Failures of splenic nonoperative management: Is the glass half empty or half full?

Background: Published contraindications to nonoperative management (NOM) of blunt splenic injury (BSI) include age greater than or equal to 55, Glasgo w Coma Scale score less than or equal to 13, admission blood pressure < 100 mm Hg, major (grades 3-5) injuries, and large amounts of hemoperitoneum. R ecently reported NOM rates approximate 60%, with failure rates of 10% to 15 %. This study evaluated our failures of NOM for BSI relative to these clini cal factors. Methods: An patients with BSI at a Level I trauma center over a 46-month pe riod ending September 1999 were reviewed. Failures of NOM included patients initially selected for NOM who subsequently required splenectomy/splenorrh aphy. Results: Five hundred fifty-eight had BSI, Twenty-three percent (128) under went emergent laparotomy for hemodynamic instability and 77% (430) were obs erved. The NOM failure rate was only 8%. Univariate analysis identified mod erate to large hemoperitoneum (p < 0.03), grades 3 to 5 (p < 0.004), and ag e <greater than or equal to> 55 (p < 0.0006) as being significantly associa ted with failure. Multivariate analysis identified age <greater than or equ al to> 55 and grades 3 to 5 injuries as independent predictors of failure. The highest failure rates (30-40%) occurred in patients age greater than or equal to 55 with major injury for moderate to large hemoperitoneum, Mortal ity rates for successful NOM were 12%, and 9% for failed NOM. Conclusion: Inclusion of all high-risk patients increased the NOM rate whil e maintaining a low failure rate, Although age greater than or equal to 55 and major BSI were independently associated with failure of NOM, approximat ely 80% of these high-risk patients were successfully managed nonoperativel y, There was no increased mortality associated with failure. Although these factors may indeed predict failure, they do not necessarily contraindicate NOM.