Follow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children

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.     

Justification for an abbreviated protocol in the management of blunt spleen and liver injury in children

Objective(s)

The current management of blunt spleen/liver injury in children requires a number of days of bed rest equal to the grade of injury plus 1. This protocol is used even when there is no clinical indication of ongoing bleeding. To establish a prospective protocol with an abbreviated period of bed rest, we conducted a retrospective review of our blunt spleen and liver trauma experience to examine the safety of such an attenuated protocol.

Methods

A retrospective analysis of our most recent 10-year experience (January 1996 to December 2005) with blunt spleen or liver injury was performed. Patient demographics, vital signs, hemoglobin levels, need for transfusion, operations, and outcomes were measured. An abbreviated protocol using 1 night of bed rest for grades 1 and 2 injuries and 2 nights of bed rest for higher grades was designed. This protocol was then applied to our patient population to assess its safety. Data are expressed as mean ± SD.

Results

During the study period, 243 patients were admitted with blunt spleen and/or liver injury. The mean patient age was 9.0 ± 4.6 years, and the mean weight was 35.3 ± 19.3 kg. Sixty-three percent were male. The spleen was injured in 148 (61.2%) patients and the liver in 121 (50.0%), and 26 (10.6%) had both. The mean grade was 2.0 ± 1.1, for which the mean bed rest was 3.5 ± 1.1 days. This resulted in 5.6 ± 6.5 days of hospitalization. There were 9 patients who died, 7 with severe brain injury and 2 with massive liver hemorrhage on presentation. No patient required an operation or transfusion after 2 nights of observation who did not have clinically obvious signs of ongoing blood loss. Implementation of the abbreviated protocol would have affected 65.8% of our patients and would have saved a mean of 2.0 ± 1.5 hospital days per patient.

Conclusions

According to our data, an abbreviated trauma protocol with overnight bed rest for grades 1 and 2 injuries and 2 nights for higher grades could be safely used. This protocol would immensely improve current resource use. Based on these retrospectively collected data, we have initiated a prospective consecutive controlled series to assess the safety of such an attenuated protocol.     

National trends in pediatric blunt spleen and liver injury management and potential benefits of an abbreviated bed rest protocol

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.     

Reimaging in pediatric blunt spleen and liver injury

Background

APSA guidelines do not recommend routine reimaging for pediatric blunt liver or spleen injury (BLSI). This study characterizes the symptoms, reimaging, and outcomes associated with a selective reimaging strategy for pediatric BLSI patients.

Reducing scheduled phlebotomy in stable pediatric patients with blunt liver or spleen injury

Background/Purpose

Although consensus-based guidelines exist for managing pediatric liver/spleen injuries, optimal phlebotomy frequency is unknown. We hypothesize surgeons order more phlebotomy than necessary and propose a pathway with one blood draw, early ambulation and discharge, fewer ICU admissions, and physiology-driven interventions.

Methods

Records of 120 children with solid organ injury from two hospital registries (2008–2012) were analyzed. We compared resource utilization between our current management and management if the proposed pathway were in place. Paired t-test was used for statistical analysis.

Results

Sixty-one patients were included (35 spleen, 22 liver, 4 combined). Average age was 11.6 (± 4.2) years, injury severity score 9 (± 5), and median injury grade 3. 51% of children were admitted to the ICU. Average phlebotomy per patient was 5 (± 2) and length-of-stay 4.3 (± 1.5) days. Three patients became unstable and required transfusion. No patients required operation or angioembolization. Our pathway would decrease ICU admissions by 65% (p < 0.001), blood draws by 70% (p < 0.001), and length-of-stay by 37% (p < 0.001), while identifying all patients requiring transfusion based on hemodynamic status.

Conclusion

Our data suggest that clinical parameters could identify patients requiring intervention and decrease resource utilization. This suggests that serial phlebotomy may be unnecessary, and the proposed pathway is worthy of prospective validation.     

Natural history of nonoperative management for grade 4 and 5 liver and spleen injuries in children

Purpose

Nonoperative management is standard treatment of blunt liver or spleen injuries. However, there are few reports outlining the natural history and outcomes of severe blunt hepatic and splenic trauma. Therefore, we reviewed our experience with nonoperative management of grade 4 or 5 liver and spleen injuries.

Methods

A retrospective analysis was performed on patients with grade 4 or 5 (high-grade) blunt liver and/or spleen injuries from April 1997 to July 2007 at our children's hospital. Demographics, hospital course data, and follow-up data were analyzed.

Results

There were 74 high-grade injuries in 72 patients. There were 30 high-grade liver and 44 high-grade spleen injuries. Two patients had both a liver and splenic injury. High-grade liver injuries had a significantly longer length of intensive care and hospital stay compared to high-grade spleen injuries. There were also a significantly higher number of transfusions, radiographs, and total charges in the high-grade liver injuries when compared to the high-grade splenic injuries. The only mortality from solid organ injury was a grade 4 liver injury with portal vein disruption. In contrast, there was only one complication from a high-grade splenic injury—a pleural effusion treated with thoracentesis. There were 5 patients with complications from their liver injury requiring 18 therapeutic procedures. Three patients (10%) with liver injury required readmission as follows: one 5 times, one 3 times, and another one time.

