DOI: http://dx.doi.org/10.18203/2349-2902.isj20213132

Experience with clinical pathway for management of high grade blunt splenic injuries: a prospective study in adults at two tertiary trauma centers

Don Campbell, Elizabeth Wake, John Grieve, Muddassir Rashid, Martin Wullschleger, Bhavik Patel

Abstract


Background: There is ambiguity regarding anatomical site of embolization, frequency of follow-up scans and splenic function following angioembolisation in the management of high grade blunt splenic injury. A splenic salvage pathway in patients who are hemodynamically stable or resuscitated to stability was introduced across two trauma centres. The aims of this project were: to develop a clinical pathway to manage hemodynamically stable blunt splenic injury patients and to determine rates of splenic salvage for patients with high grade splenic injury, assess complications and splenic function following completion of the pathway.

Methods: Prospective study over a period of 24 months. Data was collected to evaluate rates of splenic salvage, complications and function of the spleen following angioembolisation.

Results: Thirty-three patients, predominantly males (n=29) between the ages of 14-85 years, were included in the study. Three (9%) with grade V injury, underwent angioembolization on admission but required splenectomy as an inpatient. On day 14, all patients (n=30) with splenic salvage underwent blood tests, with 3 patients (9%) receiving vaccination for altered red cell morphology. The introduction of clinical pathway led to an increase in our splenic salvage rate to 91%.

Conclusions: We believe that introduction of proposed clinical pathway may result in increased rates of splenic salvage with preservation of function following angioembolisation.

 


Keywords


Spleen, Angioembolisation

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References


Hildebrand DR, Ben-sassi A, Ross NP, Macvicar R, Frizelle FA, A J M Watson. Modern management of splenic trauma. BMJ. 2014;348:1-7.

Stassen NA, Bhullar I, Cheng JD, Crandall ML, Friese RS, Guillamondegui OD et al. Selective nonoperative management of blunt splenic injury: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73:S294-300.

Muroya T, Ogura H, Shimizu K, Tasaki O, Kuwagata Y, Fuse T et al. Delayed formation of splenic pseudoaneurysm following nonoperative management in blunt splenic injury: Multi-institutional study in Osaka, Japan. J Trauma Acute Care Surg. 2013;75:417-20.

Cioci AC, Parreco JP, Lindenmaier LB, Olufajo OA, Namias N, Askari R et al. Readmission for infection after blunt splenic injury: A national comparison of management techniques. J Trauma Acute Care Surg. 2020;88(3):390-95.

Tugnoli G, Bianchi E, Biscardi A, Coniglio C, Isceri S, Simonetti L et al. Nonoperative management of blunt splenic injury in adults: there is (still) a long way to go. The results of the Bologna-Maggiore Hospital trauma centre experience and development of a clinical algorithm. Surgery Today. October 2015;45(10):1210-17.

Vanhaecht K, De Witte K, Panella M, Sermeus W. Do pathways lead to better organized care processes? Journal of evaluation in clinical practice. 2009;15(5):782-88.

Rotter T, Kinsman L, James E, Machotta A, Gothe H, Willis J et al. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev. 2010;(3):CD006632.

Queensland Health Clinical Pathways Board. 2020.

Shi H, Teoh WC, Chin FWK, Tirukonda PS, Cheong SCW, Yiin RSZ. CT of blunt splenic injuries: what the trauma team wants to know from the radiologist. Clinical Radiology. 2019;74(12):903-11.

de Porto APNA, Lammers AJJ, Bennink RJ, Berge I, Speelman P, Hoekstra JBL. Assessment of splenic function. Eur J Clin Microbiol Infect Dis. 2010;29(12):1465-73.

Constantino BT. Reporting and grading of abnormal red blood cell morphology. Int Jnl Lab Hem. 2015;37:1-7.

Shafi S, Aboutanos M, Brown CVR, Ciesla D, Cohen MJ, Crandall ML et al. American Association for the Surgery of Trauma Committee on patient assessment and outcomes. Measuring anatomic severity of disease in emergency general surgery. J Trauma Acute Care Surg. 2014;76:884-87.

