Is early discharge following isolated splenic injury in the hemodynamically stable child possible?

Minimizing variance in Care of Pediatric Blunt Solid Organ Injury through Utilization of a hemodynamic-driven protocol: a multi-institution study

BACKGROUND

An expedited recovery protocol for management of pediatric blunt solid organ injury (spleen, liver, and kidney) was instituted across two Level 1 Trauma Centers, managed by nine pediatric surgeons within three hospital systems.

METHODS

Data were collected for 18months on consecutive patients after protocol implementation. Patient demographics (including grade of injury), surgeon compliance, National Surgical Quality Improvement Program (NSQIP) complications, direct hospital cost, length of stay, time in the ICU, phlebotomy, and re-admission were compared to an 18-month control period immediately preceding study initiation.

RESULTS

A total of 106 patients were treated (control=55, protocol=51). Demographics were similar among groups, and compliance was 78%. Hospital stay (4.6 vs. 3.5days, p=0.04), ICU stay (1.9 vs. 1.0days, p=0.02), and total phlebotomy (7.7 vs. 5.3 draws, p=0.007) were significantly less in the protocol group. A decrease in direct hospital costs was also observed ($11,965 vs. $8795, p=0.09). Complication rates (1.8% vs. 3.9%, p=0.86, no deaths) were similar.

CONCLUSIONS

An expedited, hemodynamic-driven, pediatric solid organ injury protocol is achievable across hospital systems and surgeons. Through implementation we maintained quality while impacting length of stay, ICU utilization, phlebotomy, and cost. Future protocols should work to further limit resource utilization.

TYPE OF STUDY

Retrospective cohort study.

LEVEL OF EVIDENCE

Level II.

Splenic trauma: WSES classification and guidelines for adult and pediatric patients

Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.

Can we safely decrease intensive care unit admissions for children with high grade isolated solid organ injuries? Using the shock index, pediatric age-adjusted and hematocrit to modify APSA admission guidelines

BACKGROUND

In 2000, the American Pediatric Surgical Association (APSA) disseminated consensus practice guidelines for the management of blunt liver and splenic injury which included intensive care unit (ICU) admission for children with grade IV injuries. We sought to determine if we could better predict which children with isolated solid organ injuries (SOI) underwent an ICU-level intervention, thus necessitating ICU admission.

METHODS

Children with isolated liver, spleen, or kidney injuries admitted to the ICU from November 2003 to August 2015 were identified in our trauma registry, and data were extracted from the medical record. ICU-level interventions were defined as transfusion, vasopressor use, intubation, and operative/procedural intervention. Shock index and pediatric age-adjusted (SIPA) was calculated for all patients. The sensitivity and negative predictive values (NPV) were determined.

RESULTS

133 children met inclusion criteria. 19 (14.3%) required ICU-level intervention, and 114 (85.1%) did not. 95% (n=18) of the intervention group had either an elevated SIPA or a hematocrit <30% on admission compared to 22% (n=25) of patients in the no intervention group. Sensitivity was 95%, and NPV was 99%.

CONCLUSIONS

Limiting ICU admission in children with isolated SOI to those with an elevated SIPA or hematocrit <30% would reduce the ICU admission rate by two-thirds while maintaining patient safety.

TYPE OF STUDY

Diagnostic study.

LEVEL OF EVIDENCE

III.

Factors predicting the need for splenectomy in children with blunt splenic trauma

BACKGROUND/PURPOSE

Non-operative management of blunt splenic trauma (BST) in children is the standard of care with a success rate of greater than 90%. This paper aims to determine the factors which could predict the need for operative intervention in children with BST.

METHODS

Prospectively entered data of 69 children with BST, between 1997 and 2008, from a single tertiary level trauma centre, were retrospectively analysed. A radiologist blinded to the outcome reviewed all computed tomography scans retrospectively.

RESULTS

Forty-two children had isolated BST (61%) and 27 children had associated injuries (39%). All except one survived the injury and non-operative treatment was successful in 91%. Six of the 69 children (9%) with BST underwent splenectomy. There was no independent correlation to age, gender, mechanism of injury (MOI), injury grade and the need for splenectomy, whereas haemodynamic instability within 6 h of injury defined as failed resuscitation had a 100% correlation.

