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Annam A, Alexander ES, Cahill AM, Foley D, Green J, Himes EA, Johnson DT, Josephs S, Kulungowski AM, Leonard JC, Nance ML, Patel S, Pezeshkmehr A, Riggle K. Society of Interventional Radiology Position Statement on Endovascular Trauma Intervention in the Pediatric Population. J Vasc Interv Radiol 2024; 35:1104-1116.e19. [PMID: 38631607 DOI: 10.1016/j.jvir.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/03/2024] [Accepted: 04/04/2024] [Indexed: 04/19/2024] Open
Affiliation(s)
- Aparna Annam
- Division of Pediatric Radiology, Department of Radiology, University of Colorado, School of Medicine, Children's Hospital Colorado, Aurora, Colorado.
| | - Erica S Alexander
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne Marie Cahill
- Department of Interventional Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David Foley
- Department of Surgery, University of Louisville, School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Jared Green
- Joe DiMaggio Children's Hospital, Envision Radiology Associates of Hollywood, Pembroke Pines, Florida
| | | | | | - Shellie Josephs
- Department of Radiology, Texas Children's Hospital North Austin/Baylor College of Medicine, Austin, Texas
| | - Ann M Kulungowski
- Division of Pediatric Surgery, Department of Surgery, University of Colorado, School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Julie C Leonard
- Division of Emergency Medicine, Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Michael L Nance
- Department of Surgery, Division of Pediatric General and Thoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Amir Pezeshkmehr
- Department of Radiology, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Kevin Riggle
- Department of Surgery, University of Louisville, School of Medicine, Norton Children's Hospital, Louisville, Kentucky
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Wang T, Truche P, Sachs R, Thenappan A, Lee YH, Burjonrappa SC. Opportunity for Reduction of Intensive Care Unit Resource Utilization in Pediatric Blunt Liver and Spleen Injuries: A National Trauma Data Bank Analysis. J Pediatr Surg 2024; 59:1309-1314. [PMID: 38575447 DOI: 10.1016/j.jpedsurg.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 03/01/2024] [Indexed: 04/06/2024]
Abstract
INTRODUCTION Guidelines for blunt liver and spleen injury (BLSI) by the Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium (ATOMAC) emphasize hemodynamic stability over injury grade when considering non-operative management (NOM). In this study, we examined rates of intensive care unit (ICU) admission for children with isolated low-risk BLSI among US hospitals. METHODS The National Trauma Data Bank (NTDB) was queried for patients ages 1-15 admitted between 2017 and 2019 with BLSI. Patients with penetrating injuries and/or concomitant non-abdominal injuries with AIS score ≥3 were excluded. Isolated BLSI was considered low-risk if the patient had normal admission vitals and did not require operative intervention. Primary outcomes measured were ICU admission, ICU length of stay (LOS), and overall LOS. RESULTS 5777 patients ages 15 and under presented with isolated BLSI during the study period. 2031/5777 (35.2%) were considered low-risk. Low-risk patients had lower rates of ICU admission compared to high-risk patients (30.9% vs. 41.6%, p < 0.001) and had shorter ICU LOS (median 2 days vs. 2, p < 0.001) and shorter overall LOS (median 41 h vs. 54, p < 0.001). Pediatric verified and non-pediatric verified trauma centers had similar rates of ICU admission (36.8% vs. 38.9%, p = 0.11). CONCLUSION Further work is needed to capture opportunities for reduction in ICU utilization in isolated BLSI. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Theodore Wang
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Paul Truche
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, Rutgers, NJ, USA
| | - Rachel Sachs
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, Rutgers, NJ, USA
| | | | - Yi-Horng Lee
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, Rutgers, NJ, USA
