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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Booth BJ, Bowman SM, Escobar MA, Sharar SR. Long-term sustainability of Washington State's quality improvement initiative for the management of pediatric spleen injuries. J Pediatr Surg 2018; 53:2209-2213. [PMID: 29884556 DOI: 10.1016/j.jpedsurg.2018.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 04/07/2018] [Accepted: 05/07/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Initial results of Washington State's quality improvement initiative addressing the management of blunt traumatic pediatric spleen injuries were published in 2008. In this update, we evaluated whether these effects were sustained over time. METHODS Data from the Washington Trauma Registry for years 1999-2001 (pre-intervention), 2003-2005 (post-intervention), and 2012-2014 (follow-up) were used in a retrospective cohort study. Children between ages 0 to 14 years who were hospitalized with a traumatic blunt spleen injury were included. Multivariable logistic regression was used to account for patient, injury, and hospital characteristics. RESULTS Overall, splenectomies continued to be less common with 8.3% of pediatric patients receiving splenectomies in the follow-up period compared with 14.3% and 7.2% in the preintervention and post-intervention periods (p = 0.034). After adjustment, splenectomies remained less likely to be performed in both post-intervention (OR = 0.37; 95% CI = 0.16-0.90) and follow-up periods (OR = 0.29; 95% CI = 0.12-0.70) compared to pre-intervention. Children were much more likely to be cared for at pediatric trauma hospitals in the follow-up period (OR = 5.13; 95% CI = 2.79-9.43) after adjustment. CONCLUSIONS Evaluation of this statewide quality improvement initiative showed that positive changes in management practices persist. This evidence suggests that statewide quality improvement initiatives can be sustainable with minimal ongoing effort. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Benjamin J Booth
- Office of Community Health Systems, Washington State Department of Health, Olympia, WA.
| | - Stephen M Bowman
- Office of Community Health Systems, Washington State Department of Health, Olympia, WA.
| | - Mauricio A Escobar
- Department of Pediatric Surgery, Mary Bridge Children's Hospital & Health Center, Tacoma, WA.
| | - Sam R Sharar
- Department of Anesthesiology, Harborview Medical Center, University of Washington, Seattle, WA.
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Swaid F, Peleg K, Alfici R, Matter I, Olsha O, Ashkenazi I, Givon A, Kessel B. Concomitant hollow viscus injuries in patients with blunt hepatic and splenic injuries: an analysis of a National Trauma Registry database. Injury 2014; 45:1409-12. [PMID: 24656303 DOI: 10.1016/j.injury.2014.02.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 02/12/2014] [Accepted: 02/20/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Non-operative management has become the standard approach for treating stable patients sustaining blunt hepatic or splenic injuries in the absence of other indications for laparotomy. The liberal use of computed tomography (CT) has reduced the rate of unnecessary immediate laparotomies; however, due to its limited sensitivity in the diagnosis of hollow viscus injuries (HVI), this may be at the expense of a rise in the incidence of missed HVI. The aim of this study was to assess the incidence of concomitant HVI in blunt trauma patients diagnosed with hepatic and/or splenic injuries, and to evaluate whether a correlation exists between this incidence and the severity of hepatic or splenic injuries. METHODS A retrospective cohort study involving blunt trauma patients with splenic and/or liver injuries, between the years 1998 and 2012 registered in the Israel National Trauma Registry. The association between the presence and severity of splenic and/or liver injuries and the incidence of HVI was examined. RESULTS Of the 57,130 trauma victims identified as suffering from blunt torso injuries, 2335 (4%) sustained hepatic injuries without splenic injuries (H group), 3127 (5.4%) had splenic injuries without hepatic injuries (S group), and 564 (1%) suffered from both hepatic and splenic injuries (H+S group). Overall, 957 patients sustained 1063 HVI. The incidence of HVI among blunt torso trauma victims who sustained neither splenic nor hepatic injuries was 1.5% which is significantly lower than in the S (3.1%), H (3.1%), and H+S (6.7%) groups. In the S group, there was a clear correlation between the severity of the splenic injury and the incidence of HVI. This correlation was not found in the H group. CONCLUSIONS The presence of blunt splenic and/or hepatic injuries predicts a higher incidence of HVI, especially if combined. While in blunt splenic injury patients there is a clear correlation between the incidence of HVI and the severity of splenic injury, such a correlation does not exist in patients with blunt hepatic injury.
