Nonoperative management of splenic injury has become more common over time. Although approximately 40% of patients with splenic injury will require immediate operative intervention, nonoperative management is reasonable for hemodynamically stable patients.23
Appropriate patient selection is the most important element of nonoperative management. Determining which patients require emergency surgery and which can be initially managed nonoperatively is sometimes difficult, although hemodynamic status, age, grade of splenic injury, quantity of hemoperitoneum, and associated injuries have been shown to roughly correlate with the success or failure of nonoperative management. The decision for nonoperative management must also consider the institutional resources available.
Of paramount importance in the determination of the appropriateness of nonoperative management is the hemodynamic stability of the patient. Hemodynamic stability can be a somewhat illusory concept, and one for which there is no consensus definition; but hypotension is generally considered to be worthy of concern. Historically, a prehospital systolic blood pressure (SBP) less than 90 mm Hg has mandated triage to a trauma center. In fact, that criterion is too low, as a prehospital SBP less than 110 mm Hg has been shown to be associated with poor outcomes.24,25 Hypotension in the prehospital period or emergency department is worrisome, and a high index of suspicion for ongoing hemorrhage should be maintained when either is present. Patients who have been hemodynamically unstable in the prehospital phase and remain hemodynamically unstable during their initial emergency department stay are, in most instances, inappropriate candidates for abdominal CT scanning. They require either a direct trip to the operating room (OR) or, more commonly, abdominal ultrasonography or DPL to help guide the initial decision-making process (see Chapters 10 and 16).
Assuming hemodynamic stability, the other important prerequisite for consideration of nonoperative management is the patient’s abdominal examination. In patients who are awake and alert and can cooperate with a physical examination and provide feedback, it is important that they not have diffuse peritonitis. Although patients with splenic injury will often have localized pain and tenderness in the left upper quadrant and abdominal findings secondary to intraperitoneal blood, obvious diffuse peritonitis can be a sign of intestinal injury and mandates an abdominal exploration. If a patient with a splenic injury is sent for CT scanning and subsequent nonoperative management, it is important to perform repeat physical examinations. If the examination worsens, the possibility of a blunt intestinal injury should be considered. The most common CT finding in patients with blunt intestinal injury is free fluid in the peritoneal cavity. As previously noted, the free fluid can be mistakenly attributed solely to the splenic injury, and the presence of an associated injury to the bowel can be missed.
The success rates of nonoperative management of splenic injuries are very high in many of the published series. Reported success rates for nonoperative management are 95% or higher for pediatric patients and 80–94% in adults.26,27,28,29,30 These high success rates can be misleading, however, in that they apply only to the group of patients in whom nonoperative management was chosen rather than all patients with splenic injury. When patients undergoing immediate splenectomy are included, the overall splenic salvage rates tend to be 50–60% in adult patients. It is important to remember that these series generally do not include patients in whom the initial plan was for nonoperative management, but an emergency operation was necessary when the patient became hypotensive or developed peritonitis in the emergency department or in the CT scanner. The published series of nonoperatively managed spleens generally include only the selected patients who were stable enough to undergo CT scanning of the abdomen and in whom the CT scan showed an injured spleen. Patients who became unstable either before or during the scan and were taken emergently to surgery are usually not counted as patients who underwent “nonoperative” management. When these patients are reported at all, they are placed into the “operative” group rather than into the “failed nonoperative” group. Published series of splenic injuries, particularly in pediatric patients, are more likely to describe patients treated at referral centers where there are large numbers of transfer patients who have already been triaged for stability prior to their arrival at the referral center. Finally, the literature on the success of nonoperative management of splenic injury should be interpreted with the awareness that publication bias tends to favor series in which success rates are high.