CONCLUSION

Haemodynamic instability, which failed to respond to resuscitation within 6 h, predicted the need for splenectomy in children with BST. Splenic injury grade assessed by computed tomography scan does not predict the need for splenectomy.

Throwing out the "grade" book: management of isolated spleen and liver injury based on hemodynamic status

PURPOSE

Current organizational guidelines for the management of isolated spleen and liver injuries are based on injury grade. We propose that management based on hemodynamic status is safe in children and results in decreased length of stay (LOS) and resource use compared to current grade-based guidelines.

METHODS

Patients with spleen or liver injuries for a 5-year period were identified using our institutional trauma registry. All patients were managed using a pathway based on hemodynamic status. Charts were reviewed for demographics, mechanism, hematrocrit values, transfusion requirement, imaging, injury grade, LOS, and outcome. Exclusion criteria included penetrating mechanism, associated injuries altering LOS or ambulation status, combined spleen/liver injury, initial operative management or death. Statistical comparison was performed using Student's t test; P < .05 is significant.

RESULTS

One hundred one patients (50 spleen, 51 liver) meeting inclusion criteria were identified. Average actual LOS for all patients was 1.9 days vs 3.2 projected days based on American Pediatric Surgical Association guidelines (P < .0001). Actual vs projected LOS for grades III to V was 2.5 vs 4.3 days (P < .0001). All patients returned to full activity without complication.

CONCLUSIONS

Isolated blunt spleen and liver injuries, regardless of grade, can be safely managed using a pathway based on hemodynamic status, resulting in decreased LOS and resource use compared to current guidelines.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Survey of EAST Member Practices in Blunt Splenic Injury: A Description of Current Trends and Opportunities for Improvement

BACKGROUND

The literature on blunt splenic trauma provides little evidence-based direction for nonsurgical management. The appropriate role of computed tomography (CT) after initial diagnosis, activity restriction and follow-up are continuing controversies.

METHODS

Active EAST members were surveyed regarding in-hospital management and follow-up of patients with isolated and near-isolated blunt splenic injury. Analyses were performed using descriptive and correlational statistics.

RESULTS

A 38.4% response rate was obtained. 82.6% of respondents practiced at a Level I trauma centers. 97% of respondents considered hemodynamic instability as the primary indication for immediate splenectomy. 71.6% of respondents preferred ultrasound for initial imaging in hemodynamically stable patients. One-third of respondents admitted stable Grade I patients to monitored settings. 85.5% would not routinely perform predischarge abdominal CT scan in the absence of clinical deterioration, extravasation on initial CT or high-grade injury. Activity restriction varied by grade (table). The majority of respondents (78.1%) relied on clinical judgment alone for activity recommendations in lower grades of injury while a higher reliance on CT was used for Grades IV and V (49.8%).

CONCLUSIONS

Despite the lack of evidence-based guidelines, many in-hospital and follow-up practices were reasonably consistent. However, some important contradictions were noted (such as monitoring very low risk patients and not intervening in patients with contrast blush). Activity restrictions were usually based on clinical judgment supplemented by CT at the highest grades of injury. Lack of evidence-based guidelines and high reliance on clinical judgment underscore the need for a well-designed prospective study to define optimal management and follow-up.

Pediatric splenic injuries with a contrast blush: successful nonoperative management without angiography and embolization

BACKGROUND

The presence of a contrast blush on computed tomography (CT) in adult splenic trauma is a risk factor for failure of nonoperative management. Arterial embolization is believed to reduce this failure rate. The significance of a blush in pediatric trauma is unknown. The authors evaluated the outcome of children with blunt splenic trauma and contrast extravasation.

METHODS

The trauma registry was queried for all pediatric patients with blunt splenic injuries. Admission CT was reviewed for injury grade and presence of an arterial blush by a radiologist blinded to patient outcome. Hospital and office charts were reviewed for success of nonoperative management, late splenic rupture, and other complications.

RESULTS

One hundred seven children with blunt splenic trauma were identified over a 6-year period. Mean injury grade was 2.9. Six patients required emergency splenectomy. An additional 7 patients met hemodynamic criteria for surgical intervention (3 splenectomies, 4 splenorrhaphies). Admission CT was available in 63 patients. An arterial blush was identified in 5 (9.7%). Four remained stable and were treated conservatively. One underwent splenectomy for hemodynamic instability. There were no cases of delayed splenic rupture, failed nonoperative treatment, or long-term complications.