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Affiliation(s)
- Forat Swaid
- General Surgery Department, Bnai-Zion Medical Center, Haifa, Israel.
| | - Kobi Peleg
- National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel
| | - Ricardo Alfici
- Surgical Division, Hillel Yaffe Medical Center, Hadera, Israel
| | - Ibrahim Matter
- General Surgery Department, Bnai-Zion Medical Center, Haifa, Israel
| | - Oded Olsha
- Surgery Department, Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - Adi Givon
- National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel
| | | | - Boris Kessel
- Trauma Unit, Hillel Yaffe Medical Center, Hadera, Israel
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Dodgion CM, Gosain A, Rogers A, St Peter SD, Nichol PF, Ostlie DJ. National trends in pediatric blunt spleen and liver injury management and potential benefits of an abbreviated bed rest protocol. J Pediatr Surg 2014; 49:1004-8; discussion 1008. [PMID: 24888852 DOI: 10.1016/j.jpedsurg.2014.01.041] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Accepted: 01/27/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Recent reports suggest that an abbreviated bed rest protocol (ABRP) may safely reduce length of stay (LOS) and resource utilization in pediatric blunt spleen and liver injury (BSLI) patients. This study evaluates national temporal trends in BLSI management and estimates national reduction in LOS using an ABRP. METHODS Pediatric patients (<18 years old) sustaining BLSI were identified in the Kids' Inpatient Database from 2000 to 2009. Yearly rates of injury and operative intervention were examined and stratified by type of injury. APSA guidelines and the reported ABRP were applied based on abbreviated injury score (AIS) and compared with actual LOS. RESULTS 22,153 patients were identified. Over the study period, operative rates for spleen and liver injuries and overall mortality significantly declined: LOS=3.1 days (±1.6) and 2.7 days (±1.9) for spleen and liver, respectively. If APSA guidelines were followed, the rates were LOS=3.7 days (±1.1) and 3.4 days (±0.7), respectively. Application of the ABRP would result in LOS=1.3 days (±0.5) for all BSLI patients. An ABRP could potentially save 1.7 hospital days/patient or 36,964 patient hospital days nationally. CONCLUSION Our study confirms a significant national decrease in operative intervention and overall mortality in patients with BSLI. Additionally, it appears that a shorter observation period than the APSA guidelines is being utilized. The implementation of ABRP holds potential in further reducing LOS and resource utilization.
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Affiliation(s)
- Christopher M Dodgion
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin Hospitals and Clinics, Madison, WI
| | - Ankush Gosain
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Andrew Rogers
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | | | - Peter F Nichol
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Daniel J Ostlie
- Department of Surgery, University of Wisconsin, Madison, Wisconsin.
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St Peter SD, Aguayo P, Juang D, Sharp SW, Snyder CL, Holcomb GW, Ostlie DJ. Follow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Pediatr Surg 2013; 48:2437-41. [PMID: 24314183 DOI: 10.1016/j.jpedsurg.2013.08.018] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 08/26/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Current APSA recommendations for blunt spleen/liver injury (BSLI) entail bedrest equal to grade of injury plus one. We reported our experience 3 years ago with a prospectively implemented abbreviated protocol, one concern of which was that more numbers would be needed to support the safety of such a protocol. We are now reporting the final experience with this protocol as we move forward with further investigation. METHODS Following IRB approval, data were collected prospectively in all patients with BSLI up to 8 weeks after discharge. There were no exclusion criteria, and patient accrual was consecutive. Bedrest was restricted to one night for Grade I & II injuries and two nights for Grade ≥ III. RESULTS Between 11/2006 and 10/2012, 249 patients were admitted with BSLI. Mean age and weight were 10.3±4.8 years and 40.1±19.8 kg, respectively. Injuries included isolated spleen in 130 (52%), liver only in 107 (43%), and both in 12 (5%). One splenectomy was required for a grade V injury. Transfusions were used in 40 patients (16%), with 28 (11%) due to the injured solid organ. Bedrest for solid organ injury was applicable to 199 patients (80%), for which the mean grade of injury was 2.7±1.0 and mean bedrest was 1.6±0.6 days, resulting in 2.5±1.9 days of hospitalization. The need for bedrest was the limiting factor for length of stay in 155 patients (62%), for which mean grade of injury was 2.5±1.0 and mean bedrest was 1.6±0.6 days, resulting in 1.7±0.8 days of hospitalization. There were 4 deaths, 3 from brain injury and 1 from grade V liver injury. There were no patients readmitted for complications of solid organ injury. CONCLUSIONS These data further validate that an abbreviated protocol of one night of bedrest for grade I and II injuries and two nights for grade ≥ III can be safely employed, resulting in dramatic decreases in hospitalization compared to the current APSA recommendations.
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Affiliation(s)
- Shawn D St Peter
- The Center For Prospective Clinical Trials The Children's Mercy Hospital Kansas City, MO
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