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Eldredge RS, Notrica DM, Nickoles T, Ochoa B, Garvey E, Bae JO, Jamshidi R, Russell KW, Rowe D, McGovern P, Molitor M, van Leeuwen K, Padilla BE, Ostlie D, Lee J. Contemporary National Trend in Surgical Management of Hemodynamically Unstable Pediatric Blunt Splenic Injury. J Pediatr Surg 2024:161918. [PMID: 39368856 DOI: 10.1016/j.jpedsurg.2024.161918] [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] [Received: 09/02/2024] [Accepted: 09/07/2024] [Indexed: 10/07/2024]
Abstract
BACKGROUND Evaluation of response to blood transfusion after blunt splenic injury (BSI) may prevent the need for splenectomy. The aim of this study was to evaluate factors associated with splenectomy in pediatric patients with isolated BSI who presented with hemodynamic instability with a focus on timing of transfusion. METHODS The 2021 Trauma Quality Improvement Project database was queried for children ≤18 years with BSI who arrived with a shock index>1.1. Interfacility transfer patients and those with additional intra-abdominal injuries were excluded. Demographic, injury characteristic and timing, transfusion, operative, and outcome data were collected. A sub-analysis of patients without brain injury was also performed. RESULTS 516 patients met inclusion criteria; 60.1% were male, with mean age 12.3 ± 5.5 years. Initial mean shock index was 1.4 ± 0.4, ISS was 31.7 ± 15.1, and GCS was 10.7 ± 5. Splenectomy occurred in 27% of patients. Among splenectomy patients, 26.2% did not receive blood prior to splenectomy. While treatment at a pediatric trauma center showed an increased OR of splenectomy in univariable analysis, when controlling for lack of transfusion, no differences in splenectomy persisted. Patient Age (aOR-1.26, p < 0.001), BSI grade (aOR-2.30, P < 0.001), male gender, (aOR-2.2, p = 0.003), being non-white (aOR-2.0) ISS (aOR-1.03, p = 0.003), and GCS (aOR-0.95, p = 0.034) were associated with splenectomy. CONCLUSION More than 26% of patients undergoing splenectomy did not receive blood prior to surgery. Differences in risk of splenectomy by center type seen on univariable analysis were not seen when controlling for transfusion. Evaluating response to blood transfusion may be an opportunity to reduce the frequency of splenectomy. LEVEL OF EVIDENCE Treatment Study Level III.
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Affiliation(s)
- R Scott Eldredge
- Phoenix Children's, Division of Pediatric Surgery, 1919 E Thomas Rd, Phoenix, AZ, USA; Mayo Clinic, Department of General Surgery, 5777 E Mayo Blvd, Phoenix, AZ, USA.
| | - David M Notrica
- Phoenix Children's, Division of Pediatric Surgery, 1919 E Thomas Rd, Phoenix, AZ, USA; Mayo Clinic, Department of General Surgery, 5777 E Mayo Blvd, Phoenix, AZ, USA
| | - Todd Nickoles
- Phoenix Children's, Division of Pediatric Surgery, 1919 E Thomas Rd, Phoenix, AZ, USA
| | - Brielle Ochoa
- Phoenix Children's, Division of Pediatric Surgery, 1919 E Thomas Rd, Phoenix, AZ, USA
| | - Erin Garvey
- Phoenix Children's, Division of Pediatric Surgery, 1919 E Thomas Rd, Phoenix, AZ, USA
| | - Jae-O Bae
- Phoenix Children's, Division of Pediatric Surgery, 1919 E Thomas Rd, Phoenix, AZ, USA
| | - Ramin Jamshidi
- Phoenix Children's, Division of Pediatric Surgery, 1919 E Thomas Rd, Phoenix, AZ, USA
| | - Katie W Russell
- University of Utah, Department of General Surgery, Division of Pediatric Surgery, Salt Lake City, UT, USA
| | - Dorothy Rowe
- Phoenix Children's, Division of Pediatric Surgery, 1919 E Thomas Rd, Phoenix, AZ, USA
| | - Patrick McGovern
- Phoenix Children's, Division of Pediatric Surgery, 1919 E Thomas Rd, Phoenix, AZ, USA
| | - Mark Molitor
- Phoenix Children's, Division of Pediatric Surgery, 1919 E Thomas Rd, Phoenix, AZ, USA
| | - Kathleen van Leeuwen
- Phoenix Children's, Division of Pediatric Surgery, 1919 E Thomas Rd, Phoenix, AZ, USA
| | - Benjamin E Padilla
- Phoenix Children's, Division of Pediatric Surgery, 1919 E Thomas Rd, Phoenix, AZ, USA
| | - Daniel Ostlie
- Phoenix Children's, Division of Pediatric Surgery, 1919 E Thomas Rd, Phoenix, AZ, USA; Mayo Clinic, Department of General Surgery, 5777 E Mayo Blvd, Phoenix, AZ, USA
| | - Justin Lee
- Phoenix Children's, Division of Pediatric Surgery, 1919 E Thomas Rd, Phoenix, AZ, USA
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Lyttle BD, Williams RF, Stylianos S. Management of Pediatric Solid Organ Injuries. CHILDREN (BASEL, SWITZERLAND) 2024; 11:667. [PMID: 38929246 PMCID: PMC11202015 DOI: 10.3390/children11060667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 05/24/2024] [Accepted: 05/26/2024] [Indexed: 06/28/2024]
Abstract
Solid organ injury (SOI) is common in children who experience abdominal trauma, and the management of such injuries has evolved significantly over the past several decades. In 2000, the American Pediatric Surgical Association (APSA) published the first societal guidelines for the management of blunt spleen and/or liver injury (BLSI), advocating for optimized resource utilization while maintaining patient safety. Nonoperative management (NOM) has become the mainstay of treatment for SOI, and since the publication of the APSA guidelines, numerous groups have evaluated how invasive procedures, hospitalization, and activity restrictions may be safely minimized in children with SOI. Here, we review the current evidence-based management guidelines in place for the treatment of injuries to the spleen, liver, kidney, and pancreas in children, including initial evaluation, inpatient management, and long-term care, as well as gaps that exist in the current literature that may be targeted for further optimization of protocols for pediatric SOI.
