Variation in the management of pediatric splenic injuries in New England

BACKGROUND:Nonoperative management of stable children with splenic injuries is the standard of care but has been variably applied in New England. The influence of surgeon training on this variation was analyzed. METHODS: A region-wide administrative data set was queried for children with a splenic injury from 1990 through 1998. The influence of a range of patient- and hospital-specific variables, including surgeon pediatric training, on the risk of operation was analyzed. RESULTS: The risk of operation increased with age, severity of splenic injury, and the presence of multiple injuries, but also trauma center status and the presence of a surgical training program. After allowance for these variables, the risk of operation was reduced by half when children with splenic injuries were cared for by a surgeon with pediatric specialty training. CONCLUSION: The risk of operation for pediatric splenic injury in New England is dependent on several variables, including the surgeon's training.     

Pediatric cardiac and great vessel injuries: Recent experience at two pediatric trauma centers

Background: Cardiac injuries are rare in pediatric trauma patients and data regarding this type of injury is limited. There is even less data on traumatic great vessel injuries. This study sought to examine and summarize our recent experience at two pediatric trauma centers, which serve a major metropolitan area and large geographic region.Methods: This is a retrospective review of pediatric (<18 years) patients who sustained cardiac or great vessel injuries and were managed at a Level 1 or Level 2 pediatric trauma center between January 1, 2010 and June 30, 2020. Demographic and clinical characteristics were compared using two-sample t-tests, Wilcoxon Rank-Sum tests, Fisher's exact tests and chi-squared tests for continuous, non-normally distributed continuous, and categorical variables, respectively.Results: A total of 53 patients sustained cardiac and/or great vessel injuries. Of these, 37 (70%) sustained cardiac, 9 (17%) sustained great vessel, and 7 (13%) sustained both types of injuries. The median age was 14.9 years and 74% (n = 39) were male. The median injury severity score (ISS) was 36.0 and the injury mechanism was blunt in 31 (58%) patients. The most common cardiac and great vessel injury locations were left ventricle (n = 9) and thoracic aorta (n = 11), respectively. The overall mortality rate was 53% (n = 28). Mortality was highest among those who sustained great vessel injuries (89%).Conclusions: There is substantial heterogeneity in cardiac and great vessel injuries. Regardless, they are highly morbid and lethal, despite aggressive surgical and catheter-based interventions.     

Variation in the management of pediatric splenic injuries in the United States

BACKGROUND: This study examines the existence and sources of variation in the management of pediatric splenic injuries among hospitals in the United States and the factors associated with splenectomy. METHODS: Information on children 15 years of age and younger with a splenic injury diagnosis code was extracted from the Kids' Inpatient Database 2000, a pediatric inpatient database of 2,784 hospitals in 27 states covering 72% of the nation's population for the year 2000. Patient variables included age, sex, race, injury diagnoses, grade of splenic injury, splenic procedure code, and calculated Injury Severity Score. Hospital variables included pediatric status (free-standing, unit and adult), teaching status, annual pediatric splenic trauma volume, and national region. A multivariate logistic regression model was used to predict the factors associated with splenectomy based upon patient and hospital characteristics. RESULTS: In all, 2,191 children with splenic injuries were identified; 253 (12%) underwent splenectomy. The crude rate of splenectomy varied significantly among pediatric hospital types: 3% (11/339) at freestanding children's hospitals, 9% (45/525) at unit hospitals and 15% (197/1327) at adult hospitals (p < 0.001). Risk of splenectomy increased with the grade of splenic injury, patient age, and the presence of multiple injuries. Teaching hospitals and hospitals with higher patient volume were associated with lower risk for splenectomy. There was no relationship between splenectomy and gender, race, or national region. Despite adjustment for the above noted hospital and patient-specific variables, children treated at an adult hospital had 2.8 times the odds, and those treated at a unit pediatric hospital 2.6 times the odds, of undergoing splenectomy as those cared for at a free-standing pediatric hospital (p = 0.003 and 0.013, respectively). CONCLUSION: Nationally, children cared for at freestanding pediatric hospitals have a significantly lower risk of splenectomy than children treated at either adult hospitals or pediatric hospitals within an adult hospital. This may have implications for education, trauma triage and the establishment of practice guidelines.     