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Dantes G, Kolousek A, Doshi N, Dutreuil V, Sciarretta JD, Sola R, Shah J, Smith RN, Smith AD, Koganti D. Utilization of Angiography in Pediatric Blunt Abdominal Injury at Adult versus Pediatric Trauma Centers. J Surg Res 2024; 293:561-569. [PMID: 37832307 DOI: 10.1016/j.jss.2023.08.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/24/2023] [Accepted: 08/26/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION Angiography has been widely accepted as an adjunct in the management of blunt abdominal trauma in adults. However, the role of angiography with or without angioembolization (AE) is still being defined in pediatric solid organ injury. We sought to compare the use of angiography in solid organ injury (SOI) at pediatric trauma centers (PTCs) versus an adult trauma center (ATC) in a large metropolitan city. METHODS Data were drawn from a collaborative effort of three Trauma centers (one adult and two pediatric) in Atlanta, GA. All pediatric patients (ages 1-18) treated for SOI between January 1, 2016 and December 31, 2021 were included (n = 350). Registry data obtained included demographics, mechanism of injury, injury grade, injury severity score (ISS), procedures performed, and transfusions. Multivariate regression analysis was used to identify factors associated with angiography. RESULTS A total of 350 patients were identified during the study period with 101 treated at ATC and 249 treated at the two PTCs. The median age at the ATC was 17 y (IQR 16, 18) compared to nine (6, 13) at the PTCs. ISS was significantly higher at the ATC 22 (14, 34) compared to 16 (9, 22) at PTCs (P < 0.001). At the ATC, 11 (10.9%) patients underwent angiography, 4 (4.9%) of which underwent AE compared to seven (2.8%) patients who underwent angiography and AE at PTCs. In the multivariate analysis, factors associated with angiography use included age (OR 1.44, 95% CI 1.09-1.90, P = 0.010) and ISS (OR 1.05, 95% CI 1.02-1.09, P = 0.004). Through setting, ATC versus PTC was significant on univariable analysis, it did not remain a significant predictor of angiography on multivariable regression. CONCLUSIONS Our study demonstrated increased utilization of angiography for the management of SOI in pediatric patients treated at ATCs versus PTCs. On regression analysis, age and ISS remained significant predictors for angiography utilization, while setting (ATC versus PTC) was notably not a significant predictor. This data would suggest that differences in angiography utilization for pediatric SOI at PTCs and ATCs are influenced by differing patient populations (older and higher ISS), with otherwise uniform use. These findings provide a basis for future treatment algorithm revisions for pediatric blunt abdominal trauma that include angiography and provide support for the development of formal guidelines.
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Affiliation(s)
- Goeto Dantes
- Department of Surgery, Emory University, Atlanta, Georgia.
| | | | - Neil Doshi
- Morehouse School of Medicine, Morehouse University, Atlanta, Georgia
| | - Valerie Dutreuil
- Pediatric Biostatistics Core, Department of Pediatrics, Emory School of Medicine Atlanta, Georgia
| | - Jason D Sciarretta
- Department of Surgery, Emory University, Atlanta, Georgia; Department of Trauma Surgery, Emory University, Grady Memorial Hospital, Atlanta, Georgia
| | - Richard Sola
- Morehouse School of Medicine, Morehouse University, Atlanta, Georgia
| | - Jay Shah
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Randi N Smith
- Department of Surgery, Emory University, Atlanta, Georgia; Department of Trauma Surgery, Emory University, Grady Memorial Hospital, Atlanta, Georgia; Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Alexis D Smith
- Department of Surgery, Emory University, Atlanta, Georgia; Pediatric Biostatistics Core, Department of Pediatrics, Emory School of Medicine Atlanta, Georgia
| | - Deepika Koganti
- Department of Surgery, Emory University, Atlanta, Georgia; Department of Trauma Surgery, Emory University, Grady Memorial Hospital, Atlanta, Georgia; Rollins School of Public Health, Emory University, Atlanta, Georgia
