Jay Menaker1, Bellal Joseph, Deborah M Stein, Thomas M Scalea. 1. Department of Surgery, University of Maryland School of Medicine, Division Trauma/Critical Care, R Adams Cowley Shock Trauma Center, 22 South Greene Street, T1R60, Baltimore, MD 21201, USA. jmenaker@umm.edu
Abstract
BACKGROUND: Nonoperative management (NOM) of solid organ injury after blunt trauma is now standard. Recently, angioembolization (AE) has been used to extend NOM. Few data exist on evaluating NOM of blunt renal injuries (BRIs). We sought to determine the overall efficacy of NOM as well as the outcome of AE in patients with BRI. METHODS: The trauma registry was used to identify all patients with BRI between January 2002 and December 2008. Medical records were reviewed for demographics, grade of injury, use of angiographic intervention, and outcome. RESULTS: A total of 434 patients with BRI were identified, 416 of whom had planned NOM; 337 (81%) patients were successfully managed without further intervention for their BRI. In all, 79 (19%) patients underwent angiography; 22 (27.8%) of these patients underwent AE, and 6 (27.2%) failed 1.2 ± 0.8 days after AE. Patients who failed AE had a significantly higher blood transfusion requirement during the first 24 h of admission (p = 0.01). Seven patients not embolized failed 1.9 ± 1.9 days after angiography. Thus, of the 79 patients having angiography, 13 (16.5%) failed and required laparotomy to treat their BRIs. Overall failure rate of NOM was 3.1% (13/416). Patients who failed angiography, with or without AE, required more blood during the first 24 h after admission (p = 0.03). CONCLUSIONS: NOM of BRI is safe and effective, with an overall failure rate of 3.1%. However, angiography with or without AE has substantial failure rates. Patients with higher-grade injuries and active vascular extravasation on admission computed tomography scan also fail NOM regardless of therapy. The blood transfusion requirement during the first 24 h may indicate who will require operative intervention following angiography. Close observation and/or early laparotomy are wise for these high-risk patients.
BACKGROUND: Nonoperative management (NOM) of solid organ injury after blunt trauma is now standard. Recently, angioembolization (AE) has been used to extend NOM. Few data exist on evaluating NOM of blunt renal injuries (BRIs). We sought to determine the overall efficacy of NOM as well as the outcome of AE in patients with BRI. METHODS: The trauma registry was used to identify all patients with BRI between January 2002 and December 2008. Medical records were reviewed for demographics, grade of injury, use of angiographic intervention, and outcome. RESULTS: A total of 434 patients with BRI were identified, 416 of whom had planned NOM; 337 (81%) patients were successfully managed without further intervention for their BRI. In all, 79 (19%) patients underwent angiography; 22 (27.8%) of these patients underwent AE, and 6 (27.2%) failed 1.2 ± 0.8 days after AE. Patients who failed AE had a significantly higher blood transfusion requirement during the first 24 h of admission (p = 0.01). Seven patients not embolized failed 1.9 ± 1.9 days after angiography. Thus, of the 79 patients having angiography, 13 (16.5%) failed and required laparotomy to treat their BRIs. Overall failure rate of NOM was 3.1% (13/416). Patients who failed angiography, with or without AE, required more blood during the first 24 h after admission (p = 0.03). CONCLUSIONS: NOM of BRI is safe and effective, with an overall failure rate of 3.1%. However, angiography with or without AE has substantial failure rates. Patients with higher-grade injuries and active vascular extravasation on admission computed tomography scan also fail NOM regardless of therapy. The blood transfusion requirement during the first 24 h may indicate who will require operative intervention following angiography. Close observation and/or early laparotomy are wise for these high-risk patients.
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