CONCLUSIONS

Contrast blush in children with blunt splenic trauma is rare, and its presence alone does not appear to predict delayed rupture or failure of nonoperative treatment. Based on this limited series, splenic artery embolization does not have a place in the management of splenic injuries in children.

Pleuro-pulmonary involvement in children with blunt splenic trauma

OBJECTIVE

Evaluation of the importance of pleuro-pulmonary involvement in paediatric patients with blunt splenic trauma.

METHOD

A retrospective chart review of 27 patients, aged 2-16 years, treated for blunt splenic injury between 1992 and 1999 was performed.

RESULTS

All patients except one were treated conservatively. In 12 patients (44.4%) left-sided pleuro-pulmonary involvement was diagnosed as primary traumatic injury or as a late complication. While Grade I and II splenic injuries were prevalent, pleuro-pulmonary involvement patients had a more severe degree of splenic injury. Chest pain, dyspnoea and diminished respiratory sounds were present on primary examination in patients with chest trauma. Body temperature during the first 5 post-trauma days was significantly higher among pleuro-pulmonary involvement patients. Specific pleuro-pulmonary involvement diagnoses on admission in six children with primary chest trauma were: lung contusion, pleural thickness, or haemo-pneumothorax. Three of them developed delayed pleural effusion. In the other six children with pleuro-pulmonary involvement, late complications appeared during 2-5 days post-trauma.

CONCLUSIONS

Pleuro-pulmonary involvement was observed in almost half of patients with blunt splenic trauma. Pleuro-pulmonary involvement occurred either early as a result of direct chest trauma or was delayed. High suspicion, careful monitoring of body temperature and repeated chest X-ray studies are recommended for early diagnosis and treatment of delayed pleuro-pulmonary involvement.

Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. The APSA Trauma Committee

PURPOSE

This study is intended to resolve the disparity and reach consensus on issues regarding the treatment of children with isolated spleen or liver injuries. To maximize patient safety and assure efficient, cost-effective utilization of resources, it was essential to determine current practice.

METHODS

Data from the case records of 856 children with isolated spleen or liver injury treated at 32 pediatric surgical centers from July 1995 to June 1997 were collected. The severity of injury was classified by computed tomography (CT) grade and the data analyzed for intensive care unit (ICU) stay, length of hospital stay, transfusion requirement, need for operation, pre- and postdischarge imaging, and restriction of physical activity. Patients with grade V injuries (2.8%) were excluded leaving 832 patients for detailed review. These data and available literature were analyzed for consensus by the 1998 APSA Trauma Committee.

RESULTS

Resource utilization increased with injury severity (see Table 2). Based on the data analysis, literature search, and consensus conference, the authors propose guidelines (see Table 3) for the safe and optimal utilization of resources in routine cases. It is important to emphasize that no recommendation falls outside the 25th percentile of current practice at participating centers.

CONCLUSIONS

Diversity of treatment, with attendant variation in resource utilization in children with isolated spleen and liver injury of comparable severity is confirmed. This analysis has stimulated a prospective outcomes study with the objective of validating the evidence-based guidelines proposed. This evidence-based study design can bring order and conformity to patient management resulting in optimal utilization of resources while maximizing patient safety.

Nonoperative management of solid organ injuries. Past, present, and future

All patients with injuries to the solid organs of the abdomen and who are hemodynamically stable should be considered candidates for nonoperative management after their injuries have been staged by abdominal CT scanning, but because the CT stage of the injury does not always predict which patients require laparotomy, these patients must remain under the care of experienced trauma surgeons who can not only recognize the presence of an associated hollow viscus injury in need of repair but also will be readily available to operate if the nonoperative approach fails. Until continued bleeding can be safely ruled out, a period of close monitoring in an ICU-like setting seems warranted. Although delayed bleeding from the liver seems extremely rare, delayed rupture of the spleen and continued hemorrhage into the retroperitoneum from an injured kidney are not unusual, so patients with splenic and renal injuries should be considered candidates for repeat imaging procedures before discharge. Others likely to benefit from a second look at their injuries include patients with subcapsular hematomas, patients with recognized extravasation on the initial scan, and athletes anxious to return to contact sports. Experience from major trauma centers suggests that the incidence of missed intestinal injuries is low in adults and children managed nonoperatively, but surgeons must be diligent in monitoring for increasing abdominal pain, abdominal distention, vomiting, and signs of inflammation, which may be delayed manifestations of intestinal disruption. Patients with vascular injuries (grade V injuries to the spleen, liver, or kidney) may be candidates for radiologic procedures, such as angioembolization or stenting, but some of these patients are best served by immediate laparotomy. Selected patients with penetrating injuries may also be candidates for the nonoperative approach, but further research in this area is needed before this approach can be widely embraced. As we approach the year 2000, the nonoperative approach to hepatic, splenic, and renal injuries will continue to have a major role in the treatment of trauma patients. Currently, the morbidity and mortality rates of nonoperative management are acceptably low, but surgeons still must monitor their results carefully as they apply these methods more liberally among injured patients.