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Griffin KL, Richardson C, Brierley S, Stullich RM, Gates RL. Validation for Abbreviated Hospital Stay in Pediatric Patients with Solid Organ Injury. Am Surg 2023; 89:5921-5926. [PMID: 37257502 DOI: 10.1177/00031348231180935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND In 2000, the American Pediatric Surgical Association (APSA) published guidelines for the management of pediatric solid organ injury, recommending a hospital length of stay (LOS) of grade of injury plus 1 day. Since the publication of these guidelines, several studies have suggested that it is safe to discharge patients sooner based upon hemodynamic and clinical factors. The results of several of these studies have been confounded by the existence of other injuries. The aim of this study was to examine LOS and outcomes in children with strictly isolated solid organ injuries. MATERIALS AND METHODS This is a 12-year retrospective review of pediatric patients with isolated trauma to the kidney, liver, or spleen to determine LOS. Patients were excluded for associated intracranial, neurologic, orthopedic, or pulmonary injuries which would impact length of stay. Documented hemodynamic parameters were reviewed as determinants of patient stability. RESULTS A total of 156 patients were included in the study. The projected average LOS for all patients based on the 2000 APSA guidelines would have been 3.71 ± 0.98 days. The actual average LOS for all patients 2.85 ± 3.32 days. Need for operation, ICU stay, and transfusion all contributed to increased LOS. The number of episodes of abnormal vitals positively correlated with increased LOS. DISCUSSION This study validates that management of isolated solid organ injuries based upon hemodynamic parameters and clinical status is safe and decreases hospital length of stay. Consistently normal vital signs indicate these children can be safely discharged sooner.
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Affiliation(s)
| | | | | | - Renee M Stullich
- School of Medicine, University of South Carolina, Greenville, SC, USA
| | - Robert L Gates
- Prisma Health Upstate, Greenville, SC, USA
- School of Medicine, University of South Carolina, Greenville, SC, USA
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Zakaria OM, Daoud MYI, Zakaria HM, Al Naim A, Al Bshr FA, Al Arfaj H, Al Abdulqader AA, Al Mulhim KN, Buhalim MA, Al Moslem AR, Bubshait MS, AlAlwan QM, Eid AF, AlAlwan MQ, Albuali WH, Hassan AA, Kamal AH, Majzoub RA, AlAlwan AQ, Saleh OA. Management of pediatric blunt abdominal trauma with split liver or spleen injuries: a retrospective study. Pediatr Surg Int 2023; 39:106. [PMID: 36757505 DOI: 10.1007/s00383-023-05379-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND Blunt abdominal trauma is a prevailing cause of pediatric morbidity and mortality. It constitutes the most frequent type of pediatric injuries. Contrast-enhanced sonography (CEUS) and contrast-enhanced computed tomography (CECT) are considered pivotal diagnostic modalities in hemodynamically stable patients. AIM To report the experience in management of pediatric split liver and spleen injuries using CEUS and CECT. PATIENTS AND METHODS This study included 246 children who sustained blunt abdominal trauma, and admitted and treated at three tertiary hospitals in the period of 5 years. Primary resuscitation was offered to all children based on the advanced trauma and life support (ATLS) protocol. A special algorithm for decision-making was followed. It incorporated the FAST, baseline ultrasound (US), CEUS, and CECT. Patients were treated according to the imaging findings and hemodynamic stability. RESULTS All 246 children who sustained a blunt abdominal were studied. Patients' age was 10.5 ± 2.1. Road traffic accidents were the most common cause of trauma; 155 patients (63%). CECT showed the extent of injury in 153 patients' spleen (62%) and 78 patients' liver (32%), while the remaining 15 (6%) patients had both injuries. CEUS detected 142 (57.7%) spleen injury, and 67 (27.2%) liver injury. CONCLUSIONS CEUS may be a useful diagnostic tool among hemodynamically stable children who sustained low-to-moderate energy isolated blunt abdominal trauma. It may be also helpful for further evaluation of uncertain CECT findings and follow-up of conservatively managed traumatic injuries.
