Non-operative management of splenic injuries.

[dr-awale]

 NOM in Children
Non-operative management of splenic injuries in children has become well established over the past two decades with many studies reporting ? 95% success rates. The evolution of current practice is well documented. (1) Moog in a review of 88 children managed for splenic injury reported only one case of operative intervention. (2) Hemodynamic stability remains a key requirement for NOM; while the position of NOM in cases with higher injury grades and the need for ICU requirement remain less resolved. These decisions should depend on the individual merits of each case. (3, 4) Splenic artery embolization (SAE) has enjoyed increasing acceptance in the past five years. (5) (See 1.4 Angiography)

1.2. NOM in Adults
The success of NOM in children encouraged the drive towards the same approach in adults even though the risk of OPSI is low in adult trauma patients. NOM has become the preferred approach in hemodynamically stable patients. (6, 7) However clinical evidence of ongoing blood loss or instability should be addressed with prompt surgical intervention. (6) Careful patient selection is of utmost importance in NOM. Predictors of success remain debatable. Bala studied 64 patients and found that admission systolic blood pressure and associated injury to less than 3 extra abdominal regions were predictors of success; while the need for blood transfusion was a strong predictor for splenectomy. ( In a large retrospective review, age greater than 55 years, ISS higher than 25, along with admission to a level III or IV trauma hospital were associated with significant risk of failure of NOM.(9) While these issues remain unresolved, the success rates of NOM for splenic injuries have continued to improve, even in low-volume tropical countries. (9, 10) In a 15 year review of NOM, success rates moved from 77% to 96%. (11) The authors noted an increasing use of SAE to be contributory to improved success rates.
http://www.ptolemy.ca/members/archives/2010/Splenic/index.html

Failure of NOM is defined as need for surgical intervention after initially being selected for observation. This may be secondary to hemodynamic instability, peritonitis or persistent decline in hemoglobin after transfusion requirement ? 2 units of blood. (12) The optimum time for observation of blunt splenic patients in hospital has not been determined. Most patients who fail NOM do so within 48 hours. (12) Observation for 3-5 days would be an acceptable compromise.
There is no evidence based answer to the question of when an individual, who underwent successful NOM for splenic injury, should return to contact sports but many centres still favor the traditional 3 months.