Transfusion requirements in conservative nonoperative management of blunt splenic and hepatic injuries during childhood

To save a child's spleen: 50 years from Toronto to ATOMAC

Pediatric surgeons brought forth non-operative treatment for children with blunt spleen injury more than 50 years ago. At the time, this proposal was deemed reckless by many adult surgeons, and debate ensued for decades. Despite criticisms, pediatric surgeons refined the clinical pathways for children with spleen injury leading to current safe and efficient outcomes. These outcomes are defined by rare splenectomies, few blood transfusions, and short length of hospital stay. This review will address the role of the spleen through historical perceptions and scientific evidence. In addition, evolution of contemporary clinical pathways will be outlined.

Trauma surgeons practice what they preach: The NTDB story on solid organ injury management

BACKGROUND

Recent studies advocate a nonoperative approach for hepatic and splenic trauma. The purpose of this study was to determine whether the literature has impacted surgical practice and, if so, whether or not the overall mortality of these injuries had changed.

METHODS

The American College of Surgeons' National Trauma Data Bank (NTDB 4.0) was analyzed using trauma admission dates ranging from 1994 to 2003. All hepatic and splenic injuries were identified by ICD-9 codes. As renal trauma management has not changed during the study period, renal injuries were included as a control. Nonoperative management (NOM) rates and overall mortality were determined for each organ. Proportions were compared using chi analysis with significance set at p < 0.05.

RESULTS

There were 87,237 solid abdominal organ injuries reported and included: 35,767 splenic, 35,510 hepatic, 15,960 renal injuries. There was a significant (p < 0.00000000005) increase in percentage of NOM for hepatic and splenic trauma whereas renal NOM remained stable for the study period. Despite an increase in NOM for splenic and hepatic injuries, mortality has remained unchanged.

CONCLUSIONS

This study demonstrates that the management of hepatic and splenic injuries has significantly changed in the past 10 years with no appreciable effect on mortality. NOM has become the standard of care for the management of hepatic and splenic trauma. The NTDB can be used to monitor changes in trauma care in response to new knowledge regarding improved outcomes.

Nonoperative Management of Pediatric Blunt Hepatic Trauma

The purpose of this study was to examine the effect of operative versus nonoperative management of blunt hepatic trauma in children including transfusion practices. We reviewed the experience at our American College of Surgeons-verified Level I trauma center with pediatric commitment over a 5-year period. Children ≤16 years of age suffering blunt liver injury as documented on admission CT scan were included in the study. Liver injuries identified on CT scan were classified according to the American Association for the Surgery of Trauma's Organ Injury Scaling system. All data are presented as mean ± standard error. One case of pediatric liver trauma not identified on CT was excluded (prehospital cardiopulmonary resuscitation). Twenty-seven patients were included [age 9.3 ± 1.0 years (range 3–16)]. Mechanisms of injury included motor vehicle crash (14), pedestrian struck by motor vehicle (7), bicycle crash (4), fall from height (1), and pedestrian struck by falling object (1). Trauma Score was 11.5 ± 0.3. Distribution of Liver Injury Grade was as follows: grade I, 13; grade II, 9; grade III, 3; grade IV, 2; and grade V, 0. All five patients who underwent operative management had multiple organ injuries; three had concomitant splenic injury requiring operative repair; the remaining two had small bowel injury requiring repair. Hepatorrhaphy did not correlate with severity of liver injury: grade I, n = 1; II, n = 2; III, n = 1; and IV, n = 1. Three operated patients received blood transfusions. Twenty-two patients were managed with nonoperative treatment, of these only one required blood transfusion. No patients in the study died, three were transferred to subacute rehabilitation, one was transferred to another hospital, and 23 were discharged home. Our findings indicate that a majority of children with blunt hepatic injury as documented on CT scan can be managed with nonoperative treatment, and few require blood transfusions. Patients with multiple organ injury including simultaneous splenic injury are likely ideally managed through operative exploration and repair, whereas those with isolated liver injuries can be successfully managed nonoperatively.