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Affiliation(s)
- Ossama M Zakaria
- Departments of Surgery, Emergency, and Pediatrics College of Medicine, King Faisal University, Al Hofuf, Saudi Arabia. .,Departments of Surgery and Emergency, Faculty of Medicine, Suez Canal University, Ismailia, Egypt. .,Division of Pediatric Surgery, Department of Surgery, College of Medicine, King Faisal University, Al Hofuf, Saudi Arabia.
| | - Mohamed Yasser I Daoud
- Departments of Surgery, Emergency, and Pediatrics College of Medicine, King Faisal University, Al Hofuf, Saudi Arabia
| | - Hazem M Zakaria
- Departments of Surgery and Pediatrics, Imam Abdul Rahman Al-Faisal University, Dammam, Saudi Arabia
| | - Abdulrahman Al Naim
- Departments of Surgery, Emergency, and Pediatrics College of Medicine, King Faisal University, Al Hofuf, Saudi Arabia
| | - Fatemah A Al Bshr
- Departments of Surgery, Emergency, and Pediatrics College of Medicine, King Faisal University, Al Hofuf, Saudi Arabia
| | - Haytham Al Arfaj
- Departments of Surgery, Emergency, and Pediatrics College of Medicine, King Faisal University, Al Hofuf, Saudi Arabia
| | - Ahmad A Al Abdulqader
- Departments of Surgery, Emergency, and Pediatrics College of Medicine, King Faisal University, Al Hofuf, Saudi Arabia
| | - Khalid N Al Mulhim
- Departments of Surgery, Emergency, and Pediatrics College of Medicine, King Faisal University, Al Hofuf, Saudi Arabia
| | - Mohamed A Buhalim
- Departments of Surgery, Emergency, and Pediatrics College of Medicine, King Faisal University, Al Hofuf, Saudi Arabia
| | - Abdulrahman R Al Moslem
- Departments of Surgery, Emergency, and Pediatrics College of Medicine, King Faisal University, Al Hofuf, Saudi Arabia
| | - Mohammed S Bubshait
- Departments of Surgery, Emergency, and Pediatrics College of Medicine, King Faisal University, Al Hofuf, Saudi Arabia
| | - Qasem M AlAlwan
- Radiology Department of King Fahd Hospital, Al-Ahsa, l-Ministry of Health-Saudi Arabia, Riyadh, Saudi Arabia
| | - Ahmed F Eid
- Medical Imaging Department, King Abdul-Aziz Hospital, Health Affairs of the Ministry of National Guard, Al-Ahsa, Saudi Arabia
| | - Mohammed Q AlAlwan
- Radiology Department of King Fahd Hospital, Al-Ahsa, l-Ministry of Health-Saudi Arabia, Riyadh, Saudi Arabia
| | - Waleed H Albuali
- Departments of Surgery and Pediatrics, Imam Abdul Rahman Al-Faisal University, Dammam, Saudi Arabia
| | | | - Ahmed Hassan Kamal
- Departments of Surgery, Emergency, and Pediatrics College of Medicine, King Faisal University, Al Hofuf, Saudi Arabia
| | - Rabab Abbas Majzoub
- Departments of Surgery, Emergency, and Pediatrics College of Medicine, King Faisal University, Al Hofuf, Saudi Arabia
| | - Abdullah Q AlAlwan
- Departments of Surgery, Emergency, and Pediatrics College of Medicine, King Faisal University, Al Hofuf, Saudi Arabia
| | - Omar Abdelrahman Saleh
- Departments of Surgery and Emergency, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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Reppucci ML, Stevens J, Cooper E, Meier M, Phillips R, Shahi N, Nolan M, Acker SN, Moulton SL, Bensard DD. Discreet Values of Shock Index Pediatric Age-Adjusted (SIPA) to Predict Intervention in Children With Blunt Organ Injuries. J Surg Res 2022; 279:17-24. [PMID: 35716446 DOI: 10.1016/j.jss.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 04/30/2022] [Accepted: 05/23/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Elevated shock index pediatric age-adjusted (SIPA) has been shown to be associated with the need for both blood transfusion and intervention in pediatric patients with blunt liver and spleen injuries (BLSI). SIPA has traditionally been used as a binary value, which can be classified as elevated or normal, and this study aimed to assess if discreet values above SIPA cutoffs are associated with an increased probability of blood transfusion and failure of nonoperative management (NOM) in bluntly injured children. MATERIALS AND METHODS Children aged 1-18 y with any BLSI admitted to a Level-1 pediatric trauma center between 2009 and 2020 were analyzed. Blood transfusion was defined as any transfusion within 24 h of arrival, and failure of NOM was defined as any abdominal operation or angioembolization procedure for hemorrhage control. The probabilities of receiving