Article 1
Readmission for infection after blunt splenic injury: A national comparison of management techniques. Cioci AC, Parreco JP, Lindenmaier LB, Olufajo OA, Namias N, Askari R, DeRosa L, Rattan R. J Trauma Acute Care Surg. 2020 Mar;88(3):390-395.
The management of blunt splenic injury (BSI) in the hemodynamically stable trauma patient has shifted toward non-operative management (NOM) and splenic artery embolization (SAE). While operative management (OM) carries the risk of overwhelming post-splenectomy infection, rates of infectious complications after NOM/SAE have not been elucidated. The authors hypothesized that SAE would have a higher rate of infectious complications than NOM.
This study reviewed the National Readmission Database from 2010-2014 for patient with a primary diagnosis of splenic injury and divided into groups by treatment: NOM, SAE and OM. Outcomes were 30-day and 1-year readmission rates for surgical site infection (SSI), NSQIP tracked infections and sepsis. Multiple demographic, clinical and hospital variables derived from the database were included in logistic regression creation.
Patient undergoing OM had the highest frequency of Grade 5 injuries and ISS>25 while least likely to have private insurance. NOM patients were younger, had fewer comorbidities and more likely to be discharged home. OM carried the highest rates of infection during initial hospitalization; however, SAE also had higher rates of organ space SSI (1.0% vs. 0.7%, p=0.01), NSQIP infections (12.4% vs. 5.2%, p=0.001), and sepsis (1.6% vs. 0.3%, p=0.001) than NOM. More patients with SAE were readmitted with organ space SSI at 30 days (2.9 % vs. 2.0%, p=0.001) and 1 year (3.9% vs. 2.2%, p=0.001) compared with OM. When controlling other factor in a multivariate logistic regression, SAE had increased risk of organ space SSI at both 30 days (OR 1.76) and 1 year (OR 1.99) that was not observed in OM. Both low (grade I-II) and high (III-V) grade injuries managed with SAE had increased risk of organ space SSI and NSQIP infections. Only low grade BSI undergoing SAE had no increase in risk of sepsis at 30 days and 1 year. Both OM and SAE had higher rates of readmission for percutaneous drainage than NOM. Not surprisingly, SAE had higher rates of admission for splenic operation compared to OM, but not when compared to NOM.
In summary, this study demonstrated that SAE had increased rates of infectious complications compared to NOM at both 30 days and 1 year. Overall, OM had the highest rates of infectious complications, except for post-discharge organ space SSI for which SAE was higher at both time points. This increase risk for organ space SSI persisted even after controlling for other factors. Limitations to this paper include the use of a claims database that may not include important clinical variables (e.g. post-splenectomy vaccination), non-specific diagnostic/procedural coding and limits or confounding in relating longer term outcomes to the index hospitalization/care. Further study could evaluate the long-term outcomes and risk factors for the management of BSI and the cost of different treatment algorithms.
Article 2
A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (Chest Wall Injury Society NONFLAIL). Pieracci FM, Leasia K, Bauman Z, Eriksson EA, Lottenberg L, Majercik S, Powell L, Sarani B, Semon G, Thomas B, Zhao F, Dyke C, Doben AR. J Trauma Acute Care Surg. 2020 Feb;88(2):249-257.
Surgical stabilization of rib fractures (SSRF) is employed in cases of severe chest injury to restore stability to the chest wall while managing associated pain. SSRF has been mostly evaluated in the setting of flail chest, with little independent data on the benefit in nonflail patterns. This clinical trial investigated the efficacy of SSRF for patients with severe, nonflail rib fractures, specifically in terms of pain control, narcotic consumption, pulmonary function and risk of complications.
Twelve US trauma centers participated in this prospective, multicenter clinical trial conducted by the CWIS. Patients were eligible for inclusion with 3 or more ipsilateral, bicortical, severely displaced (>50%) fractures in ribs 3-10 with pulmonary derangements after locoregional pain control and SSRF expected in less than 72 hours. Patient with flail chest, ventilator dependence and significant polytrauma (e.g. moderate-severe TBI, spinal cord injury or pelvic fracture) during index admission were excluded. This study design contained both randomized and observational arms. Non-operative management was standardized with an oral analgesic regimen and locoregional modalities (epidural, pain pump or rib blocks). Outcomes include numeric pain score (NPS), narcotic requirements, spirometry, length of stay and complications.
Of the 110 patients enrolled, 23 (21%) subjects underwent randomization while 87 participated in the observational arm. There was no difference in the demographics, injury severity scores and associated injuries of the 51 (46%) individuals having SSRF and 59 with non-operative treatment. SSRF occurred at a median of 2 days (0-3) with 4 ribs fixed (3-6) and a ratio of repaired to fractured ribs 0.6 (0.5-0.8). Length of stay (hospital and ICU) and readmission rate was similar between groups. The frequency of pneumonia was similar (2% vs. 6.7%); however, SSRF patients had fewer pleural space complications (0 vs. 10.2%, p=0.02). The NPS was significantly lower for the SSRF group starting at hospital day (HD) 7, then at 2, 4 and 8-week outpatient follow-up visits. Narcotic use trended toward higher in the SSRF group initially (HD1), but this reversed on HD7 and through outpatient follow-up though never reached statistical significance. Objective spirometry measurements (FEV1) and overall QoL scores were not significantly different at any time point.
This study demonstrated decreased pain scores and pleural space complications in patients undergoing SSRF for displaced, non-flail rib fracture patterns in this prospective trial. Length of stay, objective pulmonary measurements and QoL scores were not different between the operative and control groups. Limitations include the pooling of both randomized and observational patients, limited duration, loss to follow-up and possible heterogeneity among participating institutions. This data supports a role for SSRF in patients with severe, non-flail chest injuries with evidence of pulmonary derangement.
