Contemporary Management of Pediatric Blunt Splenic Trauma: A National Trauma Databank Analysis
In pediatric patients with blunt splenic injury, what are the treatment outcomes and utilization of non-operative management (NOM), splenic artery embolization (SAE), splenic repair and splenectomy?
NOM is a common first-line therapy for all splenic injury grades with low failure rate in appropriate patients. If intervention is needed, SAE is effective and increasingly utilized.
Shinn, K., et al., Contemporary Management of Pediatric Blunt Splenic Trauma: A National Trauma Databank Analysis. Journal of Vascular and Interventional Radiology, 2021. 32(5): p. 692-702
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Emory University Department of Emergency Radiology and Interventional Radiology, who purchased access to the National Trauma Data Bank.
Multi-center self-reported entry into National Trauma Data Bank (NTDB) maintained by the American College of Surgeons (ACS).
Isolated splenic injury accounts for 48-60% of all pediatric blunt abdominal traumas. Splenic injury management has dramatically changed from splenectomy to non-operative management in more than 90% of cases. Non-Operative Management (NOM) is defined as conservative management without associated intervention (e.g. surgery, embolization, etc.). In the adult population, SAE plays a key role in the treatment of acute traumatic injury, however data in pediatric population is scarce.
Using the NTDB, from 2007 – 2015 pediatric patients with splenic injury were identified and 24,128 met inclusion criteria. Patients were grouped based on management techniques including NOM, splenectomy, splenic repair, interventional radiology procedures (angiography or embolization), or a combination therapy. Patients were considered failed NOM if splenectomy or embolization more than 24 hours after hospitalization occurred. Similarly, SAE failure was defined as surgical intervention after SAE in the first 24 hours of admission. Failed NOM occurred in 1.5% (180/12,378) of patients and was associated with increased splenic injury severity. Of all SAE patients, 1.3% (6/456) failed; however, the embolization failure rate was 0% in lower severity splenic injury grades (I/II). In higher severity (grade V) splenic injuries, embolization failure was up to 33.3% (1/3). NOM was independently associated with a decreased mortality rate when compared to splenectomy (OR: 0.1, P<0.001) and combination therapy (OR: 0.09, P< 0.001). SAE was associated with a lower mortality rate compared to splenectomy (OR: 0.1, P< .001) and combination therapy (OR: 0.009, P<.001). No statistically significant mortality difference was seen between SAE and NOM (OR 0.96, P=1). After controlling for age, gender, baseline systolic blood pressure, type of facility and grade of splenic injury, NOM had the lowest mortality rate, followed by SAE and finally by splenectomy or combination therapy.
The authors concluded that NOM is appropriate therapy for pediatric splenic injury meeting inclusion criteria. In addition, NOM demonstrated improved clinical outcomes including LOS and few ICU days. Adjusted data demonstrated that SAE resulted in decreased morbidity and mortality when compared to splenectomy. The rate of failure of embolization in clinical practice was found to be very low, with only 1.3% of the cohort requiring a subsequent splenectomy.
This review demonstrates the high success rate for NOM and the increasing utilization of SAE over splenectomy in pediatric patients with traumatic splenic injury. If using the American Association for Surgery of Trauma Organ Injury Scale splenic injury grade, this review suggests that grade I and II injuries that fail NOM should be treated with SAE as embolization failure rate was 0%. Grade V injuries treated with SAE (n=3) demonstrated a 33.3% failure rate (1/3), however the overall failure rate (1.3%) and lower mortality rate of SAE compared to splenectomy or combination therapy suggests that the less invasive nature may be warranted as a first option for higher grade injuries.
Limitations of the review is the nature of the NTDB as a self-reported registry, with limited data regarding 30-day survival, as well as long term follow to determine associated complication rates of the management options. The variable availability of SAE as a treatment at the included centers is another confounding variable.
Anel Yakupovich, MD
Integrated Vascular & Interventional Radiology Residency, Class of 2024
Rush University Medical Center
David M. Tabriz, MD
Rush University Medical Center
Edited and formatted by @NingchengLi