Saksobhavivat N, Shanmuganathan K, Chen HH, DuBose JJ, Richard H, Khan MA et al. Blunt splenic injury: use of a multidetector CT-based splenic injury grading system and clinical parameters for triage of patients at admission. Radiology. 2015;274:702-7.

Dolejs S, Savage S, Hartwell J, Zarzaur B. Overall Splenectomy rates stable despite increasing usage of angiography in the management of high-grade splenic injury. Annals of Surgery. 2018;268(1):179-85.

Miller PR, Chang MC, Hoth JJ, Mowery NT, Hildreth AN, Martin RS et al. Prospective Trial of Angiography and Embolization for All Grade III to V Blunt Splenic Injuries: Nonoperative Management Success Rate Is Significantly Improved. Journal of the American College of Surgeons. 2014;218(4):644-48.

Malhotra AK, Carter RF, Lebman DA, Carter DS, Riaz OJ, Aboutanos MB et al. Preservation of splenic immunocompetence after splenic artery angioembolization for blunt splenic injury. J Trauma. 2012;69:1126-31.

Pirasteh A, Snyder LL, Lin R, Rosenblum D, Reed S, Sattar A et al. Temporal assessment of splenic function in patients who have undergone percutaneous image-guided splenic artery embolization in the setting of trauma. J Vasc Interv Radiol. 2012;23:80-2.

Ellison EC, Fabri PJ. Complications of splenectomy: Aetiology, prevention and management. Surg. Clin. North Am. 1983;63:1313-28.

Wilson RH, Moorehead RJ. Management of splenic trauma. Injury. 1992;23:5-9.

Feliciano PD, Mullins RJ, Trunkey DD, Crass RA, Beck JR, Helfland M. A decision analysis of traumatic splenic injuries. J. Trauma. 1992;33:340-8.

Aidonopoulos AP, Papavramidis ST, Goutzamanis GD, Filos GG, Deligiannidis NP, Vogiatzis IM. Splenorrhaphy for splenic damage in patients with multiple injuries. Eur J Surg. 1995;161:247-51.

Langley JM, Dodds L, Fell D, Langley GR. Pneumococcal and influenza immunization in asplenic persons: a retrospective population-based cohort study 1990-2002. BMC Infect Dis. 2010;10:219.

Tolstrup MB, Watt SK, Gögenur I. Morbidity and mortality rates after emergency abdominal surgery: an analysis of 4346 patients scheduled for emergency laparotomy or laparoscopy. Langenbecks Arch Surg. 2017;402(4):615-23.

Tagliati C, Argalia G, Graziani B, Salmistraro D, Giuseppetti GM, Giovagnon A. Contrast‑enhanced ultrasound in the evaluation of splenic injury healing time and grade. La radiologia medica. 2019;124:163-69.

Kozar RA, Crandall M, Shanmuganathan K, Zarzaur BL, Coburn M, Cribari C et al. Organ injury scaling 2018 update: Spleen, liver, and kidney. J Trauma Acute Care Surg. 2018;85(6):1119-22.

Moran CG, Lecky F, Bouamra O, Lawrence T, Edwards A, Woodford M et al. Changing the System - Major Trauma Patients and Their Outcomes in the NHS (England) 2008–17. E Clinical Medicine. 2018;2:13-21.

Gabbe BJ, Simpson PM, Sutherland AM, Wolfe R, Fitzgerald MC, Judson R et al. Improved functional outcomes for major trauma patients in a regionalized, inclusive trauma system. Ann Surg. 2012;255(6):1009-15.

National Institute for Health and Care Excellence Guidelines. https://www.nice.org.uk. Accessed on

Ament SMC, de Groot JJA, Maessen JMC, Dirksen CD, van der Weijden T, Kleijnen J. Sustainability of professional’s adherence to clinical practice guidelines in medical care: a systematic review. BMJ Open. 2015;5:e008073.