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Affiliation(s)
- Bailey D. Lyttle
- Department of Surgery, University of Colorado School of Medicine and Children’s Hospital Colorado, 12631 East 17th Avenue, Room 6111, Aurora, CO 80045, USA;
| | - Regan F. Williams
- Department of Surgery, Le Bonheur Children’s Hospital, 49 North Dunlap Avenue, Second Floor, Memphis, TN 38105, USA;
| | - Steven Stylianos
- Division of Pediatric Surgery, Columbia University Vagelos College of Physicians & Surgeons, Morgan Stanley Children’s Hospital, 3959 Broadway—Rm 204 N, New York, NY 10032, USA
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Eldredge RS, Ochoa B, Notrica D, Lee J. National Management Trends in Pediatric Splenic Trauma - Are We There yet? J Pediatr Surg 2024; 59:320-325. [PMID: 37953159 DOI: 10.1016/j.jpedsurg.2023.10.024] [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: 10/13/2023] [Accepted: 10/14/2023] [Indexed: 11/14/2023]
Abstract
INTRODUCTION Guidelines recommend nonoperative management of blunt splenic injury (BSI) for hemodynamically stable children. The aim of this study was to determine the contemporary national trends of nonoperative management in pediatric BSI. METHODS A retrospective review was preformed utilizing KIDS database between 2012 and 2019. Pediatric BSI cases age ≤16 years were selected for analysis. Patient demographics, severity, and interventions were compared between hospital types. RESULTS 8,296 BSIs were identified, with 74.3% treated at non-pediatric hospitals. Overall, 96.3% of BSI were nonoperative; 2.5% undergoing angioembolization. Rates of splenectomy from 2012 to 2019 remained stable (6.8% versus 7.1% (p = 0.856)). Splenic injuries treated at adult hospitals were more likely to undergo operative management (11.9% versus 4.4%, OR 2.94, p < 0.001) and more likely to undergo angiography (4.8% vs 1.3%, OR 3.133, p < 0.001). On multivariate regression pediatric BSI treated at adult centers were associated with triple the risk of splenectomy (OR 3.50, p < 0.001). Over seven years, high grade BSI treated at children's hospitals increased from 14.6% to 51.7% (p < 0.001) and, splenectomy rates at children's hospitals increased from 1% to 4% (p < 0.001). CONCLUSION More than 70% of pediatric splenic injuries are treated at adult hospitals, however, children's hospitals predominately caring for high-grade BSI. After controlling for confounding factors, children treated at adult centers continue to have 3-fold likelihood of splenectomy. Over the last 7 years, pediatric hospitals have seen a significant rise in their overall splenectomy rate, which may suggest a shift in case severity to children's hospitals. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Treatment study.
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Affiliation(s)
- R Scott Eldredge
- Mayo Clinic, Department of General Surgery, Phoenix, AZ, USA; Phoenix Children's, Division of Pediatric Surgery, Phoenix, AZ, USA
| | - Brielle Ochoa
- Phoenix Children's, Division of Pediatric Surgery, Phoenix, AZ, USA
| | - David Notrica
- Phoenix Children's, Division of Pediatric Surgery, Phoenix, AZ, USA
| | - Justin Lee
- Phoenix Children's, Division of Pediatric Surgery, Phoenix, AZ, USA.
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Moore L, Freire G, Turgeon AF, Bérubé M, Boukar KM, Tardif PA, Stelfox HT, Beno S, Lauzier F, Beaudin M, Zemek R, Gagnon IJ, Beaulieu E, Weiss MJ, Carsen S, Gabbe B, Stang A, Ben Abdeljelil A, Gnanvi E, Yanchar N. Pediatric vs Adult or Mixed Trauma Centers in Children Admitted to Hospitals Following Trauma: A Systematic Review and Meta-Analysis. JAMA Netw Open 2023; 6:e2334266. [PMID: 37721752 PMCID: PMC10507486 DOI: 10.1001/jamanetworkopen.2023.34266] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/10/2023] [Indexed: 09/19/2023] Open
Abstract
Importance Adult trauma centers (ATCs) have been shown to decrease injury mortality and morbidity in major trauma, but a synthesis of evidence for pediatric trauma centers (PTCs) is lacking. Objective To assess the effectiveness of PTCs compared with ATCs, combined trauma centers (CTCs), or nondesignated hospitals in reducing mortality and morbidity among children admitted to hospitals following trauma. Data Sources MEDLINE, Embase, and Web of Science through March 2023. Study Selection Studies comparing PTCs with ATCs, CTCs, or nondesignated hospitals for pediatric trauma populations (aged ≤19 years). Data Extraction and Synthesis This systematic review and meta-analysis was performed following the Preferred Reporting Items for Systematic Review and Meta-analysis and Meta-analysis of Observational Studies in Epidemiology guidelines. Pairs of reviewers independently extracted data and evaluated risk of bias using the Risk of Bias in Nonrandomized Studies of Interventions tool. A meta-analysis was conducted if more than 2 studies evaluated the same intervention-comparator-outcome and controlled minimally for age and injury severity. Subgroup analyses were planned for age, injury type and severity, trauma center designation level and verification body, country, and year of conduct. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to assess certainty of evidence. Main Outcome(s) and Measure(s) Primary outcomes were mortality, complications, functional status, discharge destination, and quality of life. Secondary outcomes were resource use and processes of care, including computed tomography (CT) and operative management of blunt solid organ injury (SOI). Results A total of 56 studies with 286 051 participants were included overall, and 34 were included in the meta-analysis. When compared with ATCs, PTCs were associated with a 41% lower risk of mortality (OR, 0.59; 95% CI, 0.46-0.76), a 52% lower risk of CT use (OR, 0.48; 95% CI, 0.26-0.89) and a 64% lower risk of operative management for blunt SOI (OR, 0.36; 95% CI, 0.23-0.57). The OR for complications was 0.80 (95% CI, 0.41-1.56). There was no association for mortality for older children (OR, 0.71; 95% CI, 0.47-1.06), and the association was closer to the null when PTCs were compared with CTCs (OR, 0.73; 95% CI, 0.53-0.99). Results remained similar for other subgroup analyses. GRADE certainty of evidence was very low for all outcomes. Conclusions and Relevance In this systematic review and meta-analysis, results suggested that PTCs were associated with lower odds of mortality, CT use, and operative management for SOI than ATCs for children admitted to hospitals following trauma, but certainty of evidence was very low. Future studies should strive to address selection and confounding biases.