Operative management of injured children at an adult level I trauma center

BACKGROUND

The geographic distribution of trauma centers results in a significant number of children being treated in adult centers. The emphasis on nonoperative management of pediatric blunt trauma has heightened concern that in adult trauma centers, an aggressive operative approach will continue to be used. We hypothesized that pediatric commitment at a Level I trauma center results in appropriate nonoperative care of injured children as established by regional pediatric trauma centers.

METHODS

The records of 1,792 consecutively treated children admitted to the trauma service during a 6-year period (January of 1990 to December of 1995) were reviewed. Patients were stratified into one of three age groups: 0 to 5, 6 to 11, and 12 to 17 years of age.

RESULTS

Mean age of the study patients was 10.0 +/- 0.1 years, 1,147 were boys (64%), and their mean Injury Severity Score was 7.3 +/- 0.3. The injury mechanism was blunt in 1,550 (87%) and 132 (7%) required laparotomy. In the 0- to 5-year-old blunt mechanism group, 6% underwent laparotomy or thoracotomy from 1990 to 1992. In comparison, only 1% of this age group had a laparotomy from 1993 to 1995 (p < 0.05, Fisher's exact test). A similar trend was found in the 6- to 11-year-old children after blunt injury (4% laparotomy rate from 1990 to 1992; 2% from 1993-1995).

CONCLUSION

There has been a declining trend in the operative management of blunt pediatric trauma, especially in children less than 6 years old, whereas the operative management of penetrating injuries has remained stable. These data confirm that pediatric commitment in a Level I trauma center results in nonoperative treatment of injured children commensurate with that established in regional pediatric trauma centers.

Childhood trauma. Now and in the new millennium

Given the magnitude of childhood injuries that occur yearly in the United States, physicians need integrated echelons of care that include regional pediatric trauma centers, trauma centers with pediatric commitment, and EDs appropriate for children. Head injury is the most significant cause of morbidity and mortality among children, but physicians are far from effectively evaluating the dynamics of cerebral metabolism and oxygen delivery in the acute resuscitation of injured children. Critically injured children must be kept normothermic, and attention to the signs of hypovolemic shock must be monitored. Secondary brain ischemia frequently occurs because the details of resuscitation are not carefully monitored. A "leader" must be designated, and this should be someone experienced in childhood trauma. The younger the child and the more severe the injury, the more important is the notion of "experience." The ultimate goal, now and in the new millennium, should not be who, where, or when to administer care to critically ill or injured children but rather the quality of the treatment of these children.

Practice patterns of pediatric surgeons caring for stable patients with traumatic solid organ injury

BACKGROUND

Managed care financing has resulted in pressure to decrease hospital days and lower per diem costs. This influence may ultimately affect nonoperative management of blunt solid organ injuries in children (spleen, liver, kidneys).

METHODS

Pediatric surgeons caring for trauma patients were surveyed regarding current practice patterns. One survey was sent to a representative staff pediatric surgeon at each major children's hospital or children's unit involved in the care of the injured child in the United States.

RESULTS

There were 87 responses to 117 surveys (75%). Relatively few children fail nonoperative management. For major management decisions, including radiographic study of choice; when to transfuse; and when to allow out of bed, home, and back to school, there was often a clear majority opinion of appropriate care. However, there was a wide variance in response for some questions.

CONCLUSIONS

Surgical judgment must be individualized, but a low number of failures of nonoperative management is helpful in delineating safe practice guidelines. Surgeons using fewer resources than the norm may help delineate management schemes that are equally effective to more expensive care. Based on these responses a management protocol is recommended.