a blood transfusion or failure of NOM were calculated at different increments of 0.1. RESULTS There were 493 patients included in the analysis. The odds of requiring blood transfusion increased by 1.67 (95% CI 1.49, 1.90) for each 0.1 unit increase of SIPA (P < 0.001). A similar trend was seen initially for the probability of failure of nonoperative management, but beyond a threshold, increasing values were not associated with failure of NOM. On subanalysis excluding patients with a head injury, increased 0.1 increments were associated with increased odds for both interventions. CONCLUSIONS Discreet values above age-related SIPA cutoffs are correlated with higher probabilities of blood transfusion in pediatric patients with BLSI and failure of NOM in those without head injury. The use of discreet values may provide clinicians with more granular information about which patients require increased resources upon presentation.
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Affiliation(s)
- Marina L Reppucci
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado.
| | - Jenny Stevens
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Emily Cooper
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Ryan Phillips
- Department of Surgery, Ochsner Medical Center, New Orleans, Louisiana
| | - Niti Shahi
- Department of Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Margo Nolan
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado
| | - Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Steven L Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Denis D Bensard
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado; Department of Surgery, Denver Health Medical Center, Denver, Colorado
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Evans LL, Williams RF, Jin C, Plumblee L, Naik-Mathuria B, Streck CJ, Jensen AR. Hospital-based intervention is rarely needed for children with low-grade blunt abdominal solid organ injury: An analysis of the Trauma Quality Improvement Program registry. J Trauma Acute Care Surg 2021; 91:590-598. [PMID: 34559162 PMCID: PMC8553177 DOI: 10.1097/ta.0000000000003206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Children with low-grade blunt solid organ injury (SOI) have historically been admitted to an inpatient setting for monitoring, but the evidence supporting the necessity of this practice is lacking. The purpose of this study was to quantify the frequency and timing of intervention for hemorrhage and to describe hospital-based resource utilization for low-grade SOI in the absence of other major injuries (OMIs). METHODS A cohort of children (aged <16 years) with blunt American Association for the Surgery of Trauma grade 1 or 2 SOI from the American College of Surgeons Trauma Quality Improvement Program registry (2007-2017) was analyzed. Children were excluded if they had confounding factors associated with intervention for hemorrhage (comorbidities, OMIs, or extra-abdominal surgical procedures). Outcomes included frequency and timing of intervention (laparotomy, angiography, or transfusion) for hemorrhage, as well as hospital-based resource utilization. RESULTS A total of 1,019 children were identified with low-grade blunt SOI and no OMIs. Nine hundred eighty-six (96.8%) of these children were admitted to an inpatient unit. Admitted children with low-grade SOI had a median length-of-stay of 2 days and a 23.9% intensive care unit admission rate. Only 1.7% (n = 17) of patients with low-grade SOI underwent an intervention, with the median time to intervention being the first hospital day. No child who underwent angiography was transfused or had an abnormal initial ED shock index. CONCLUSION Children with low-grade SOI are routinely admitted to the hospital and often to the intensive care unit but rarely undergo hospital-based intervention. The most common intervention was angiography, with questionable indications in this cohort. These data question the need for inpatient admission for low-grade SOI and suggest that discharge from the emergency room may be safe. Prospective investigation into granular risk factors to identify the rare patient needing hospital-based intervention is needed, as is validation of the safety of ambulatory management. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.