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Affiliation(s)
- Lynne Moore
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec, Canada
| | - Gabrielle Freire
- Division of Emergency Medicine, Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alexis F. Turgeon
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
- Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Khadidja Malloum Boukar
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
| | - Henry T. Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Suzanne Beno
- Division of Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Marianne Beaudin
- Sainte-Justine Hospital, Department of Paediatric Surgery, Université de Montréal, Montréal, Québec, Canada
| | - Roger Zemek
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Isabelle J. Gagnon
- Division of Pediatric Emergency Medicine, McGill University Health Centre, Montreal Children’s Hospital, Montréal, Québec, Canada
- School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
| | - Emilie Beaulieu
- Département de pédiatrie, Faculté de médecine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Matthew John Weiss
- Centre Mère-Enfant Soleil du CHU de Québec, Transplant Québec, Québec, Québec, Canada
| | - Sasha Carsen
- Division of Orthopaedic Surgery, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Antonia Stang
- Pediatrics, Emergency Medicine, and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Anis Ben Abdeljelil
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
| | - Eunice Gnanvi
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
| | - Natalie Yanchar
- Department of Surgery, University of Calgary, Calgary, Canada
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Austin JR, Ye C, Lee MO, Chao SD. Does shock index, pediatric age-adjusted predict mortality by trauma center type? J Trauma Acute Care Surg 2021; 91:649-654. [PMID: 34559163 DOI: 10.1097/ta.0000000000003197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric trauma patients are treated at adult trauma centers (ATCs), mixed pediatric and ATCs (MTC), or pediatric trauma centers (PTCs). Shock index, pediatric age-adjusted (SIPA) can prospectively identify severely injured children. This study characterized the differences in mortality and hospital length of stay (LOS) among pediatric trauma patients with elevated SIPA (eSIPA) at different trauma centers types. METHODS Pediatric patients (1-14 years) were queried from the 2013 to 2016 National Trauma Data Bank. Patients with eSIPA were included for analysis. The primary outcome was mortality. Secondary outcomes included rates of splenectomy, computed tomography chest scans, laparotomy, and hospital LOS. Unadjusted frequencies and multivariable regression analyses were performed. An alpha level of 0.01 was used to determine significance. RESULTS Out of 189,003 pediatric trauma patients, 15,832 were included for analysis. After controlling for age, race, sex, payment method, Injury Severity Score, Glasgow Coma Scale score, hospital teaching status, and number of hospital beds, there was no significant difference in mortality among eSIPA patients at ATCs (odds ratio [OR], 0.753; p = 0.078) and MTCs (OR, 1.051; p = 0.776) when compared with PTCs. This remained true even among the most severely injured eSIPA patients (Injury Severity Score > 25). Splenectomy rates were higher at ATCs (OR, 3.234; p = 0.005), as were computed tomography chest scan rates (ATC OR, 4.423; p < 0.001; MTC OR, 6.070; p < 0.001) than at PTCs. There was a trend toward higher splenectomy rates at MTCs (OR, 2.910; p = 0.030) compared with PTCs, but this did not reach statistical significance. Laparotomy rates and hospital LOS were not significantly different. CONCLUSION Among eSIPA pediatric trauma patients, there was no difference in mortality between trauma center types. However, other secondary findings indicate that specialty care at PTCs may help optimize the care of pediatric trauma patients. LEVEL OF EVIDENCE Retrospective cohort study, level IV.
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Affiliation(s)
- John R Austin
- From the Division of Pediatric Surgery, Department of Surgery (J.R.A., C.Y., S.D.C.) and Department of Emergency Medicine (M.O.L.), Stanford University School of Medicine, Stanford, California
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Yanchar NL, Lockyer L, Ball CG, Assen S. Pediatric versus adult paradigms for management of adolescent injuries within a regional trauma system. J Pediatr Surg 2021; 56:512-519. [PMID: 32933764 DOI: 10.1016/j.jpedsurg.2020.07.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 07/07/2020] [Accepted: 07/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND We aimed to examine process and outcome indicators for adolescents with specific injury patterns managed in pediatric versus adult paradigms within the same trauma system. METHODS Adolescents (15-17 years old) admitted to the region's adult trauma center (ATC) or pediatric trauma center (PTC) with an abdominal injury, femur fracture or traumatic brain injury (TBI) were reviewed retrospectively. Global and injury-specific process and outcome indicators were compared. RESULTS Of 141 ATC and 69 PTC patients, injury patterns differed significantly with more TBI and abdominal injuries at the ATC and femur fractures at the PTC. Overall injury severity was greater at the ATC. Patients with solid organ injuries appeared more likely to undergo embolization or splenectomy at the ATC; however, higher injury grade and later time period were the only variables significantly associated with this. Computed tomography (CT) was used significantly more frequently at the ATC overall, most notable with panscanning and head CTs for major TBI. Time to operative management did not differ for patients with isolated femur fractures. Neuropsychological follow up after minor TBI was documented more often at the PTC than the ATC; there was no difference for those with more severe TBIs. CONCLUSIONS Management varies for adolescents between PTCs and ATCs with more exposure to radiation and less neuropsychological follow-up of less severe TBIs at the ATC. This presents distinct opportunities to identify best policies for triage and sharing of management practices within a single regional inclusive trauma system in order to optimize short and long-term outcomes for this population. TYPE OF STUDY Retrospective cohort. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Natalie L Yanchar
- Alberta Children's Hospital Trauma Program, 28 Oki Drive NW, Calgary, Alberta, Canada, T3B6A8; Department of Surgery, University of Calgary, 3333 Hospital Drive NW, Calgary, Alberta, Canada, T2N4N1.