Nonoperative management of solid organ injuries in children results in decreased blood utilization

BACKGROUND

The administration of blood products to injured children has been recognized as a potential risk of nonoperative management. The purpose of this study was to evaluate blood utilization in the management of solid organ injuries in pediatric blunt abdominal trauma victims.

METHODS

One hundred sixty-one children (< or =16 years old) with solid organ injuries over an 8-year study period (1990 through 1997) were identified from the trauma registries at 2 urban regional trauma centers.

RESULTS

Mean age of the study patients was 7.9+/-0.4 years, 95 (59%) were boys, and their mean injury severity score (ISS) was 17.8+/-1.2. Patients were divided into 4-year study cohorts (1990 through 1993 and 1994 through 1997) to examine changes in operative management and blood utilization. For each time period examined, those treated nonoperatively received fewer blood transfusions (46% v 9% and 44% v 13%, P<.05 by Fisher's Exact test), and the hospital length of stay was shorter (12.3+/-2.1 v 5.0+/-0.7 and 7.8+/-1.9 v 4.2+/-0.4 days, P<.0001 by analysis of variance/Scheffe's) compared with the laparotomy cohort.

CONCLUSIONS

The appropriate nonoperative management of injured children actually reduces the risks of receiving blood transfusion and decreases the length of hospital stay compared with aggressive operative intervention. Blood transfusion should be reserved only for those injured children with solid organ injuries who are hemodynamically unstable.

Pediatric splenic injury: pathway to play?

BACKGROUND

Nonoperative management of blunt splenic injury (BSI) remains a "gold standard" in pediatric trauma care. Controversy exists regarding the minimal hospital stay necessary for the care of these patients and the appropriate duration of reduced activity required after discharge.

METHODS

A clinical pathway was developed in an attempt to standardize the hospital and outpatient management of children with BSI cared for at the Children's Hospital of Philadelphia. From July 1, 1996 to September 30, 1997, all children with BSI were treated using this pathway (pathway group). To better evaluate outcome, data were compared with an historical control of consecutive children treated at our institution during the previous 2 years (control group).

RESULTS

Twenty-eight children in the control group and 21 children in the pathway group comprise the study population. Average age, injury mechanism, grade of splenic injury, injury severity score, length of intensive care unit stay, and number of transfusions were not significantly different between the two groups (P<.05). As expected, there was a significant decrease in the length of stay on the general care units (5.3+/-1.2 v 2.9+/-0.9 days, control v pathway, P<.05), which, in turn, resulted in a significant decrease in the total length of hospitalization (6.7+/-1.4 v 3.9+/-1.2 days, P<.05) and estimated hospital charges. During follow-up, no complications or missed injuries were identified at a standard 3-week and the 3-month office visit.

CONCLUSION

Hemodynamically stable children with isolated blunt splenic injuries may be treated safely with a 4-day hospital stay followed by 3 weeks of quiet activities at home and 3 months of light activity before return to full, unrestricted activity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Changes in the management of pediatric blunt splenic and hepatic injuries

BACKGROUND/PURPOSE

Intensive care monitoring, blood replacement, and nonoperative treatment of splenic and hepatic injuries in stable patients is the standard practice in pediatric surgery with a success rate of 90% in children's trauma centers.

METHODS

During the past 5 years, 55 children under 14 years of age have been treated for laceration of spleen, liver, or both, proven by computed tomography.

