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Selective Nonoperative Management of Blunt Splenic Injury: an Eastern Association for the Surgery of Trauma Practice Management Guideline

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Selective Nonoperative Management of Blunt Splenic Injury: an Eastern Association for the Surgery of Trauma Practice Management Guideline GUIDELINE Selective nonoperative management of blunt splenic injury: An Eastern Association for the Surgery of Trauma practice management guideline Nicole A. Stassen, MD, Indermeet Bhullar, MD, Julius D. Cheng, MD, Marie L. Crandall, MD, Randall S. Friese, MD, Oscar D. Guillamondegui, MD, Randeep S. Jawa, MD, Adrian A. Maung, MD, Thomas J. Rohs, Jr, MD, Ayodele Sangosanya, MD, Kevin M. Schuster, MD, Mark J. Seamon, MD, Kathryn M. Tchorz, MD, Ben L. Zarzuar, MD, and Andrew J. Kerwin, MD BACKGROUND: During the last century, the management of blunt force trauma to the spleen has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative man- agement. These issues were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the Practice Management Guidelines for Non-operative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the current EAST guideline. METHODS: The National Library of Medicine and the National Institute of Health MEDLINE database was searched using Pub Med (www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords splenic injury and blunt abdominal trauma. RESULTS: One hundred seventy-six articles were reviewed, of which 125 were used to create the current practice management guideline for the selective nonoperative management of blunt splenic injury. CONCLUSION: There has been a plethora of literature regarding nonoperative management of blunt splenic injuries published since the original EAST practice management guideline was written. Nonoperative management of blunt splenic injuries is now the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury, patient age, or the presence of associated injuries. Its use is associated with a low overall morbidity and mortality when applied to an appropriate patient population. Nonoperative management of blunt splenic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and has an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt splenic injuries. Repeat imaging should be guided by a patient’s clinical status. Adjunctive therapies like angiography with embolization are increasingly important adjuncts to nonoperative management of splenic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt splenic injuries remain without conclusive answers in the literature. (J Trauma Acute Care Surg. 2012;73: S294YS300. Copyright * 2012 by Lippincott Williams & Wilkins) KEY WORDS: Guideline; spleen; blunt abdominal trauma; surgery. STATEMENT OF THE PROBLEM avoiding nontherapeutic celiotomies (and their associated cost and morbidity), fewer intra-abdominal complications, and re- During the last century, the management of blunt force trauma duced transfusion rates associated with an overall improve- to the spleen has changed from observation and expectant ment in mortality of these injuries.1 Pachter et al.,2 in 1998, management in the early part of the 1900s to operative inter- showed that 65% of all blunt splenic injuries and could be vention for all injuries, to the current practice of selective managed nonoperatively with minimal transfusions, morbidi- operative and nonoperative management. The current nonop- ty, or mortality, with a success rate of 98%. These issues were erative paradigm in adults was stimulated by the success of first addressed by the Eastern Association for the Surgery of nonoperative management of solid-organ injuries in hemody- Trauma (EAST) in the Practice Management Guidelines for namically stable children. The advantages of nonoperative Non-operative Management of Blunt Injury to the Liver and management include lower hospital cost, earlier discharge, Spleen published online in 2003.3 Since that time, a large (M.J.S.), Cooper Health System, Camden, New Jersey; the Department of Surgery Submitted: June 6, 2012, Revised: August 8, 2012, Accepted: August 8, 2012. (K.M.T.), Wright State University, Dayton, Ohio; Department of Surgery (I.B., From the Practice Management Guideline Committee (N.A.S., J.D.C., A.S.), East- A.J.K.), University of Florida College of Medicine, Jacksonville, Florida. ern Association for the Surgery of Trauma; Department of Surgery (M.L.C.), Supplemental digital content is available for this article. Direct URL citations ap- Northwestern University, Chicago, Illinois; Department of Surgery (N.A.S., pear in the printed text, and links to the digital files are provided in the HTML J.D.C., A.S.), University of Rochester, Rochester, New York; Department of text of this article on the journal’s Web site (www.jtrauma.com). Surgery (R.S.F.), University of Arizona, Tuscon, Arizona; Department of Surgery Address for reprints: Nicole A. Stassen, MD, Department of Surgery, University of (O.D.G.), Vanderbilt University, Nashville; and Department of Surgery (B.L.Z.), Rochester 601 Elmwood Ave, Box SURG Rochester, NY 14642; email: University of Tennessee Health Science Center, Memphis, Tennessee; Department [email protected]. Surgery (O.D.G.), University of Nebraska, Omaha, Nebraska; Department of Surgery (A.A.M., K.M.S.), Yale University, New Haven, Connecticut; Bor- gess Trauma Services (T.J.R.), Kalamazoo, Michigan; Department of Surgery DOI: 10.1097/TA.0b013e3182702afc J Trauma Acute Care Surg S294 Volume 73, Number 5, Supplement 4 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. J Trauma Acute Care Surg Volume 73, Number 5, Supplement 4 Stassen et al. volume of literature on these topics has been published. As Health and Human Services was used to group the references a result, the Practice Management Guidelines Committee of into three classes.9 EAST set out to develop updated guidelines for the nonopera- tive management of splenic injuries. This practice management Class I: Prospective randomized studies (no references). guideline update has been split into separate recommenda- Class II: Prospective, noncomparative studies; retrospective tions for the nonoperative management of blunt hepatic and series with controls (19 references). splenic injuries in adult trauma patients, rather than the amal- Class III: Retrospective analyses (case series, databases or gamated recommendations included in the 2003 practice man- registries, and case reviews) (105 references). agement guideline. Reports of nonoperative management in adults with Based on the review and assessment of the selected re- injuries to the liver continue to support nonoperative man- ferences, three levels of recommendations are proposed. agement in hemodynamically stable adults, but questions still exist about efficacy, patient selection, and details of manage- Level 1 ment.4Y8 These questions include the following: The recommendation is convincingly justifiable based on the available scientific information alone. This recom- & Are the 2003 recommendations still valid? mendation is usually based on Class I data; however, strong & Is nonoperative management appropriate for all hemody- Class II evidence may form the basis for a Level 1 recom- namically stable adults regardless of severity of solid-organ mendation, especially if the issue does not lend itself to testing injury or presence of associated injuries? in a randomized format. Conversely, low-quality or contra- & What role should angiography and other adjunctive thera- dictory Class I data may not be able to support a Level 1 pies play in nonoperative management? recommendation. & Is the risk of missing a hollow viscous injury a deterrent to nonoperative management? Level 2 & What is the best way to diagnose injury to the spleen? The recommendation is reasonably justifiable by avail- & What roles do computed tomographic (CT) scan and/or able scientific evidence and strongly supported by expert ultrasonography have in the hospital management of the opinion. This recommendation is usually supported by Class patient being managed nonoperatively? II data or a preponderance of Class III evidence. & Is the need for transfusion greater for patients managed Level 3 nonoperatively? The recommendation is supported by available data, but & Should patients be placed on a ‘‘bed rest’’ activity status, adequate scientific evidence is lacking. This recommendation and if so, for what duration? is generally supported by Class III data. This type of recom- & Finally, what period and evaluation is needed before re- mendation is useful for educational purposes and in guiding leasing patients back to full activity? future clinical research. PROCESS RECOMMENDATIONS Identification of References Upon review of the updated literature, it was found that References were identified by research librarians at the the majority of recommendations from the 2003 guideline University of Rochester, Miner Medical Library. The MED- remain valid. The previous guidelines were incorporated into LINE database in the National
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