When blood runs thin: A national analysis of failure of nonoperative management of high-grade splenic injuries in patients on pre-injury anticoagulant or antiplatelet therapy.

Abstract

The proportion of trauma patients on anticoagulant and/or antiplatelet (AC/AP) therapy is increasing. Currently, there are no clinical guidelines on how to best manage blunt splenic injuries in patients on pre-injury AC/AP. This study aims to compare failure rates of nonoperative management (FNOM) among patients with high-grade splenic injuries who were on pre-injury AC/AP to those who were not. We hypothesized that patients with high-grade splenic injuries on AC/AP have higher rates of FNOM compared with those not on AC/AP. A retrospective study was conducted using the Trauma Quality Improvement Program dataset from 2017 to 2021 of patients aged 18 years and older admitted with a high-grade (grades III-V) blunt splenic injury. Those who died within 24 hours of admission or had an extra-abdominal abbreviated injury scale (AIS) of three or greater were excluded. Patients were categorized based on whether they were on prehospital AC/AP or not. The primary outcome was FNOM. Inverse probability of treatment weighting was used to control for confounders. A logistic regression model was run on the weighted data with FNOM as the outcome. A separate multivariable logistic regression analysis was performed to identify risk factors associated with FNOM. A total of 18,589 patients met the inclusion criteria, of which 4.0% were on AC/AP. AC/AP patients were older (70 vs. 38 y, p<0.001) and more likely to have undergone splenic angioembolization. AC/AP patients had a higher FNOM rate (9.2% vs. 5.4%, p<0.001). FNOM rates were similar after inverse probability of treatment weighting, irrespective of whether angioembolization was performed. AC/AP status was not independently associated with FNOM [AOR=1.38 (95% CI=0.91-2.08), p=0.126]. Patients on AC/AP with high-grade splenic injuries have higher rates of FNOM. However, AC/AP status alone is not associated with FNOM. AC/AP status should not preclude a trial of NOM for patients who are otherwise candidates for this care pathway. (J Trauma Acute Care Surg. 2026;00:00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved). Prognostic/Epidemiological; Level III.