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Affiliation(s)
- Lauren L Evans
- Division of Pediatric Surgery, University of California San Francisco Benioff Children’s Hospital Oakland, Oakland, CA 94611
| | - Regan F Williams
- Division of Pediatric Surgery, Le Bonheur Children’s Hospital, The University of Tennessee Health Science Center, Memphis, TN, 38103
| | - Chengshi Jin
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, 94143
| | - Leah Plumblee
- Division of Pediatric Surgery, Children’s Health, Medical University of South Carolina, Charleston, SC, 29425
| | - Bindi Naik-Mathuria
- Division of Pediatric Surgery, Texas Children’s Hospital, Houston, TX, 77030
| | - Christian J Streck
- Division of Pediatric Surgery, Children’s Health, Medical University of South Carolina, Charleston, SC, 29425
| | - Aaron R Jensen
- Division of Pediatric Surgery, University of California San Francisco Benioff Children’s Hospital Oakland, Oakland, CA 94611
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA 93721
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Implementation of an evidence-based accelerated pathway: can hospital length of stay for children with blunt solid organ injury be safely decreased? Pediatr Surg Int 2021; 37:695-704. [PMID: 33782737 DOI: 10.1007/s00383-021-04896-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Recent work has demonstrated that an accelerated pathway for pediatric patients with blunt solid organ injuries is safe; however, this is not well-studied in a dual trauma center. We hypothesized that implementation of an accelerated pathway would decrease length of stay (LOS) and hospitalization cost without increased mortality. METHODS Retrospective review of patients < 15 years presenting to a dual level 1 trauma center between 2015 and 2020 with traumatic blunt liver and splenic injuries. Patients presenting pre- and post-protocol implementation were compared. The primary outcome was total hospital LOS. Secondary outcomes were number of lab draws, intensive care unit (ICU) LOS, cost of hospitalization, readmissions within 30 days, and mortality. RESULTS 103 patients were evaluated, 67 pre-protocol and 63 post-protocol. LOS was significantly shorter post-protocol (2 days vs. 4 days, p < 0.001). The ICU LOS was unchanged. There was a decrease in direct hospitalization cost per patient from $6,246 pre-protocol to $4,294 post-protocol (p = 0.001). There was one readmission post-protocol and none pre-protocol. There were no deaths. CONCLUSION Implementation of an accelerated pathway for management of blunt solid organ injury at a dual trauma center was associated with decreased LOS and decreased costs with no increased morbidity or mortality.
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Steinberger AE, Wilson NA, Fairfax C, Treon SJ, Herndon M, Levene TL, Keller MS. Implementation of a clinical guideline for nonoperative management of isolated blunt renal injury in children. Surg Open Sci 2021; 5:19-24. [PMID: 34337373 PMCID: PMC8324460 DOI: 10.1016/j.sopen.2021.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/12/2021] [Accepted: 04/26/2021] [Indexed: 11/20/2022] Open
Abstract
Background The aim was to evaluate the impact of a standardized nonoperative management protocol by comparing patients with isolated blunt renal injury before and after implementation. Methods We retrospectively reviewed the trauma registry at our Level 1 pediatric trauma center. We compared consecutive patients (≤ 18 years) managed nonoperatively for blunt renal injury Pre (1/2010–9/2014) and Post (10/2014–3/2020) implementation of a clinical guideline. Outcomes included length of stay, intensive care unit admission, urinary catheter use, and imaging studies. Results We included 48 patients with isolated blunt renal injuries (29 Pre, 19 Post). There were no differences in age, sex, injury grade, or mechanism (P > .05). Postprotocol had decreased length of stay (P = .040), intensive care unit admissions (P = .015), urinary catheter use (P = .031), and ionizing radiation imaging (P < .001). Conclusion These data suggest improved outcomes and resource utilization following implementation of a nonoperative management protocol of pediatric isolated blunt renal injuries. Implementation of a standardized nonoperative management protocol for pediatric patients with isolated blunt renal injury improved outcomes and resource utilization. Protocol implementation was associated with decreased length of stay, ICU admissions, urinary catheter use, and ionizing radiation imaging. There were no differences in demographics, mechanism, or grade of injury between pre- and postprotocol groups.
