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90th Annual Meeting Abstracts


Management of the Most Severely Injured Spleen: A Multi-center Study of the Research Consortium of New England Centers for Trauma (ReCONECT)
George C Velmahos, MD, PhD1, *Nikos Zacharias, MD1, Timothy Emhoff, MD2, *James Feeney, MD3, James Hurst, MD4, *Bruce Crookes, MD5, *David Harrington, MD6, *Gregg Shea, MD6, *Sheldon Brotman, MD7, Peter Burke, MD8, *Kimberly Davis, MD9, *Rajan Gupta, MD10, *Robert Winchell, MD11, *Steven Desjardins, MD11, *Reginald Alouidor, MD12, Ronald Gross, MD12, Michael Rosenblatt, MD13, *John Schultz, MD14
1Massachusetts General Hospital, Boston, MA;2University of Massachusetts Memorial Hospital, Worchester, MA;3Hartford Hospital, Hartford, CT;4Beth Israel Deaconess Medical Center, Boston, MA;5Fletcher Allen Healthcare, Burlington, VT;6Rhode Island Hospital, Providence, RI;7Berkshires Medical Center, Pittsfield, MA;8Boston Medical Center, Boston, MA;9Yale New Haven Hospital, New Haven, CT;10Hitchckock Dartmouth Medical Center, Lebanon, NH;11Maine Medical Center, Portland, ME;12Baystate Medical Center, Springfield, MA;13Lahey Clinic, Burlington, MA;14Bridgeport Hospital, Bridgeport, CT

Objective: To determine the rate and risk factors of failure of non-operative management (NOM) in grade IV and V blunt splenic injuries.
Design: Retrospective case series.
Setting: 14 New England trauma centers.
Patients: 389 adult blunt trauma patients with an American Association for the Surgery of Trauma (AAST) grade of IV or V splenic injury on computed tomography (1/1/01 to 8/31/08). Patients who had incomplete data (48), no CT (72), or arrived dead (3) were excluded.
Main outcome measures: Failure of NOM (f-NOM).
Results: 164 (42%) patients were operated on immediately. Of the remaining 225 who were offered a trial of NOM, 92 (41%) eventually required an operation. Overall 66% of the patients underwent a splenectomy. Multiple logistic regression identified 2 predictors of f-NOM that achieved and 2 that approached statistical significance:
PredictorOdds Ratio95% Confidence Intervalp-value
Male gender2.311.23 - 4.360.009
Grade V (vs. grade IV)2.931.24 - 6.950.014
Assault (vs. MCV or fall)4.070.91 - 18.260.067
Age > 55 years1.920.91 - 4.050.085

The likelihood of f-NOM was 100% if all predictors were present but remained 29% even when all predictors were absent. Of f-NOM patients 63% developed a complication and 6.5% died. Their average length of hospital stay was 18+28 days (median: 8).
Conclusions: Two thirds of patients with grade IV/V blunt splenic injury require an operation. Among those who are initially treated by NOM, the presence of certain simple clinical factors predicts failure with a likelihood of 100%. This data must be taken into account when generalizations are made about the overall high success rates of NOM, which usually do not reflect severe splenic injuries.


 

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