable patients with CT documented grade III or IV splenic trauma- (30 patients with grade III and 20 patients with grade IV). Advanced Trauma Life Support (ATLS) protocol was routinely applied. Grade I and II splenic injuries are usually managed nonoperatively. Protocol of nonoperative treatment in AAST-OIS  grade IV blunt splenic trauma was followed.
Inclusion criteria include patients with splenic injury from blunt abdominal trauma who had no signs of peritonitis and were hemodynamically stable defined as systolic blood pressure >90 mmHg and initial hemoglobin level >8 g/dL after initial resuscitation with maximum 2 units of red blood cells. Patients whose CT revealed absence of associated injuries to hollow viscera or pneumoperitoneum and absence of splenic contrast blush were also included.
NOM protocol: Monitoring
- Hemoglobin or hematocrit measurement every 6 h in the first 24 h or more frequently in the case of clinical deterioration.
- Arterial blood gas measurements every 12 h in the first 24 h or more frequently in the case of clinical deterioration.
- ICU admission.
NOM failure was defined by the need for surgical intervention due to continuous hemodynamic instability, progressive fall of hemoglobin or hematocrit levels, with recurrent blood transfusion or clinical signs of peritonitis.
Above protocol was followed in our study to a great extent except for the routine ICU admission. Vigorous monitoring was done in general surgical ward setup during first 2-3 days of trauma consisting of hourly monitoring by the resident doctor on the 1 st day and 3-hourly monitoring thereafter. Monitoring parameters included pulse, respiratory rate, blood pressure, temperature, input, and output. Patients were discharged on day 5 th -7 th . Follow-up was scheduled at 2 weeks, 1 month, 3 months, and so on.
Indications for operative management in a stable splenic trauma patient:
- Other clear indications for exploratory laprotomy.
- Associated health conditions that carry an increased risk of bleeding (coagulopathy, hepatic failure, use of anticoagulants, specific coagulation factor deficiency).
- Contrast extravasation on CT.
- Non availability of the operating surgeon round the clock (in case need arises).
| Results|| |
The study included 50 patients of splenic trauma [Figure 1] with initial hemodynamic stability and CT scan documented grade III (group A) or IV (group B) splenic trauma (30 patients with grade III and 20 patients with grade IV ) as shown in [Table 1]. Most common mode of trauma was road traffic accident (20, 40%) followed by fall from height (15, 30%), human violence (10, 20%), and others including animal assault (5,10%). As for as demographic distribution is concerned, 30 (60%) patients were from urban areas and 20 (40%) from rural areas. Most of our patients (47,94%) were managed nonoperatively. Fourteen patients from group A (Grade III) and 17 patients from group B (Grade IV) required blood transfusions. The amount of blood transfused ranged from 0 to 3 units. Twenty-eight (93.3%) patients from group A and nine (45%) patients from group B were managed in the ward setting without any need for ICU setup. The AAST grades for splenic trauma are given in [Table 1].
|Table 1: American Association for the Surgery of Trauma (AAST) grades for splenic trauma |
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The sex and age distribution of patients and various parameters are given in [Table 2] and [Table 3], respectively. The age of the patients ranged from 13 to 57 years. The NOM failed in three patients from group B and were operated. The indication for terminating NOM was worsening of abdominal pain and hypovolemic shock in two patients and clinical signs of peritonitis in one patient.
| Discussion|| |
"NOM for blunt splenic injuries replaces splenorrhaphy which was the usual method for preserving the spleen". , The incidence of NOM has increased from 59% (1991) to 75% (1994) and that of splenectomy has decreased from 35% (1991) to 24% (1994).  The incidence of splenorrhaphy has significantly dropped from 6 to 1%.  Even 2 units of transfused blood during the first 48 h (in order to maintain a hemoglobin level above 8 g/dl) is compatible with a successful NOM. , Similar results were obtained in our study (14 cases in group A and 17 cases in group B required blood transfusions). Accelerated splenic healing that grants a successful NOM in children and young adults is explained by the early accumulation of myofibroblasts at the lesion site. Benya et al.,  conducted a study that included children with grade I-II splenic injuries with complete resolution on CT scans after 4 months from the initial injury; for severe lesions the healing time is extended to over 6 months for grade III and over 11 months for grade IV injuries. In our study, children with grade III laceration showed complete resolution on CT after an average of 5.2 months and those with grade IV laceration on CT after an average of 9.3 months. Archer's results indicated that NOM in patients with altered mental status is safe in a strictly monitored environment as confirmed by the rate of success of NOM in patients with GCS <13 (93%).  Likewise, Cocanour  considers that brain injuries are not a contraindication for NOM. In a setup with limited ICU facilities like ours, the threshold for operative management should be low in patients of splenic trauma associated with brain injuries. Sartorelli et al.'s, study  about multiple intra-abdominal parenchymal injuries established a rate of success for NOM of 94.1%, therefore confirming its safety.
Recent protocols for NOM are applicable in all multiple trauma patients with splenic injuries (but without hemorrhage), requiring more than 4 units of transfused units (usually following pelvic fractures) only in trauma centers.  It is important to remember that prolonged bleeding may cause clotting disturbances, affecting the overall outcome of NOM, thus emphasizing the importance of an accurate clinical assessment.  Multiple transfusions are actually the hallmark of failed NOM. 
Patients with a prolonged prothrombin time (PT) should not be approached by NOM in case of splenic trauma even if cirrhosis is not present.  Unsuccessful NOM rate ranges between 2 and 31%. , In our study, unsuccessful NOM rate was 3(6%) patients. The indication for terminating NOM was worsening of abdominal pain and hypovolemic shock in two patients and clinical signs of peritonitis in one patient. Factors like proper selection of patients, cooperation of patients (limitation of activity), and aggressive monitoring contributed to good success rate in our study.
| Conclusion|| |
NOM of higher grades of splenic trauma (grade III and IV) appears to be feasible even in centers with limited ICU facilities, though it demands strict and continuous monitoring. Most of our patients were managed well in the ward setup without any mortality. NOM of splenic trauma has proven to have advantages, such as low hospital costs, avoidance of nontherapeutic laparotomies, low rates of intra-abdominal complications, low rate of blood transfusions, and low mortality rate. Most of our patients were managed well in the ward setup without any mortality. Hence, we recommend conservative management (NOM) in grade III/IV splenic trauma in ICU limited settings, though it needs frequent monitoring during initial 2-3 days.
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[Table 1], [Table 2], [Table 3]