Conclusions

Patients with high-grade liver injuries have a longer recovery, more complications, and greater use of resources than in patients with similar injuries to the spleen.     

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.     

Prospective observational study with an abbreviated protocol in the management of blunt renal injury in children

Background

There are no published management schemes for blunt renal injuries. We are conducting a 2-center prospective observational study with a fixed management scheme.

Methods

Children with CT proven renal injuries were enrolled with permission. Ambulation is allowed when able regardless of grade. Discharge occurs when tolerating a diet and pain is controlled regardless of hematuria. Urinalysis occurs at follow up in 2–4 weeks and repeated as indicated.

Results

Between 9/2008 and 9/2012, 70 patients were enrolled. Mean age was 11.8 years (3–17), and 70% were male. The mean grade of injury was 2.8 ± 1.1 , , ,  and . One nephrectomy (1.4%) was performed for a grade 5 injury. Other renal interventions included an embolization for the hilar bleed and one cystotomy for a clot. Mean LOS was 2.9 days ± 2.4 days. In patients without other major injury, LOS was 1.9 ± 1.7 days (0.4–8 days). There were 5 (7%) readmissions: 3 for pain, 1 for hematuria, and 1 for a bladder clot. 58 patients (83%) gave urinalysis samples at initial follow up (med 18 days), where 31 (53%) were positive for blood.

Conclusions

Children with blunt renal injury may benefit from management without strict bedrest guidelines. Hematuria appears to have little influence on recovery.     

Traumatic bile leaks from blunt liver injury in children: A multidisciplinary and minimally invasive approach to management

Background

Selective non-operative management (NOM) of hemodynamically stable pediatric patients with blunt hepatic trauma is the standard of care. Traumatic bile leaks (TBL) are a potential complication following liver injury. The use of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of TBL is described in adults, but limited in the pediatric literature. We report our experience with a multidisciplinary and minimally invasive approach to the management of TBL.

Methods

This was an IRB-approved 13-year retrospective review (January 1999-December 2012) of an institutional pediatric trauma registry; 294 patients (≤ 17 years old) sustained blunt hepatic injury. Those with TBL were identified. Patient demographics, mechanism of injury, management strategy and outcomes were reviewed.

Results

Eleven patients were identified with TBL. Hepatobiliary iminodiacetic scan (HIDA) was diagnostic. Combinations of peri-hepatic drain placement, ERCP with biliary stenting and/or sphincterotomy were performed with successful resolution of TBL in all cases. No child required surgical repair or reconstruction of the leak. Cholangitis developed in one child. There were no long-term complications.

Conclusions

A multidisciplinary and minimally invasive approach employing peri-hepatic external drainage catheters and ERCP with sphincterotomy and stenting of the ampulla is a safe and effective management strategy for TBL in children.     

Management of blunt splenic injury in children: evolution of the nonoperative approach

Background

Nonoperative management of blunt splenic injury (BSI) was first proposed at our institution in 1948. Since that time, treatment of patients with BSI has evolved from routine splenectomy to an aggressive spleen-preserving philosophy. This report summarizes our institutional experience for the last 50 years.

Methods

All children (0-18 years) admitted to our pediatric trauma center with BSI during 4 eras (1956-1965, 1972-1977, 1981-1986, and 1992-2006) were retrospectively reviewed for demographics, injury patterns, management, and complications.

Results

During the 4 eras captured for the last 5 decades, 486 children experienced BSI. The mean age was 10 years with 347 males (71%). Nonoperative management rate increased from 42% to 97% with improvement in splenic salvage rate (42%-99%). Mean length of stay decreased from 17 to 5 days. In patients with isolated splenic injuries (50%), nonoperative management rate increased (36%-100%) and fewer received transfusions (60%-1%). Overall mortality rate improved (19%-6.6%, 8%-0.7% in isolated injuries).

Conclusion

The management of BSI in children has changed dramatically for the last 50 years. This study clearly demonstrates the safety of nonoperative management and documents progressively lower rates of splenectomy and transfusion, shorter hospitalization, and an extremely low risk of mortality.     

Reduction of resource utilization in children with blunt solid organ injury

Background/purpose

Nonoperative management of blunt solid organ injuries continues to progress and improve cost-effective utilization of resources while maximizing patient safety. The purpose of this study is to compare resource utilization and patient outcomes after changing admission criteria from a grade-based protocol to one based on hemodynamic stability.

Transection of the stomach after blunt injury in the pediatric population

The incidence of gastric rupture after abdominal blunt injury ranges between 0.02% and 1.7% and is associated with a high morbidity (Tejerina Alvarez EE, Holanda MS, Lopex-Espadas F, Dominguez MJ, Ots E, Diaz-Reganon J. Gastric rupture from blunt abdominal trauma. Injury. 2004;35:228-231, Allen GS, Moore FA, Cox CS. Hollow visceral injury and blunt trauma. J Trauma. 1998;45:69-75.). Stomach transection represents an even rarer type of blunt gastric injury. Although not specifically included in the accepted classification of stomach injury, its clinical manifestation is dramatic, requiring immediate surgical management. We present a case report from our institution and reviewed the international literature focusing on the pediatric patient to illustrate this injury in terms of mechanism of injury, clinical presentation, and surgical management.     