| | - Lisette Lockyer
- Alberta Children's Hospital Trauma Program, 28 Oki Drive NW, Calgary, Alberta, Canada, T3B6A8
| | - Chad G Ball
- Foothills Medical Center Trauma Program, 1403 29 St NW, Calgary, Alberta, Canada, T2N2T9; Department of Surgery, University of Calgary, 3333 Hospital Drive NW, Calgary, Alberta, Canada, T2N4N1
| | - Scott Assen
- Department of Surgery, University of Calgary, 3333 Hospital Drive NW, Calgary, Alberta, Canada, T2N4N1
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The adherence of adult trauma centers to American Pediatric Surgical Association guidelines on management of blunt splenic injuries. J Pediatr Surg 2020; 55:1748-1753. [PMID: 32035594 DOI: 10.1016/j.jpedsurg.2020.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 11/20/2019] [Accepted: 01/02/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Nonoperative management (NOM) is commonly utilized in hemodynamically stable children with blunt splenic injuries (BSI). Guidelines published by the American Pediatric Surgical Association over the past 15 years support this approach. We sought to determine the rates and outcomes of NOM in pediatric BSI and compare trends between pediatric (PTC), mixed (MTC) and adult trauma centers (ATC). METHODS This was a retrospective database analysis of the NTDB data from 2011 to 2015 including pediatric patients with BSI, as described by ICD-9-CM Codes 865.00-865.09. Patients with head injuries with AIS > 2, multiple intraabdominal injuries, and transfers-out were excluded. According to ACS and/or state designation, trauma facilities were defined as PTC (level I/II pediatric only), MTC (level I/II adult and pediatric) and ATC (level I/II adult only). OM group was defined as presence of procedure codes reflecting exploratory laparotomy/laparoscopy and/or any splenic procedures. NOM group consisted of patients who were observed, transfused or had transarterial embolization (TAE). Variables analyzed were age, ISS, spleen AIS, amount and type of blood products transfused, and intensive care unit (ICU) and hospital (H) length of stay (LOS). RESULTS 5323 children met the inclusion criteria. 11.4% received care at PTC (NOM, 97%), 40.7% at MTC (NOM, 89.9%) and 47.8% at ATC (NOM, 83.8%) (P < 0.001). In NOM group, PTC patients had the highest spleen AIS (3.46 ± 0.95, P < 0.001). TAE was predominantly used at MTC and ATC (P = 0.001). MTC and ATC were more likely to transfuse than PTC (P = 0.002). MTC and ATC OM rates were lower in children aged ≤12 than in children aged >12 (P < 0.001). Splenectomy rate was 1.5% at PTC, 8.4% at MTC, and 14.4% at ATC (P < 0.001). In OM group, PTC patients had a higher ISS (P = 0.018) and spleen AIS (P = 0.048) than both MTC and ATC. The proportion of patients treated by NOM at ATC increased during the 5-year period studied (P = 0.015). Treatment at MTC or ATC increased the risk for OM by 3.89 and 5.36 times respectively (P < 0.001). CONCLUSIONS PTCs still outperform ATCs in NOM success rates despite higher ISS and splenic injury grades. From 2011 to 2015, ATC OM rates dropped from 17% to 12.4% suggesting increased adoption of the APSA guidelines. Further educational initiatives may help augment this trend. LEVEL OF EVIDENCE II TYPE OF STUDY: Retrospective.
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Candy S, Schuurman N, MacPherson A, Schoon R, Rondeau K, Yanchar NL. "Who is the right patient?" Insights into decisions to transfer pediatric trauma patients. J Pediatr Surg 2020; 55:930-937. [PMID: 32063372 DOI: 10.1016/j.jpedsurg.2020.01.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 01/25/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We aim to determine what variables may influence physician decision-making about transfer of pediatric patients from a Level III Trauma Center (L3TC) to a Pediatric Trauma Center (PTC). METHODS Emergency L3TC physicians and PTC emergency physicians/TTLs were surveyed with clinical scenarios of children presenting to a L3TC with 5 injury parameters: age, hemodynamic status, GCS, intra-abdominal injury, femur/ pelvic fracture, and asked if the patient should be transferred to a PTC. Associations between parameters and physician demographics in the decision to transfer were examined. RESULTS One hundred seven and 94 surveys were completed at L3TCs and PTCs, respectively. Parameters associated with decision to transfer: pelvic and GI tract injuries, GCS < 12, and age < 4 years. L3TCs were significantly less likely vs. PTCs to recommend transfer with femur fracture, solid organ / GI injury, or a GCS of <13. Increasing town size, access to an experienced surgeon, and formal training in emergency medicine among L3TC physicians were associated with a decision not to transfer. CONCLUSIONS Injuries requiring potential surgery or critical care influenced the decision to transfer. For cases with lesser severity or older ages, input of L3TCs on developing triage criteria is vital to allow families to stay in their home communities while ensuring optimal clinical outcomes. TYPE OF STUDY Prospective Cross Sectional Survey. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Sydney Candy
- Queen's University, School of Medicine, Kingston, ON, Canada; University of Calgary, Department of Surgery, Calgary, AB, Canada
| | - Nadine Schuurman
- Simon Fraser University, Department of Geography, Vancouver, BC, Canada
| | - Alison MacPherson
- York University, Faculty of Kinesiology and Health Sciences, Toronto, ON, Canada
| | | | - Kimberly Rondeau
- University of Calgary, Department of Surgery, Calgary, AB, Canada
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Stylianos S. To save a child's spleen: 50 years from Toronto to ATOMAC. J Pediatr Surg 2019; 54:9-15. [PMID: 30404720 DOI: 10.1016/j.jpedsurg.2018.10.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 10/01/2018] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Steven Stylianos
- Division of Pediatric Surgery, Columbia University Vagelos College of Physicians & Surgeons, Morgan Stanley Children's Hospital, 3959 Broadway - Rm 204 N, New York, NY 10032.