Other important considerations beyond hemodynamic stability and abdominal findings in the determination of the appropriateness of nonoperative management have to do with the medical environment and some specific characteristics of the patient. Nonoperative management should only be undertaken if it will be possible to closely follow the patient. If close inpatient follow-up is simply not possible, abdominal exploration may be appropriate. Similarly, if rapid mobilization of the OR and quick operative intervention in the case of ongoing or delayed bleeding is not possible, early rather than emergent operative intervention may be appropriate. Finally, the patient’s circumstances after discharge occasionally may be important in the decision-making process. For patients who are to be discharged to a location remote from medical care, the consequences of delayed bleeding are greater in that they may not be close enough to a hospital that can perform an emergency operative procedure. In such circumstances, an otherwise reasonable candidate for nonoperative management might undergo operative intervention and, possibly, splenic repair.
For patients who are stable enough to undergo CT scanning and in whom an injured spleen is identified, nonoperative management is reasonable if they continue to remain stable. In addition to vital signs, one of the other commonly followed parameters in such patients is the hematocrit. A common practice is to determine a cutoff value below which the hematocrit will not be allowed to fall. If the hematocrit drops to that level or below, operative intervention is undertaken. Such an approach works best if there are no associated injuries; when associated injuries are present, it can be quite difficult to know if the spleen is continuing to bleed or if the fall in hematocrit is secondary to bleeding from other injuries.
In general, there is consensus that hemodynamically stable patients without obvious or progressive peritoneal signs who can be followed closely are reasonable candidates for nonoperative management. Historically, there has been a debate about certain subgroups of patients and their appropriateness for nonoperative management.31
Pediatric patients are excellent candidates for nonoperative management as they have a low incidence of delayed bleeding after splenic injury.32 As nonoperative management has become the standard of care in this population, there has been an increase in angioembolization with great success, as well.33,34 Because of the trauma mechanisms suffered by pediatric patients as opposed to adult patients, children are more likely to have isolated splenic injuries. As previously noted, the relative thickness of the splenic capsule is greater in children which likely confers more structural integrity to the spleen. The spleen in children is also more likely to fracture parallel to the splenic arterial blood supply rather than transverse to it (Fig. 30-7).35 This orientation of splenic injury tends to decrease the amount of blood loss from the splenic parenchyma. Children are more likely to have excellent physiologic reserve and minimal preexisting disease. Finally, the risks of splenectomy with respect to immunologic consequences are greater in young children than they are in adults.
Diagrammatic representation of a transverse laceration relative to the splenic vasculature in a pediatric patient. (Reproduced with permission from Upadhyaya P. Splenic trauma in children. Surg Gynecol Obstet. 1968;126:781, Copyright © Elsevier.)
Historically, older patients were thought to have a worse prognosis with respect to nonoperative management than did younger patients.36 Other series examining the question of the threshold at 55 years of age and nonoperative management suggest the success of nonoperative management is no different in this group than it is in younger patients. In fact, there is an increasing body of evidence that being elderly is not a contraindication for nonoperative management, although the evidence in this area is still somewhat conflicting.37
The presence of severe associated injuries, particularly a traumatic brain injury, has been suggested as another relative contraindication to nonoperative management of a splenic injury. As previously mentioned, following the hematocrit in a patient with severe associated injuries can be problematic. Furthermore, the effects of ongoing or delayed splenic bleeding are felt to negatively impact the prognosis of a severe traumatic brain injury (see Chapter 19); however, a National Trauma Data Bank analysis actually demonstrated better outcomes with nonoperative management for patients with severe TBI.38
While these factors do not mandate operative intervention in all patients who fall into these groups, they should lower the threshold for operative intervention on an individual basis.
There is little uniformity about what constitutes a “failed” attempt at nonoperative management. Different surgeons and different institutions have set different criteria for operative intervention, and much of the decision making is subjective. As has already been pointed out, there is no perfect relationship between the severity of injury seen on CT scanning and a patient’s subsequent success or failure of nonoperative management. Some of this discrepancy is probably related to the imperfect nature of the scoring systems and a lack of sensitivity of CT scanning. Also, it is likely that some of the differences are in the approach and thresholds for operative intervention. In some instances, concern about a “bad-looking” spleen on a CT scan might prompt more aggressive and quicker surgical intervention and make failed nonoperative management of severe splenic injuries a self-fulfilling prophecy.
