2017年,世界急诊外科学会发布了成人和小儿脾外伤患者的治疗指南。关于接受NOM治疗的脾损伤患者的随访问题仍未解决。
使用改进的Delphi方法,我们试图探索脾创伤NOM中持续存在的争议领域,并在来自五大洲的48名国际专家(非洲,欧洲,亚洲,大洋洲,美国)关于NOM治疗脾损伤患者的最佳随访策略。
就11项临床研究问题和28项建议达成共识,一致率≥80%。低级别脾外伤患者24小时后动员(WSESI类,建议使用AASTI-II级),而在高度脾损伤的患者中(WSESClassesII-III,AASTIII-V级),如果没有其他早期动员的禁忌症,根据研究小组,当三个连续的血红蛋白在第一个血红蛋白间隔8小时后彼此相差10%以内时,患者的安全动员被认为是安全的。小组建议成年患者入院1天(对于低级脾损伤-WSESI级,AASTI-II级)至3天(对于高度脾损伤-WSESII-III级,AASTIII-V级),那些严重受伤的人需要进入受监控的环境。在没有特定并发症的情况下,该小组建议在入院后48-72h内开始使用LMWH预防DVT和VTE.该小组建议脾动脉栓塞(SAE)作为血液动力学稳定和CT扫描上动脉腮红的患者的一线干预措施。无论伤害等级。关于WSESII级钝性脾损伤(AASTIII级)无造影剂外渗的患者,在存在NOM失败的危险因素的情况下,SAE的阈值较低.该小组还建议所有WSESIII级损伤(AASTIV-V级)的血流动力学稳定的成年患者的血管造影和最终SAE,即使没有CT脸红,特别是当需要改变体位的同时手术时。在脾损伤WSESII级(AASTIII级)或更高程度接受NOM治疗的创伤入院后48-72小时进行超声造影/CT扫描的随访成像被认为是及时发现血管并发症的最佳策略。
这份共识文件可以帮助指导未来的前瞻性研究,旨在通过实施前瞻性创伤数据库和随后的国际认可的指南来验证建议的策略。
In 2017, the World Society of Emergency Surgery published its
guidelines for the management of adult and pediatric patients with splenic trauma. Several issues regarding the follow-up of patients with splenic injuries treated with NOM remained unsolved.
Using a modified Delphi method, we sought to explore ongoing areas of controversy in the NOM of splenic trauma and reach a
consensus among a group of 48 international experts from five continents (Africa, Europe, Asia, Oceania, America) concerning optimal follow-up strategies in patients with splenic injuries treated with NOM.
Consensus was reached on eleven clinical research questions and 28 recommendations with an agreement rate ≥ 80%. Mobilization after 24 h in low-grade splenic trauma patients (WSES Class I, AAST Grades I-II) was suggested, while in patients with high-grade splenic injuries (WSES Classes II-III, AAST Grades III-V), if no other contraindications to early mobilization exist, safe mobilization of the patient when three successive hemoglobins 8 h apart after the first are within 10% of each other was considered safe according to the panel. The panel suggests adult patients to be admitted to hospital for 1 day (for low-grade splenic injuries-WSES Class I, AAST Grades I-II) to 3 days (for high-grade splenic injuries-WSES Classes II-III, AAST Grades III-V), with those with high-grade injuries requiring admission to a monitored setting. In the absence of specific complications, the panel suggests DVT and VTE prophylaxis with LMWH to be started within 48-72 h from hospital admission. The panel suggests splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan, irrespective of injury grade. Regarding patients with WSES Class II blunt splenic injuries (AAST Grade III) without contrast extravasation, a low threshold for SAE has been suggested in the presence of risk factors for NOM failure. The panel also suggested angiography and eventual SAE in all hemodynamically stable adult patients with WSES Class III injuries (AAST Grades IV-V), even in the absence of CT blush, especially when concomitant surgery that requires change of position is needed. Follow-up imaging with contrast-enhanced ultrasound/CT scan in 48-72 h post-admission of trauma in splenic injuries WSES Class II (AAST Grade III) or higher treated with NOM was considered the best strategy for timely detection of vascular complications.
This
consensus document could help guide future prospective studies aiming at validating the suggested strategies through the implementation of prospective trauma databases and the subsequent production of internationally endorsed
guidelines on the issue.