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10
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Yang K, Li Y, Wang C, Xiang B, Chen S, Ji Y. Clinical features and outcomes of blunt splenic injury in children: A retrospective study in a single institution in China. Medicine (Baltimore) 2017; 96:e9419. [PMID: 29390566 PMCID: PMC5758268 DOI: 10.1097/md.0000000000009419] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Although the spleen is the most commonly injured intra-abdominal organ after blunt trauma, there are limited data available in China. The objectives of this study were to investigate the clinical features and determine the risk factors for operative management (OM) in children with blunt splenic injury (BSI).A review of the medical records of children diagnosed with BSI between January 2010 and September 2016 at West China Hospital of Sichuan University was performed.A total of 101 patients diagnosed with BSI were recruited, including 76 patients transferred from other hospitals. The male-to-female ratio was 2.06:1, with a mean age of 7.8 years old. The most common injury season was summer and the most common injury mechanism was road traffic accidents. Sixty-eight patients suffered multiple injuries. Thirty-four patients received blood transfusions. Two patients died from multiple organ failure or hemorrhagic shock. Significant differences were observed in the injury season, injury mechanism, injury date, and hemoglobin levels between the isolated injury group and the multiple injuries group. The overall operative rate was 29.7%. Multivariate regression analysis revealed that age, blood transfusion, and grade of injury were independent risk factors for OM.Our study provided evidence that the management of pediatric BSI was variable. The operative rate in pediatric BSI may be higher in certain patient groups. Although nonoperative management is one of the standard treatment options, our data suggest that OM is an appropriate way to treat patients who are hemodynamically unstable.
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Affiliation(s)
- Kaiying Yang
- Division of Oncology, Department of Pediatric Surgery
| | - Yanan Li
- Division of Oncology, Department of Pediatric Surgery
| | - Chuan Wang
- Division of Oncology, Department of Pediatric Surgery
| | - Bo Xiang
- Division of Oncology, Department of Pediatric Surgery
| | - Siyuan Chen
- Pediatric Intensive Care Unit, Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Yi Ji
- Division of Oncology, Department of Pediatric Surgery
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Association between pediatric blunt splenic injury volume and the splenectomy rate. J Pediatr Surg 2017; 52:1816-1821. [PMID: 28404218 DOI: 10.1016/j.jpedsurg.2017.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 01/06/2017] [Accepted: 02/11/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND/PURPOSE While pediatric trauma centers are shown to have lower splenectomy rate as compared to adult trauma centers, it remains unknown whether other institutional factors such as case volumes would have an impact on the splenectomy rate in pediatric blunt splenic injury (BSI). METHODS Pediatric patients who sustained BSI were identified from the National Trauma Data Bank 2007-2014. A hierarchical logistic regression model was built to evaluate differences in risk-adjusted splenectomy rate and in-hospital mortality in between trauma centers with different pediatric BSI case volumes. RESULTS A total of 7621 children who met criteria were treated at trauma centers with different pediatric BSI case volumes (0-60, 61-120, 121-180, 181-240 cases during 2007-2014 for Group 1, 2, 3, and 4, respectively). High volume centers were shown to have decreased splenectomy rates (odds ratios [OR] 0.50 and 0.64, 95% confidence intervals [CI] 0.30-0.83, 0.44-0.95 for Groups 3 and 4, respectively) with an additional survival benefit in Group 4 (OR 0.452, 95%CI 0.257-0.793) when compared to the lowest volume centers (Group 1). CONCLUSIONS Higher pediatric BSI case volume was associated with lower splenectomy rate with an additional survival benefit. Trauma centers' volume in pediatric BSI may be an important factor for the improved splenic preservation. LEVEL OF EVIDENCE Retrospective comparative study, Level III.
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Jabbour G, Al-Hassani A, El-Menyar A, Abdelrahman H, Peralta R, Ellabib M, Al-Jogol H, Asim M, Al-Thani H. Clinical and Radiological Presentations and Management of Blunt Splenic Trauma: A Single Tertiary Hospital Experience. Med Sci Monit 2017; 23:3383-3392. [PMID: 28700540 PMCID: PMC5519223 DOI: 10.12659/msm.902438] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 01/10/2017] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Splenic injury is the leading cause of major bleeding after blunt abdominal trauma. We examined the clinical and radiological presentations, management, and outcome of blunt splenic injuries (BSI) in our institution. MATERIAL AND METHODS A retrospective study of BSI patients between 2011 and 2014 was conducted. We analyzed and compared management and outcome of different splenic injury grades in trauma patients. RESULTS A total of 191 BSI patients were identified with a mean (SD) age of 26.9 years (13.1); 164 (85.9%) were males. Traffic-related accident was the main mechanism of injury. Splenic contusion and hematoma (77.2%) was the most frequent finding on initial computerized tomography (CT) scans, followed by shattered spleen (11.1%), blush (11.1%), and devascularization (0.6%). Repeated CT scan revealed 3 patients with pseudoaneurysm who underwent angioembolization. Nearly a quarter of patients were managed surgically. Non-operative management failed in 1 patient who underwent splenectomy. Patients with grade V injury presented with higher mean ISS and abdominal AIS, required frequent blood transfusion, and were more likely to be FAST-positive (p=0.001). The majority of low-grade (I-III) splenic injuries were treated conservatively, while patients with high-grade (IV and V) BSI frequently required splenectomy (p=0.001). Adults were more likely to have grade I, II, and V BSI, blood transfusion, and prolonged ICU stay as compared to pediatric BSI patients. The overall mortality rate was 7.9%, which is mainly association with traumatic brain injury and hemorrhagic shock; half of the deaths occurred within the first day after injury. CONCLUSIONS Most BSI patients had grade I-III injuries that were successfully treated non-operatively, with a low failure rate. The severity of injury and presence of associated lesions should be carefully considered in developing the management plan. Thorough clinical assessment and CT scan evaluation are crucial for appropriate management of BSI.