As previously noted an objective finding on CT scan that has proven useful as a prognostic sign with respect to nonoperative management is that of a blush in the injured spleen (Fig. 30-4). Such a blush is thought to represent ongoing bleeding when it is seen shortly after injury and a pseudoaneurysm when seen on later scans. There is evidence that when such a finding is present, the chances of subsequent successful nonoperative management are decreased. A contrast blush seen on initial CT scan should be evaluated with angiography and treated with embolization if ongoing bleeding is present and the patient is normotensive (Fig. 30-8). A contrast blush is also associated with a higher need for operative intervention. This approach seems reasonable as angiography with splenic embolization has improved success rates in patients managed nonoperatively. The most dramatic improvement is seen in patients with higher-grade splenic injuries. Available data suggest an improvement in nonoperative success rates from 67 to 83% in grade IV injuries and from 25 to 83% in grade V injuries.39 It is important to remember that only highly selected patients with high-grade splenic injuries should undergo angiographic embolization. While most trauma centers practice selective angiography and embolization, a somewhat more extreme approach is to have all patients with splenic injury, with or without a CT blush, undergo early angiography and embolization as necessary. Most centers do not treat splenic injury in this way because the number of nontherapeutic angiograms with such an approach would be extremely high.
A postembolization view of a patient with a splenic injury and contrast blush on CT after angiographic coil embolization (same patient as in Fig. 30-4).
After nonoperative management has been selected, the initial resuscitation should be continued and other diagnostic and therapeutic procedures carried out as necessary. There is little scientific evidence to dictate the specifics of how nonoperative management of splenic injury should be done, and most recommendations are simply matters of common sense and opinion.23 The most rigorous attempts to systematize recommendations for nonoperative management have been in children (Table 30-2).40,41 Most patients should be admitted to an intensive care unit for their initial nonoperative management. This would include patients with grade II or above splenic injuries and patients with multiple associated injuries that make following serial hematocrit levels and physical examinations difficult. Even patients with grade I splenic injuries should be initially admitted to an intensive care unit if follow-up in a ward setting will be unreliable.
TABLE 30-2Proposed Guidelines for Resource Utilization in Children with Isolated Spleen or Liver Injury ||Download (.pdf) TABLE 30-2 Proposed Guidelines for Resource Utilization in Children with Isolated Spleen or Liver Injury
| ||CT grade |
| ||I ||II ||III ||IV |
ICU stay (days)
Hospital stay (days)
Activity restriction (weeks)a
During initial management patients should be kept with nothing by mouth in case they require rapid operative intervention. Nasogastric suction is not necessary unless needed for other reasons. Whether patients should be kept at bed rest or not is somewhat controversial. Although there are some theoretical reasons why bed rest might be a good idea, there is little empirical evidence that it makes a difference. The individual surgeon should choose the approach that works best in his or her practice.
The patient’s vital signs and urine output should be monitored closely, serial physical examinations performed, and serial hematocrits measured. As has been mentioned, changes in hematocrit can be influenced by bleeding from associated injuries as well as by bleeding from a splenic injury. This is important to take into account while following patients. As noted, many surgeons follow the practice of picking a specific hematocrit as a cutoff point below which they will not allow the patient to go without operative intervention. In fact, a multi-institutional trial demonstrated the blood transfusion during nonoperative management will actually increase mortality.42
Vaccines against encapsulated organisms, Streptococcus, meningococcus (Neisseria meningitidis), and Hemophilus influenza infections should be considered while the patient is observed nonoperatively. There are some theoretical reasons to believe that the vaccinations are more effective if given while the spleen is still in situ. Therefore, it may be beneficial to vaccinate patients who are managed nonoperatively early in their course rather than waiting to vaccinate them after they have required splenectomy. The evidence to support such a practice is contradictory, and it is very difficult to study the effectiveness of vaccination timing in splenectomized patients because the incidence of overwhelming postsplenectomy infection is extremely low.
