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, Glasgow 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. Recently reported NOM rates approximate 60%, with failure rates of 10% to 15%. This study evaluated our failures of NOM for BSI relative to these clinical factors. Methods: An patients with BSI at a Level I trauma center over a 46-month period ending September 1999 were reviewed. Failures of NOM included patients initially selected for NOM who subsequently required splenectomy/splenorrhaphy. Results: Five hundred fifty-eight had BSI, Twenty-three percent (128) underwent emergent laparotomy for hemodynamic instability and 77% (430) were observed. The NOM failure rate was only 8%. Univariate analysis identified moderate to large hemoperitoneum (p < 0.03), grades 3 to 5 (p < 0.004), and age <greater than or equal to> 55 (p < 0.0006) as being significantly associated with failure. Multivariate analysis identified age <greater than or equal 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, Mortality rates for successful NOM were 12%, and 9% for failed NOM. Conclusion: Inclusion of all high-risk patients increased the NOM rate while maintaining a low failure rate, Although age greater than or equal to 55 and major BSI were independently associated with failure of NOM, approximately 80% of these high-risk patients were successfully managed nonoperatively, There was no increased mortality associated with failure. Although these factors may indeed predict failure, they do not necessarily contraindicate NOM.