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Affiliation(s)
- Gaby Jabbour
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | | | - Ayman El-Menyar
- Department of Surgery, Trauma Surgery, Clinical Research, Hamad Medical Corporation, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | | | - Ruben Peralta
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Ellabib
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Hisham Al-Jogol
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Mohammad Asim
- Department of Surgery, Trauma Surgery, Clinical Research, Hamad Medical Corporation, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
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Adams SE, Holland A, Brown J. Management of paediatric splenic injury in the New South Wales trauma system. Injury 2017; 48:106-113. [PMID: 27866649 DOI: 10.1016/j.injury.2016.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/24/2016] [Accepted: 11/04/2016] [Indexed: 02/02/2023]
Abstract
UNLABELLED Since the 1980's, paediatric surgeons have increasingly managed blunt splenic injury (BSI) in children non-operatively. However, studies in North America have shown higher operation rates in non-paediatric centres and by adult surgeons. This association has not been examined elsewhere. OBJECTIVE To investigate the management of BSI in New South Wales (NSW) children, to determine the patient and hospital factors related to the odds of operation. Secondarily, to investigate whether the likelihood of operation varied by year. METHODS Children age 0-16 admitted to a NSW hospital between July 2000 and December 2011 with a diagnosis of BSI were identified in the NSW Admitted Patient Data Collection, and linked to deaths data from Registry of Births Deaths and Marriages, and Bureau of Statistics. The operation rate was calculated and compared between different hospital types. Univariable analysis was used to determine patient and hospital factors associated with operative management. The difference in the odds of operation between the oldest data (July 2000-December 2005) and most recent (January 2006-December 2011) was also examined. Multivariable logistic regression with stepwise elimination was then performed to determine likelihood of operative management according to hospital category and era, adjusting for potential confounders. RESULTS 955 cases were identified, with 101(10.6%) managed operatively. On multivariable analysis, factors associated with operation included age (OR 1.11, 95% CI 1.01-1.18, p<0.05), massive splenic disruption (OR 3.10, 95% CI 1.61-6.19, p<0.001), hollow viscus injury (OR 11.03, 95% CI 3.46-34.28, p<0.001) and transfusion (OR 7.70, 95% CI 4.54-13.16, p<0.001). Management outside a paediatric trauma centre remained significantly associated with operation, whether it be metropolitan adult trauma centre (OR 4.22 95% CI 1.70-10.52, p<0.01), rural trauma centre (OR 3.72 95% CI 1.83-7.83, p<0.001) or metropolitan local hospital (OR 5.23, 95% CI 1.22-18.93 p<0.05). Comparing the 2 eras, the overall operation rate fell, although not significantly, from 12.9% to 8.7% (OR 1.3, 95% CI 0.89-243 p=0.13) CONCLUSION: While Paediatric Surgeons have wholeheartedly adopted non-operative management, away from paediatric centres, children in NSW are still being operated on for BSI unnecessarily. While the factors at play may be complex, further evaluation of the management and movement of injured children within the broad NSW trauma system is required.
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Affiliation(s)
- Susan E Adams
- Department Paediatric Surgery, Sydney Children's Hospital, Randwick, NSW, Australia; School of Women's and Children's Health, University of NSW, Kensington, NSW, 2033, Australia; Neuroscience Research Australia (NeuRA), Randwick, NSW, 2031, Australia; School of Medical Science, University of NSW, Kensington, NSW, 2033, Australia.
| | - Andrew Holland
- Department of Academic Surgery, Royal Alexandria Hospital for Children, Westmead, NSW, 2145, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, NSW, 2006, Australia
| | - Julie Brown
- Neuroscience Research Australia (NeuRA), Randwick, NSW, 2031, Australia; School of Medical Science, University of NSW, Kensington, NSW, 2033, Australia
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Walther AE, Falcone RA, Pritts TA, Hanseman DJ, Robinson BR. Pediatric and adult trauma centers differ in evaluation, treatment, and outcomes for severely injured adolescents. J Pediatr Surg 2016; 51:1346-50. [PMID: 27132539 PMCID: PMC5558261 DOI: 10.1016/j.jpedsurg.2016.03.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 03/06/2016] [Accepted: 03/29/2016] [Indexed: 10/24/2022]
Abstract
BACKGROUND/PURPOSE This study aims to investigate differences in imaging, procedure utilization, and clinical outcomes of severely injured adolescents treated at adult versus pediatric trauma centers. METHODS The National Trauma Data Bank was queried retrospectively for adolescents, 15-19years old, with a length of stay (LOS) >1day and Injury Severity Score (ISS) >25 treated at adult (ATC) or pediatric (PTC) Level 1 trauma centers from 2007 to 2011. Patient demographics and utilization of imaging and procedures were analyzed. Univariate and multivariate regression analysis was used to compare outcomes. RESULTS Of 12,861 adolescents, 51% were treated at ATC. Older age and more nonwhites were seen at ATC (p<0.01). Imaging and invasive procedures were more common at ATC (p<0.01). Shorter LOS (p=0.03) and higher home discharge rates (p<0.01) were seen at PTC. ISS and mortality did not differ. Age, race, ATC care (all p<0.01), and admission systolic blood pressure (SBP) (p=0.03) were predictors of CT utilization. ISS, SBP, and race (p<0.01) were risk factors for overall mortality; SBP (p=0.03) and ISS (p<0.01) predicted death from penetrating injury. CONCLUSIONS Severely injured adolescents experience improved outcomes and decreased imaging and invasive procedures without additional mortality risk when treated at PTC. PTC is an appropriate destination for severely injured adolescents.