How long a patient should remain in the intensive care unit is not clearly defined. Most centers keep patients with splenic injury in the intensive care unit for 24–72 hours and then transfer them to a ward bed if they have been stable and other injuries permit. It is generally at this point that patients are allowed to eat unless other injuries preclude oral intake; however, many will feed patients earlier in the initial period of observation.
How long a patient should be kept in the hospital is poorly defined, also. There is no strong evidence supporting any particular approach, but a large multi-institutional study showed that most failures of nonoperative management occur within the first 6–8 days after injury.42 Some institutions will keep patients in the hospital for an arbitrary length of time which may be up to one week. This approach has obvious financial and insurance implications, but will pick up most of the delayed bleeds while the patient is still an inpatient. Our institutional approach is to consider the grade of injury, associated injuries, and social situation of the patient to determine the length of hospital stay. How long to keep the patient depends to some extent on the nature of the splenic injury, also. Trivial injuries can be safely discharged earlier than more severe injuries. In many circumstances, associated injuries dictate the length of hospitalization more than does the splenic injury. Also, it is important to pay attention to where the patient lives and how close he or she will be to medical attention when deciding about timing of discharge. Patients who live far from medical attention may need to be kept in the hospital longer.
Prophylaxis against deep venous thrombosis (DVT) is a continuing problem in patients undergoing nonoperative management for a splenic injury. Sequential compression devices on the lower extremities should be used routinely. Early mobilization or range-of-motion exercises are important in minimizing thromboembolic complications, also. Pharmacologic prophylaxis is more problematic because of concerns about exacerbating bleeding from the injured spleen. After 24–48 hours of successful nonoperative management, it is reasonable to begin pharmacologic prophylaxis against deep venous thrombosis (DVT). If associated injuries require it, warfarin prophylaxis is also reasonable beginning approximately 1 week after injury. These recommendations are based primarily on common sense rather than on solid data; however, there are an increasing number of studies supporting the safe use of early DVT chemoprophylaxis in the nonoperative management of patients with blunt splenic injuries.43,44 Both the rate of clinically significant thromboembolic events in patients with splenic injury and the rate of failure of nonoperative management in anticoagulated patients are quite low, making prospective study of the risks and benefits of anticoagulation prophylaxis in this patient population difficult.
The issue of follow-up CT scans in patients with nonoperative management of splenic injuries is controversial, also.45,46 Most series indicate that they are not necessary or that the frequency with which they alter management is extremely low. A variety of different suggestions have been made in the literature about follow-up CT scans, ranging from no follow-ups at all to follow-ups at frequent intervals. A middle course is taken by some surgeons who only study the spleen with a follow-up CT scan when there is a high grade of injury or when they are contemplating allowing patients to return to contact sports or other activities. The author’s institutional policy is to study only patients who have persistent abdominal signs and symptoms after a week of observation. On occasion such patients have developed pseudoaneurysms of the spleen, even if the initial CT scan did not demonstrate a blush. It is difficult to know exactly what the natural history of these pseudoaneurysms would be if left untreated, but they can be impressive in appearance and are amenable to angiographic embolization.
When patients are discharged, they should be counseled not to engage in contact sports or other activities where they might suffer a blow to the torso unless a follow-up CT scan has documented healing of the injured spleen. The best length of time to maintain this admonition is unknown, but typical recommendations range from 2 to 6 months. There is experimental evidence that most injured spleens have not recovered their normal integrity and strength until at least 6–8 weeks post-injury, so the recommendation to avoid contact sports for 2–6 months seems reasonable. Other than with respect to contact sports, there are no major restrictions for patients who have undergone successful nonoperative management.