RESULTS

In 34 (62%), other injuries were identified, and only 21 (38%) presented with isolated injuries. In the 21 children who had isolated injuries, 18 had laceration of spleen, two had liver lacerations, and one had liver and spleen laceration. One patient who had spleen laceration required laparotomy and splenorrhaphy because of hemodynamic instability 4 hours after admission. The other 20 patients were initially closely monitored indiscriminately in the Intensive Care Unit of the pediatric surgical nursing unit. Blood transfusion was given to four children during the first 24 hours of admission despite the fact that, retrospectively, all were hemodynamically stable. There was no morbidity or mortality in all the 55 children.

CONCLUSIONS

The results of this study suggest that intensive care monitoring is not mandatory in hemodynamically stable patients who have isolated liver or spleen injuries. Blood replacement should be indicated in patients who have hematocrit levels lower than 20% and signs of continuing blood loss. Because of structural characteristics of the young liver and spleen, early progressive mobilization can be indicated.

Nonoperative Management of Solid Abdominal Visceral Injury: Part I. Spleen

The relatively recent recognition of the immunological consequences of splenectomy in both children and adults, coupled with an increased use of noninvasive methods of detecting splenic injuries, has resulted in the development of a nonoperative approach to selected patients with blunt splenic trauma. Currently, nonoperative management of pediatric splenic injuries is the treatment of choice, with success rates greater than 90%. Due to the increased severity of injury in adult trauma patients, this method of treatment is applicable in only 50% of older patients with mild to moderate splenic trauma. As experience with nonoperative treatment has accumulated, the need for large blood transfusions, missed intestinal injuries, and delayed splenic rupture have been found to be uncommon events. However, patients selected for nonoperative management must be monitored in a setting where the treating surgeon is readily available for both serial examinations and operative intervention should nonoperative management fail.

Small bowel injury in children after blunt abdominal trauma: is diagnostic delay important?

OBJECTIVE

To assess the incidence and consequences of small bowel injury (SBI) in children suffering blunt abdominal trauma managed with the intent to treat nonoperatively.

DESIGN

Retrospective chart review.

MATERIALS AND METHODS

A total of 168 consecutive hemodynamically stable children admitted to a Level I pediatric trauma center during a 24-month period.

RESULTS

Nine of 168 children (5%) sustained SBI: three underwent early (< 4 hours) operation for recognized SBI (identified on computed tomographic scan); and six had delayed (36 +/- 16 hours) operation for missed SBI (not identified on computed tomographic scan). Increased temperature and heart rate, or decreased urine output at 24 hours suggested occult SBI. The hospital course was unaltered by delayed diagnosis. Fifty-seven percent of the children (95) suffered intra-abdominal injury; 10% required laparotomy for SBI (9) or solid organ injury (7); 90% (152) were discharged without laparotomy.

CONCLUSIONS

SBI is uncommon in children suffering blunt abdominal trauma. The diagnosis can be made using clinical and radiographic findings. Limited diagnostic delay does not seem to affect outcome. We conclude that clinical diagnosis of SBI is safe, permits the nonoperative treatment of most blunt abdominal injuries, and reduces the risk of unnecessary laparotomy associated with alternate approaches.

Blunt hepatic and splenic trauma in children: correlation of a CT injury severity scale with clinical outcome

The purpose of this report is to compare a computed tomography (CT) injury severity scale for hepatic and splenic injury with the following outcome measures: requirement for surgical hemostasis, requirement for blood transfusion and late complications. Sixty-nine children with isolated hepatic injury and 53 with isolated splenic injury were prospectively classified at CT according to extent of parenchymal involvement. Clinical records were reviewed to determine clinical outcome. Ninety-seven children (80%) were managed non-operatively without transfusion. One child with hepatic injury required surgical hemostasis, and 17 (25%) required transfusion of blood. Increasing severity of hepatic injury at CT was associated with progressively greater frequency of transfusion (P = 0.002 by chi 2-test). One child with splenic injury underwent surgery and eight (15%) required transfusion of blood. Splenic injury grade at CT did not correlate with frequency (P = 0.41 by chi 2-test) or amount (P = 0.35 by factorial analysis of variance) of transfusion. There was one late complication in the nonsurgical group. A majority of children with hepatic and splenic injury were managed non-operatively without requiring blood transfusion. The severity of injury by CT scan did not correlate with need for surgery. Increasing grade of hepatic injury at CT was associated with increasing frequency of blood transfusion. CT staging was not discriminatory in predicting transfusion requirement in splenic injury.