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Affiliation(s)
- Ashley E. Walther
- Division of Trauma and Critical Care, Department of Surgery, University of Cincinnati College of Medicine, USA
| | - Richard A. Falcone
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Department of Surgery, University of Cincinnati College of Medicine, USA
| | - Timothy A. Pritts
- Division of Trauma and Critical Care, Department of Surgery, University of Cincinnati College of Medicine, USA
| | - Dennis J. Hanseman
- Division of Trauma and Critical Care, Department of Surgery, University of Cincinnati College of Medicine, USA
| | - Bryce R.H. Robinson
- Division of Trauma, Critical Care, and Burns, Department of Surgery, University of Washington, USA,Corresponding author at: Department of Surgery, Box 359796, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA, 98104-2499, USA. Tel.: +1 206 744 8485; fax: +1 206 744 3656
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15
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McCarthy A, Curtis K, Holland AJA. Paediatric trauma systems and their impact on the health outcomes of severely injured children: An integrative review. Injury 2016; 47:574-85. [PMID: 26794709 DOI: 10.1016/j.injury.2015.12.028] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 12/18/2015] [Accepted: 12/22/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Injury is a leading cause of death and disability for children. Regionalised trauma systems have improved outcomes for severely injured adults, however the impact of adult orientated trauma systems on the outcomes of severely injured children remains unclear. AIMS This research aims to identify the impact of trauma systems on the health outcomes of children following severe injury. METHODS Integrative review with data sourced from Medline, Embase, CINAHL, Scopus and hand searched references. Abstracts were screened for inclusion/exclusion criteria with fifty nine articles appraised for quality, analysed and synthesised into 3 main categories. RESULTS The key findings from this review include: (1) a lack of consistency of prehospital and inhospital triage criteria for severely injured children leading to missed injuries, secondary transfer and poor utilisation of finite resources; (2) severely injured children treated at paediatric trauma centres had improved outcomes when compared to those treated at adult trauma centres, particularly younger children; (3) major causes of delays to secondary transfer are unnecessary imaging and failure to recognise the need for transfer; (4) a lack of functional or long term outcomes measurements identified in the literature. CONCLUSIONS Research designed to identify the best processes of care and describe the impacts of trauma systems on the long term health outcomes of severely injured children is required. Ideally all phases of care including prehospital, paediatric triage trauma criteria, hospital type and interfacility transfer should be included, focusing on timeliness and appropriateness of care. Outcome measures should include long term functional outcomes in addition to mortality.
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Affiliation(s)
- Amy McCarthy
- Sydney Nursing School, The University of Sydney, NSW, Australia; Wollongong Hospital, Wollongong, NSW, Australia.
| | - Kate Curtis
- Sydney Nursing School, The University of Sydney, NSW, Australia; St George Hospital, Kogarah, NSW, Australia
| | - Andrew J A Holland
- Discipline of Paediatrics and Child Health, The Children's Hospital at Westmead Clinical School, Sydney Medical School, The University of Sydney, NSW, Australia; The Children's Hospital at Westmead Burns Research Institute, NSW, Australia
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17
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Bairdain S, Litman HJ, Troy M, McMahon M, Almodovar H, Zurakowski D, Mooney DP. Twenty-years of splenic preservation at a level 1 pediatric trauma center. J Pediatr Surg 2015; 50:864-8. [PMID: 25783335 DOI: 10.1016/j.jpedsurg.2014.08.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 08/16/2014] [Accepted: 08/19/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Splenic preservation is the standard of care for hemodynamically stable children with splenic injuries. We report a 20-year single-institutional series of children with splenic injuries managed without a splenectomy. METHODS Children evaluated and treated for blunt splenic injury at Boston Children's Hospital from 1994 to 2014 were extracted from the trauma registry. Demographics, clinical characteristics, complications, and outcomes were reviewed. Three time-periods were evaluated based upon the development and modification of splenic injury clinical pathway guidelines (CPGs). Survival was defined as being discharged from the hospital alive. RESULTS 502 suffered isolated splenic injuries. The median AAST grade of splenic injury increased across the three CPG time periods (p<0.001). No splenic-injury related mortalities occurred. Hospital length of stay decreased significantly secondary to splenic injury CPGs (p<0.001). 99% of the patients were discharged home. CONCLUSION In children managed over the last 20years for isolated splenic injury, no patient died or underwent splenectomy. Hospital length of stay decreased across time, despite an increase in the severity of splenic injuries encountered. Splenectomy has become so unusual in the management of hemodynamically stable children with a splenic injury that it may no longer be a legitimate outcome marker.
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Affiliation(s)
- Sigrid Bairdain
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA.
| | - Heather J Litman
- Clinical Research Center, Boston Children's Hospital, Boston, MA, USA
| | - Michael Troy
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Maria McMahon
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Heidi Almodovar
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA; Department of Anesthesia, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - David P Mooney
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
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Fernandes TM, Dorigatti AE, Pereira BMT, Cruvinel Neto J, Zago TM, Fraga GP. Nonoperative management of splenic injury grade IV is safe using rigid protocol. Rev Col Bras Cir 2014; 40:323-9. [PMID: 24173484 DOI: 10.1590/s0100-69912013000400012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 10/18/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To demonstrate the protocol and experience of our service in the nonoperative management (NOM) of grade IV blunt splenic injuries. METHODS This is a retrospective study based on trauma registry of a university hospital between 1990-2010. Charts of all patients with splenic injury were reviewed and patients with grade IV lesions treated nonoperatively were included in the study. RESULTS ninety-four patients with grade IV blunt splenic injury were admitted during this period. Twenty-six (27.6%) met the inclusion criteria for NOM. The average systolic blood pressure on admission was 113.07 ± 22.22 mmHg, RTS 7.66 ± 0.49 and ISS 18.34 ± 3.90. Ten patients (38.5%) required blood transfusion, with a mean of 1.92 ± 1.77 packed red cells per patient. Associated abdominal injuries were present in two patients (7.7%). NOM failed in two patients (7.7%), operated on due to worsening of abdominal pain and hypovolemic shock. No patient developed complications related to the spleen and there were no deaths in this series. Average length of hospital stay was 7.12 ± 1.98 days. CONCLUSION Nonoperative treatment of grade IV splenic injuries in blunt abdominal trauma is safe when a rigid protocol is followed.
