Experience with the management of splenic injuries

Risk of hemorrhage and appropriate use of blood transfusions in pediatric blunt splenic injuries

OBJECTIVE

To define changes in hematocrit (Hct) and the indications for blood transfusion in pediatric blunt splenic injury.

DESIGN

Retrospective case series

MATERIALS AND METHODS

All children with blunt splenic injuries from 1990 to 1995 were studied (n = 74). Transfusion practices were reviewed for the whole group. Thirty children with isolated splenic injuries who were not transfused were analyzed to document Hct changes (mean +/- 95% confidence intervals).

MEASUREMENTS AND RESULTS

The Hct at presentation was 37 +/- 2%, which rapidly dropped to 31 +/- 2% (p < 0.05) within 24 hours. After remaining stable at that level for the next 5 days, the Hct rose to 33 +/- 4% on day 6 (p = not significant), 35 +/- 4% on day 7 (p = not significant), and 38 +/- 2% (p = not significant) on day 13 +/- 3. Fifteen children received transfusions, all but one of whom had suffered multiple injuries. The transfusion rate declined from 38% of children in 1990 to 10% in 1995.

CONCLUSIONS

After the initial drop within the first 24 hours, the Hct remains stable and rises with time to reach the baseline by day 6. Transfusion rates have declined over time, and transfusions are now used almost exclusively in severely injured children with multiple injuries.

Delayed rupture of the spleen

The concept of delayed splenic rupture is an evolving one. The cases reviewed have led us to reserve the term "delayed splenic rupture" for the situation in which early post-traumatic imaging of the spleen is normal and is followed by the diagnosis of splenic hemorrhage 48 or more hours after the initial insult. Post-traumatic splenic evaluation is indicated when the mechanism of injury is likely to injure the spleen, there is unexplained hypovolemia, or the patient complains of left upper quadrant pain or tenderness. Peritoneal lavage is indicated when hypovolemia is the main manifestation. Radionuclide study is used for screening isolated splenic or hepatic injury when the suspicion is low. Reduced availability of visceral angiogram has resulted in CT scan becoming the main diagnostic modality. When a patient presents with blunt abdominal trauma, awareness of the problem of splenic rupture and active diagnostic approach may help reduce the morbidity and mortality associated with splenic hemorrhage, either immediate or delayed.

Splenic injury: a 5-year update with improved results and changing criteria for conservative management

The policy of conservative nonoperative management of injured spleens is reviewed and recommendations are made to improve this mode of therapy. From 1981 to 1986, 75 patients were admitted with diagnosed splenic injury. Of these, ten were operated on (4 splenorrhaphies, 3 total splenectomies, 1 partial splenectomy) and three died, all from causes unrelated to splenic trauma. Only 23% of the patients treated nonoperatively required blood transfusions, and the length of both hospital stay and time spent in the intensive care unit (ICU) was reduced. The results of this review show that, in comparison with our previous 5-year report, (1) the number of patients treated without surgery rose from 70% to 87%, (2) those receiving blood transfusions dropped from 36% to 23%, and (3) the number undergoing a splenectomy fell from 24% to 4%. These data suggest that (1) most children with splenic injury can be successfully treated without operation, (2) those who are hemodynamically stable do not require ICU care, and (3) the total hospital stay for uncomplicated splenic injury can be limited to seven days. A laparotomy can be safely reserved for patients with immediate massive hemorrhage or with transfusion requirements of greater than 40 mL/kg.

Splenic injury: a 5-year update with improved results and changing criteria for conservative management

The policy of conservative nonoperative management of the injured spleen is reviewed, and recommendations are made to improve this mode of therapy. From 1981 to 1986, 75 patients were admitted with diagnosed splenic injury. Of thes, ten were operated on (four splenorrhaphies, three total splenectomies, one partial splenectomy; in two, the spleen had stopped bleeding spontaneously) and three died, all from causes unrelated to splenic trauma. Only 23% of the patients treated nonoperatively required blood transfusions, and the length of both hospital stay and time spent in the ICU was reduced. The results of this review show that, in comparison with our previous 5-year report, the number of patients treated without surgery increased from 70% to 87%, those receiving blood transfusions decreased from 36% to 23%, and the number undergoing a splenectomy decreased from 24% to 4%. These data suggest that almost all children with splenic injury can be successfully treated without an operation, those who are hemodynamically stable do not require ICU care, and the total hospital stay for uncomplicated splenic injury can be limited to seven days. A laparotomy can be safely reserved for patients with immediate massive hemorrhage or with transfusion requirements of greater than 40 mL/kg.

Management of splenic trauma in childhood

The management of splenic trauma at the Royal Children's Hospital from January 1973 to January 1984 is reviewed. During the period studied there was a trend toward non-operative management in uncomplicated cases, and where laparotomy was required splenic repair rather than splenectomy was performed. Guidelines are given for the selection of patients who can be treated in safety without operation.