Associated head injury should not prevent nonoperative management of spleen or liver injury in children

The appropriate management of children with liver or spleen injuries and associated head injury after blunt trauma remains controversial. To evaluate the success rates for nonoperative management and the impact this approach has on both abdominal and head injury outcome, children recorded in the National Pediatric Trauma Registry were reviewed. From January 1, 1994 to April 1, 1995, 107 children (aged < 19) were identified with liver, spleen, and associated head injury from blunt trauma. Forty-five (42%) children had combined head and spleen injury, 51 (48%) had head and liver injury, and 11 (10%) had head, liver, and spleen injury. Only 18 (17%) required laparotomy (head and spleen injury, 9 (8%); head and liver injury, 5 (5%); and head, liver, and spleen injury, 4 (4%)). Overall, there were no differences in Glasgow Coma Scale scores for children requiring laparotomy compared with those managed conservatively (13 vs. 14, p > 0.05). For all groups, the mean Injury Severity Score was significantly higher for children requiring laparotomy (19 vs. 31, p < 0.05). However, when comparison of the groups was stratified for type of injury and severity, the transfusion requirements, mortality, and abdominal and neurologic morbidity were all improved in children managed nonoperatively. Contrary to previous guidelines in the literature for selection of patients for nonoperative management of blunt solid organ abdominal injury, the association of altered mental status from head injury with liver and spleen injuries should not impact the decision for observational management.

The outcome for children with blunt trauma is best at a pediatric trauma center

PURPOSE

The mortality rate for pediatric trauma patients cared for in adult trauma centers has been shown, by means of TRISS methodology, not to differ significantly from that of the Major Trauma Outcome Study (MTOS). The question remains, however, whether the outcome of injured children is better in a designated pediatric trauma center (DPTC). The authors' hypothesis is that outcome is better at a DPTC.

METHODS

The records of 1,797 children (0 to 15 years of age) admitted to a DPTC between 1987 and 1993 were reviewed. TRISS methodology was used to calculate probability of survival for outcome comparison with the MTOS. The data also was compared with outcome in relation to the admitting Glasgow Coma Score (GCS) reported in the National Pediatric Trauma Registry (NPTR).

RESULTS

The outcome of all children at this DPTC had a Z score of +1.4199 (P > .1). The Z score of children admitted because of penetrating trauma (PT, n = 460) did not differ significantly from that of the MTOS. However, the children admitted because of blunt trauma (BT, n = 1,337) had a Z score of +3.3501 (M score = .90), which is significantly better than that of the MTOS (P < .001). The BT population with an ISS of > or = 9 (n = 149) had a Z score of +2.8686 (P < .005) (M = .95). By GCS comparison, the BT group had a outcome similar to that reported in the NPTR. Head injury was the cause of death for 26 (84%) of the 31 PT deaths and 20 (83%) of the 24 BT deaths (three of the remaining four had associated severe head injury). Only 1 of 24 (4%) BT liver injuries and 5 (21%) of 24 BT splenic injuries required surgical intervention. This low incidence of liver and splenic surgical invention is similar to that reported by other DPTCs, but for children treated at adult centers the rates are 37% to 58% and 43% to 53% for liver & splenic surgical intervention, respectively.

CONCLUSION

Children with BT have a significantly better outcome at a DPTC; the outcome for children with PT does not differ. Successful nonoperative treatment of blunt abdominal injuries is more likely to occur at a DPTC than at adult trauma centers "with pediatric committment." Thus, children with blunt injuries should be taken to a DPTC, when available.

Splenic injury in children: a 10 year experience

The aim of this report was to review retrospectively the management of splenic trauma at a major Australian tertiary referral centre (Westmead Hospital) over a 10 year period. Forty-nine patients (0-15 years of age) with documented blunt splenic trauma were identified. The causes of splenic injury were road trauma (73%) and falls (27%). There were 22 minor injuries (Injury severity score [ISS] < 16) and 27 severe injuries (ISS > or = 16). All nine deaths were related to road trauma (mean ISS = 59). The investigation most commonly used was CT scanning (47%). Peritoneal lavage was performed in six patients (12%). Management involved non-operative care in 29 patients (57%), exploratory laparotomy alone in 5 (10%), splenic salvage in 2 (4%) and splenectomy in 13 (26%). This experience supports the view that non-operative management of splenic injury in haemodynamically stable children is safe and is the preferred treatment. Experienced assessment and meticulous observation is necessary. Laparotomy is indicated if there is continuing haemodynamic instability despite resuscitation. Operative management is aimed at splenic salvage with splenectomy being reserved for uncontrolled haemorrhage.