Infections and Other Morbidities in Operative and Nonoperative Management of Blunt Abdominal Trauma

Author(s):
Michelle Mulder; Matthew Sussman ; Charles Karcutskie; Daniel Yeh; Edward Lineen; Nicholas Namias; Kenneth G Proctor

Background:

Nonoperative management (NOM) is the current standard for hemodynamically stable blunt solid organ trauma. Its multiple advantages include reduced mortality, hospital costs, and length of stay (LOS), but associated complications are poorly defined. No previous studies have compared rates of infection, venous thromboembolism (VTE), and bleeding between operative (OP) and NOM of blunt spleen and liver trauma. The purpose of this study is to fill this gap.

Hypothesis:

We hypothesize that morbidity rates are lower for NOM v OP.

Methods:

Isolated blunt spleen or liver trauma patients with a Greenfield Risk Assessment Profile (RAP)>8 admitted to the ICU (n=188) were retrospectively reviewed. Early deaths (<72h) were excluded. Primary outcomes were rates of infection (positive blood, urinary or bronchoalveolar lavage cultures), VTE, and bleeding (>4 transfusions/24h).

Results:

In those with infection, OP had longer LOS (51[36-78] v 25[18-37] d) and ICU LOS (31[18-39] v 15[7-24] d), higher ISS (35[29-49] v 29[22-38]) and were more likely to receive tranexamic acid (38% v 3%) (all p<0.003). The only independent predictor of infection was ICU LOS (OR: 1.21[1.12-1.30], p<0.001.)

In those with VTE, OP had higher ISS (41[34-50] v 28[27-34]) and RAP (18±7 v 10±3) (both p<0.02). The only independent predictor of VTE was RAP (OR: 1.1[1.02-1.29], p=0.02).

In those with bleeding, OP had greater: LOS (38[25-69] v 20[16-36] d), ISS (34[29-48] v 26[17-35]), RAP (15±6 v 10±4), age (50±15 v 32±16 y) and pelvic fractures (60% v 7%) (all p<0.04). Independent predictors for bleeding were heart rate (OR: 1.02[1.00-1.04], p=0.035), blood pressure (OR: 0.97 [0.95-0.99], p=0.002), and OP (OR: 65[16.7-257], p<0.001).

Conclusions:

After isolated blunt spleen or liver trauma, NOM is most likely associated with reduced rates of: 1) VTE because RAP is lower; 2) infection because OP is associated with increased LOS, which is the most important factor predicting infection; 3) bleeding because hemodynamics are more stable.