Pediatric trauma center verification improves quality of care and reduces resource utilization in blunt splenic injury

Purpose

We sought to evaluate value impact of transition from an adult trauma center treating children (ATC) to a verified pediatric trauma center (PTC) in children with blunt splenic injury (BSI).

Population-based analysis of blunt splenic injury management in children: Operative rate is an informative quality of care indicator

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.     

Recent changes in the management of blunt splenic injury: effect on splenic trauma patients and hospital implications

INTRODUCTION

Management of blunt splenic injury has been controversial with an increasing trend towards splenic conservation. A retrospective study was performed to identify the effect of this changed policy on splenic trauma patients and its implications.

PATIENTS AND METHODS

Data regarding patient demography, mode of splenic injury, CT grading, blood transfusion requirement, operative findings hospital stay and follow-up were collected. Statistical analysis of the data was performed using non-parametric Mann–Whitney tests

RESULTS

Over an 8-year period, only 21 patients were admitted with blunt splenic injury. Ten patients were managed operatively and 11 non-operatively. Non-operative management failed in one patient due to continued bleeding. Using Buntain''s CT grading, the majority of grades I and II splenic injuries were managed non-operatively and grades III and IV were managed operatively (P = 0.008). Blood transfusion requirement was significantly higher among the operative group (P = 0.004) but the non-operative group had a significantly longer hospital stay (P = 0.029). Among those managed non-operatively (median age, 24.5 years), a number of patients were followed up with CT scans with significant radiation exposure and unknown long-term consequences.

CONCLUSIONS

Non-operative management of blunt splenic trauma in adults can be performed with an acceptable outcome. Although CT is classed as the ‘gold standard’, initial imaging for detection and evaluation of blunt splenic injury, ultrasound can play a major role in follow-up imaging and potentially avoids major radiation exposure.     

Non-operative management of solid organ injuries in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee systematic review

PurposeThe American Pediatric Surgical Association (APSA) guidelines for the treatment of isolated solid organ injury (SOI) in children were published in 2000 and have been widely adopted. The aim of this systematic review by the APSA Outcomes and Evidence Based Practice Committee was to evaluate the published evidence regarding treatment of solid organ injuries in children.MethodsA comprehensive search strategy was crafted and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Four principal questions were examined based upon the previously published consensus APSA guidelines regarding length of stay (LOS), activity level, interventional radiologic procedures, and follow-up imaging. A literature search was performed including multiple databases from 1996 to 2016.ResultsLOS for children with isolated solid organ injuries should be based upon clinical findings and may not be related to grade of injury. Total LOS may be less than recommended by the previously published APSA guidelines. Restricting activity to grade of injury plus two weeks is safe but shorter periods of activity restriction have not been adequately studied. Prophylactic embolization of SOI in stable patients with image-confirmed arterial extravasation is not indicated and should be reserved for patients with evidence of ongoing bleeding. Routine follow-up imaging for asymptomatic, uncomplicated, low-grade injured children with abdominal blunt trauma is not warranted. Limited data are available to support the need for follow-up imaging for high grade injuries.ConclusionBased upon review of the recent literature, we recommend an update to the current APSA guidelines that includes: hospital length of stay based on physiology, shorter activity restrictions may be safe, minimizing post-injury imaging for lower injury grades and embolization only in patients with evidence of ongoing hemorrhage.Type of StudySystematic Review.Levels of EvidenceLevels 2–4.     

Pleural effusion following blunt splenic injury in the pediatric trauma population

Background

Pleural effusion is a potential complication following blunt splenic injury. The incidence, risk factors, and clinical management are not well described in children.

Methods

Ten-year retrospective review (January 2000–December 2010) of an institutional pediatric trauma registry identified 318 children with blunt splenic injury.

Results

Of 274 evaluable nonoperatively managed pediatric blunt splenic injures, 12 patients (4.4%) developed left-sided pleural effusions. Seven (58%) of 12 patients required left-sided tube thoracostomy for worsening pleural effusion and respiratory insufficiency. Median time from injury to diagnosis of pleural effusion was 1.5 days. Median time from diagnosis to tube thoracostomy was 2 days. Median length of stay was 4 days for those without and 7.5 days for those with pleural effusions (p < 0.001) and 6 and 8 days for those pleural effusions managed medically or with tube thoracostomy (p = 0.006), respectively. In multivariate analysis, high-grade splenic injury (IV–V) (OR 16.5, p = 0.001) was associated with higher odds of developing a pleural effusion compared to low-grade splenic injury (I–III).

Conclusions

Pleural effusion following pediatric blunt splenic injury has an incidence of 4.4% and is associated with high-grade splenic injuries and longer lengths of stay. While some symptomatic patients may be successfully managed medically, many require tube thoracostomy for progressive respiratory symptoms.