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Key Words
- AAST, American Association for the Surgery of Trauma
- ACS, American College of Surgeons
- CAUTI, catheter-associated urinary tract infections
- CBC, complete blood count
- CDC, Centers for Disease Control and Prevention (CDC)
- CT, computed tomography
- DMSA, dimercaptosuccinic acid
- ICU, intensive care unit
- LOS, length of stay
- MAG3, mercaptuacetyltriglycine scan
- ROUT, robust regression with outlier detection
- SPECT, single-photon emission computerized tomography
- VCUG, voiding cystourethrogram
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Affiliation(s)
- Allie E Steinberger
- Washington University in St. Louis School of Medicine, 1 Barnes Jewish Hospital Plaza, St. Louis, MO 63110
| | - Nicole A Wilson
- Washington University in St. Louis School of Medicine, 1 Barnes Jewish Hospital Plaza, St. Louis, MO 63110
- St. Louis Children's Hospital, 1 Children's Place, St. Louis, MO 63110
| | - Connor Fairfax
- St. Louis Children's Hospital, 1 Children's Place, St. Louis, MO 63110
| | - Stephanie J Treon
- Washington University in St. Louis School of Medicine, 1 Barnes Jewish Hospital Plaza, St. Louis, MO 63110
| | - Michele Herndon
- St. Louis Children's Hospital, 1 Children's Place, St. Louis, MO 63110
| | - Tamar L Levene
- Joe DiMaggio Children's Hospital, 1005 Joe DiMaggio Dr, Hollywood, FL 33021
| | - Martin S Keller
- Washington University in St. Louis School of Medicine, 1 Barnes Jewish Hospital Plaza, St. Louis, MO 63110
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Abstract
PURPOSE OF REVIEW Traumatic injuries are a leading cause of pediatric mortality; pediatric ICUs (PICUs) are an important but potentially limited resource associated with high costs. In an era of rising healthcare costs, appropriate resource utilization is important. Here, we examine evidence-based guidelines supporting the management of pediatric traumatic injury outside of the PICU. RECENT FINDINGS Historical management of solid organ injury and traumatic brain injury was focused on operative management. However, over the past four decades, management of solid organ injury has shifted from invasive management to nonsurgical management with a growing body of evidence supporting the safety and efficacy of this trend. The management of traumatic brain injury (TBI) has had a similar evolution to that of solid organ injury with regard to nonoperative management and management outside the critical care setting. SUMMARY The use of evidence-based guidelines to support expectant management in the setting of pediatric trauma has the potential to reduce unnecessary resource utilization of the PICU. In this review, we present findings that support nonoperative management and management of pediatric trauma outside of the PICU setting. In resource-poor areas, this approach may facilitate care for pediatric trauma patients. The implications are also important in resource-rich settings because of the unintended risks associated with PICU.