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Grimsby GM, Voelzke B, Hotaling J, Sorensen MD, Koyle M, Jacobs MA. Demographics of pediatric renal trauma. J Urol 2014; 192:1498-502. [PMID: 24907442 DOI: 10.1016/j.juro.2014.05.103] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE There is a lack of national data describing the demographics and nature of pediatric renal trauma. We used the National Trauma Data Bank to analyze mechanisms and grades of injury, demographics and treatment characteristics of pediatric renal trauma cases. MATERIALS AND METHODS Renal injuries were identified by Abbreviated Injury Scale codes and converted to American Association for the Surgery of Trauma renal injury grades. Patients were stratified by age (0 to 1, 2 to 4, 5 to 14 and 15 to 18 years) for more specific analyses of mechanisms and grades of injury. Data reviewed included mechanisms and grades of renal injury, demographics, and setting and type of treatment. RESULTS A total of 2,213 pediatric renal injuries were converted to American Association for the Surgery of Trauma grade. Mean ± SD age at injury was 13.7 ± 4.4 years, with 2,089 patients (94%) being 5 to 18 years old. Of the injuries 79% were grade I, II or III. Penetrating injury accounted for less than 10% of all pediatric renal injuries. A majority of patients (57%) were admitted to university hospitals with a dedicated trauma service (73%) and only 12% of patients were admitted to a pediatric hospital. A total of 122 nephrectomies (5.5%) were performed. CONCLUSIONS Most renal trauma in children is low grade, is blunt in nature and occurs after age 5 years. The majority of these cases are managed at adult hospitals. Although most patients are treated conservatively, the rate of nephrectomy is 3 times higher at adult hospitals than at pediatric centers.
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Affiliation(s)
- Gwen M Grimsby
- Division of Pediatric Urology, Department of Urology, UT Southwestern Medical Center, Dallas, Texas
| | - Bryan Voelzke
- Department of Urology, University of Washington School of Medicine, Seattle, Washington
| | - James Hotaling
- Center for Reconstructive Urology and Men's Health, University of Utah, Salt Lake City, Utah
| | - Mathew D Sorensen
- Department of Urology, University of Washington School of Medicine, Seattle, Washington; Division of Urology, Department of Veterans Affairs Medical Center, Seattle, Washington
| | - Martin Koyle
- University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Micah A Jacobs
- Division of Pediatric Urology, Department of Urology, UT Southwestern Medical Center, Dallas, Texas.
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Hsiao M, Sathya C, de Mestral C, Langer JC, Gomez D, Nathens AB. Population-based analysis of blunt splenic injury management in children: operative rate is an informative quality of care indicator. Injury 2014; 45:859-63. [PMID: 24405973 DOI: 10.1016/j.injury.2013.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 11/27/2013] [Accepted: 12/06/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND In hemodynamically normal children with blunt splenic injury (BSI), the standard of care is non-operative management. Several studies have reported that non-paediatric and non-trauma centres have higher operative rates in children with BSI compared to paediatric hospitals and trauma centres. We investigate the feasibility of using operative rate for BSI as a quality of care indicator. METHODS We performed a population-based retrospective cohort study of children (≤18 years) with BSI admitted to all acute-care hospitals in Canada from 2001 to 2010. The main outcome was rate of operative management for BSI. Hierarchical multivariable logistic regression models were constructed to evaluate the relationship between operative rate and different hospital types (paediatric or non-paediatric, trauma or non-trauma). These models also allowed for generation of hospital-level observed to expected (O/E) ratios for rate of operative management. RESULTS We identified 3122 children with BSI. The majority (74%) were isolated splenic injuries and the grade of splenic injury was specified in 45% of cases (n=1391, 38% grade I or II; 62% grade III, IV, or V). The overall operative rate was 11% (n=315), of which 9% were total splenectomy and 2% were spleen-preserving operations. After adjusting for age, gender, mechanism of injury, splenic injury grade, ISS, and centre volume, admission to non-paediatric hospitals was associated with a higher probability of operative management (OR 7.6, 95% CI 2.4-24.4), whereas there was no significant difference in operative management between trauma and non-trauma centres (OR 1.6, 95% CI 0.8-3.2). Outlier status based on O/E ratio was determined to identify centres with higher or lower than expected operative rates. CONCLUSIONS The operative rates for children with BSI are significantly higher in non-paediatric hospitals. In these hospitals that do not routinely care for children and have higher than expected operative rates, we have used operative rate for BSI as a quality of care indicator and identified opportunities for quality improvement initiatives. LEVEL OF EVIDENCE III, Retrospective comparative study.
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Affiliation(s)
- Marvin Hsiao
- Division of General Surgery, Department of Surgery, University of Toronto, Canada.
| | - Chethan Sathya
- Division of General Surgery, Department of Surgery, University of Toronto, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Canada.
| | - Charles de Mestral
- Division of General Surgery, Department of Surgery, University of Toronto, Canada.
| | - Jacob C Langer
- Division of General Surgery, Department of Surgery, University of Toronto, Canada; Division of General and Thoracic Surgery, Hospital for Sick Children, Canada.
| | - David Gomez
- Division of General Surgery, Department of Surgery, University of Toronto, Canada.
| | - Avery B Nathens
- Division of General Surgery, Department of Surgery, University of Toronto, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Canada; Division of General Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Canada; Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Canada.
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