Failures of Splenic Nonoperative Management: Is the Glass Half Empty or Half Full?

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Abstract
Background Published contraindications to nonoperative management (NOM) of blunt splenic injury (BSI) include age ≥ 55, Glasgow Coma Scale score ≤ 13, admission blood pressure < 100 mm Hg, major (grades 3–5) injuries, and large amounts of hemoperitoneum. Recently reported NOM rates approximate 60%, with failure rates of 10% to 15%. This study evaluated our failures of NOM for BSI relative to these clinical factors. Methods All patients with BSI at a Level I trauma center over a 46-month period ending September 1999 were reviewed. Failures of NOM included patients initially selected for NOM who subsequently required splenectomy/splenorrhaphy. Results Five hundred fifty-eight had BSI. Twenty-three percent (128) underwent emergent laparotomy for hemodynamic instability and 77% (430) were observed. The NOM failure rate was only 8%. Univariate analysis identified moderate to large hemoperitoneum (p < 0.03), grades 3 to 5 (p < 0.004), and age ≥ 55 (p < 0.0006) as being significantly associated with failure. Multivariate analysis identified age ≥ 55 and grades 3 to 5 injuries as independent predictors of failure. The highest failure rates (30–40%) occurred in patients age ≥ 55 with major injury for moderate to large hemoperitoneum. Mortality rates for successful NOM were 12%, and 9% for failed NOM. Conclusion Inclusion of all high-risk patients increased the NOM rate while maintaining a low failure rate. Although age ≥ 55 and major BSI were independently associated with failure of NOM, approximately 80% of these high-risk patients were successfully managed nonoperatively. There was no increased mortality associated with failure. Although these factors may indeed predict failure, they do not necessarily contraindicate NOM.

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