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Cunningham AJ, Rao P, Siddharthan R, Azarow KS, Ashok A, Jafri MA, Krishnaswami S, Hamilton NA, Butler MW, Lofberg KM, Zigman A, Fialkowski EA. Minimizing variance in pediatric surgical care through implementation of a perioperative colon bundle: A multi-institution retrospective cohort study. J Pediatr Surg 2020; 55:2035-2041. [PMID: 32063373 DOI: 10.1016/j.jpedsurg.2020.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 12/24/2019] [Accepted: 01/10/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Employing an institutional initiative to minimize variance in pediatric surgical care, we implemented a set of perioperative bundled interventions for all colorectal procedures to reduce surgical site infections (SSIs). METHODS Implementation of a standard colon bundle at two children's hospitals began in December 2014. Subjects who underwent a colorectal procedure during the study period were analyzed. Demographics, outcomes, and complications were compared with Wilcoxon Rank-Sum, Chi-square and Fisher exact tests, as appropriate. Multivariable logistic regression was performed to assess the influence of time period (independent of protocol implementation) on the rate of subsequent infection. RESULTS One hundred and forty-five patients were identified (preprotocol=68, postprotocol= 77). Gender, diagnosis, procedure performed and wound classification were similar between groups. Superficial SSIs (21% vs. 8%, p=0.031) and readmission (16% vs. 4%, p=0.021) were significantly decreased following implementation of a colon bundle. Median hospital days, cost, reoperation, intraabdominal abscess, and anastomotic leak were unchanged before and after protocol implementation (all p > 0.05). Multivariable logistic regression found time period to be independent of SSIs (OR: 0.810, 95% CI: 0.576-1.140). CONCLUSION Implementation of a standard pediatric perioperative colon bundle can reduce superficial SSIs. Larger prospective studies are needed to evaluate the impact of colon bundles in reducing complications, hospital stay and cost. LEVEL OF EVIDENCE III - Retrospective cohort study.
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Affiliation(s)
- Aaron J Cunningham
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
| | - Pavithra Rao
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA.
| | - Raga Siddharthan
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
| | - Kenneth S Azarow
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA.
| | - Arjun Ashok
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Mubeen A Jafri
- Division of Pediatric Surgery, Randall Children's Hospital at Legacy Emanuel, Portland, OR, USA.
| | - Sanjay Krishnaswami
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA.
| | - Nicholas A Hamilton
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA.
| | - Marilyn W Butler
- Division of Pediatric Surgery, Randall Children's Hospital at Legacy Emanuel, Portland, OR, USA.
| | - Katrine M Lofberg
- Division of Pediatric Surgery, Randall Children's Hospital at Legacy Emanuel, Portland, OR, USA.
| | - Andrew Zigman
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
| | - Elizabeth A Fialkowski
- Division of Pediatric Surgery, Randall Children's Hospital at Legacy Emanuel, Portland, OR, USA
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12
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Acker SN, Hill LRS, Bensard DD, Moulton S, Partrick DA. The benefits of limiting scheduled blood draws in children with a blunt liver or spleen injury. J Pediatr Surg 2020; 55:1219-1223. [PMID: 31133284 DOI: 10.1016/j.jpedsurg.2019.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 04/29/2019] [Accepted: 05/10/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nonoperative management protocols of blunt liver and spleen injury in children usually call for serial monitoring of the child's hemoglobin and hematocrit (H/H) at scheduled intervals. We previously demonstrated that the need for emergent intervention is triggered by changes in vital signs, not the findings of scheduled blood draws and changed our protocol accordingly. The current aim is to evaluate the safety of this change. METHODS We performed a retrospective review of all children admitted following blunt liver or spleen injury during two periods; the historic cohort 1/09-12/13 and the protocol cohort 8/15-7/17. Data evaluated included the need for intervention, number of H/H checks, and outcomes. RESULTS 330 children were included (216 historic; 114 protocol). Groups did not differ in percentage of male patients, injury severity score, or GCS. Median age in the historic cohort was younger than the protocol cohort (9 vs 12 years; p = 0.02). More children in the protocol group had a grade 5 injury (1% vs 9%; p < 0.0001). Groups did not differ in the number who required intervention or discharge disposition (including mortality). The protocol group had fewer H/H checks (median 5 vs 4, p < 0.0001); the two groups did not differ in their nadir H/H. The historic group had a longer median hospital length of stay (3 days vs 2, p = 0.0007). CONCLUSIONS Decreasing the number of scheduled blood draws following a blunt liver or spleen injury in children is safe. Additional benefits include a decrease in the number of blood draws and a decrease in length of hospital stay. STUDY TYPE Cost-effectiveness. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Lauren R S Hill
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Denis D Bensard
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, Denver, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Steven Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - David A Partrick
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
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