Spleen/Liver injury: Grade + 1 = days of bed rest; What is the current status?

Phone conversation with R3 on call:
R3: got a kid down here, has grade 4 splenic lac. Stable
Me: so, what do you want to do?
R3: "take it out"

To be fair, the kid did "collapse" on the way to the bathroom, but probably form a vagal response.

Obviously, very few Pediatric Surgeons would argue that non-operative management is the general strategy in a stable child with blunt liver or splenic trauma. What constitutes non-operative management, on the other hand, is slightly more controversial.

Until recently, we had been treating kids with liver and splenic injury with bed rest, where the days in bed were determined by the grade of the injury. Grade + 1 = days in bed (grade + 2 = weeks of limited activity). In this protocol, as pointed out by St Peter et al. in a paper published in this month's JPS, days of bed rest are considered treatment variables, suggesting that a Grade 3 splenic lac needs 4 days to stabilize. Recent literature on the subject of non-operative management of liver and splenic injury has shifted focus from an absolute grade-defined management algorithm to one determined by hemodynamic stability and physical findings in an attempt to safely truncate what some would concider to be an overkill in terms of hospital stay.

St Peter et al prospectively studies 131 patients with liver and splenic injury from blunt trauma and noted that a protocol for monitoring (not therapy), where stable patients with grades I or II splenic injury are monitored for one night (defined as spending a night in their room regardless of time admission), while those who had a grade III or more, spend two nights in the hospital, is a safe alternative that could shorten hospital stay. Based on their protocol, if a patient needed a transfusion, the clock on observation was re-zero'd.

Using this protocol, the splenic salvage rate was 98.7%, regardless of associated injuries and transfusion requirements (13% required blood transfusion for their splenic and liver injuries). Obviously, and based on this protocol, there was a substantial decrease in hospital stay requirements.

St Peter et al. Prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. Journal of Pediatric Surgery (2011) 46, 173-177