Pre- and post-implementation protocol for non-operative management of grade III-V splenic injuries: An observational study

TL;DR

A standardized protocol for managing severe splenic injuries in stable patients increased non-operative success rates and reduced surgery and blood transfusions.

Contribution

A new treatment protocol for grade III-V splenic injuries improved non-operative management success rates and reduced surgical interventions.

Findings

Non-operative management rates increased from 50.6% to 65.6% after protocol implementation.

Blood transfusion rates decreased from 64.2% to 45.9% post-protocol.

Angioembolization and follow-up CT scans became more common in the post-protocol group.

Abstract

Grade (III–V) blunt splenic injuries (BSI) in hemodynamically stable patients represent clinical challenges for successful non-operative management (NOM). In 2014, Our institution proposed a treatment protocol requiring splenic angiography and embolization for stable, intermediate, and high-grade BSI. It also included a follow-up CT scan for grade III BSI. We sought to assess the success rate of NOM in treating intermediate and high-grade BSI, following a standardized treatment protocol at a level 1 trauma center.

An observational retrospective study was conducted. Data of patients with BSI from June 2011 to September 2019 were reviewed using the Qatar National Trauma Registry. Patients’ demographics, CT scan and angiographic findings, grade of splenic injuries, and outcomes were analyzed. The pre- and post-implementation of treatment protocol periods were compared.

During the study period, a total of 552 hemodynamically stable patients with BSI were admitted, of which 240 had BSI with grade III to V. Eighty-one patients (33.8%) were admitted in the pre-protocol implementation period and 159 (66.2%) in the post-protocol implementation period. The NOM rate increased from 50.6% in the pre-protocol group to 65.6% in the post-protocol group (p = 0.02). In addition, failure of the conservative treatment did not significantly differ in the two periods, while the requirement for blood transfusion dropped from 64.2% to 45.9% (p = 0.007). The frequency of CT scan follow-up (55.3% vs. 16.3%, p = 0.001) and splenic arterial embolization (32.7% vs. 2.5%, p = 0.001) in NOM patients increased significantly in the post-protocol group compared to the pre-protocol group. Overall mortality was similar between the two periods. However, hospital and ICU length of stay and ventilatory days were higher in the post-protocol group.

NOM is an effective and safe treatment option for grade III-V BSI patients. Using standardized treatment guidelines for intermediate-to high-grade splenic injuries could increase the success rate for NOM and limit unnecessary laparotomy. Moreover, angioembolization is a crucial adjunct to NOM that could improve the success rate.

•The management of Grade III-V Splenic Injury remains a clinical challenge for trauma surgeons.•The utility of standardized treatment protocol for moderate to severe splenic injuries is effective and safe.•This protocolized approach resulted in improved non-operative management rates from 50.6% to 65.6%.•The protocol decreased the surgical intervention from 49.4% to 34.6%, and blood transfusion from 64.2% to 45.9%.•However, as with any treatment modality, the cost and risk of complications must be considered.

The management of Grade III-V Splenic Injury remains a clinical challenge for trauma surgeons.

The utility of standardized treatment protocol for moderate to severe splenic injuries is effective and safe.

This protocolized approach resulted in improved non-operative management rates from 50.6% to 65.6%.

The protocol decreased the surgical intervention from 49.4% to 34.6%, and blood transfusion from 64.2% to 45.9%.

However, as with any treatment modality, the cost and risk of complications must be considered.

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