Clinical practice guidelines for the management of acute limb compartment syndrome following trauma

Background: Acute compartment syndrome is a serious and not uncommon complication of limb trauma. The condition is a surgical emergency, and is associated with significant morbidity if not managed appropriately. There is variation in management of acute limb compartment syndrome in Australia. Methods: Clinical practice guidelines for the management of acute limb compartment syndrome following trauma were developed in accordance with Australian National Health and Medical Research Council recommendations. The guidelines were based on critically appraised literature evidence and the consensus opinion of a multidisciplinary team involved in trauma management who met in a nominal panel process. Results: Recommendations were developed for key decision nodes in the patient care pathway, including methods of diagnosis in alert and unconscious patients, appropriate assessment of compartment pressure, timing and technique of fasciotomy, fasciotomy wound management, and prevention of compartment syndrome in patients with limb injuries. The recommendations were largely consensus based in the absence of well‐designed clinical trial evidence. Conclusions: Clinical practice guidelines for the management of acute limb compartment syndrome following trauma have been developed that will support consistency in management and optimize patient health outcomes.     

Comparison between level 1 and level 2 trauma centers for the management of splenic blunt trauma

IntroductionThe management of blunt splenic trauma has evolved in the last years, from mainly operative approach to the non-operative management (NOM). The aim of this study is to investigate whether trauma center (TC) designation (level 1 and level 2) affects blunt splenic trauma management.MethodsA retrospective analysis of blunt trauma patients with splenic injury admitted to 2 Italian TCs, Niguarda (level 1) and San Carlo Borromeo (level 2), was performed, receiving either NOM or emergency surgical treatment, from January 1, 2015 to December 31, 2020. Univariate comparison was performed between the two centers, and multivariate analysis was carried out to find predictive factors associated with NOM and splenectomy.Results181 patients were included in the study, 134 from level 1 and 47 from level 2 TCs. The splenectomy/emergency laparotomy ratio was inferior at level 1 TC for high-grade splenic injuries (30.8% for level 1 and 100% for level 2), whose patients presented higher incidence of other injuries. Splenic NOM failure was registered in only one case (3.3%). At multivariate analysis, systolic pressure, spleen organ injury scale (OIS) and injury severity score (ISS) resulted significant predictive factors for NOM, and only spleen OIS was predictive factor for splenectomy (Odds Ratio 0.14, 0.04–0.49 CI 95%, P < .01).ConclusionBoth level 1 and 2 trauma centers demonstrated application of NOM with a high rate of success with some management difference in the treatment and outcome of patients with splenic injuries between the two types of TCs.     

The significance of pseudoaneurysms in the nonoperative management of pediatric blunt splenic trauma

Purpose

Nonoperative management is the standard of care for hemodynamically stable pediatric and adult blunt splenic injuries. In adults, most centers follow a well-defined protocol involving repeated imaging at 24 to 48 hours, with embolization of splenic pseudoaneurysms (SAPs). In children, the significance of radiologically detected SAP has yet to be clarified.

Methods

A systematic review of the medical literature was conducted to analyze the outcomes of documented posttraumatic SAP in the pediatric population.

Results

Sixteen articles, including 1 prospective study, 4 retrospective reviews, and 11 case reports were reviewed. Forty-five SAPs were reported. Ninety-six percent of children were reported as stable. Yet, 82% underwent splenectomy, splenorrhaphy, or embolization. The fear of delayed complications owing to SAP was often cited as the reason for intervention in otherwise stable children. Only one child with a documented pseudoaneurysm experienced a delayed splenic rupture while under observation. No deaths were reported.

Conclusions

There is no evidence to support or dispute the routine use of follow-up imaging and embolization of posttraumatic SAP in the pediatric population. At present, the decision to treat SAP in stable children is at the discretion of the treating physician. A prospective study is needed to clarify this issue.     

Management of pediatric splenic injuries in Canada

PurposeNonoperative management (NOM) of blunt splenic injuries has become the standard of care in hemodynamically stable children. This study compares the management of these injuries between pediatric and nonpediatric hospitals in Canada.MethodsData were obtained from the Canadian Institute of Health Information trauma database on all patients aged 2 to 16 years, admitted to a Canadian hospital with a diagnosis of splenic injury between May 2002 and April 2004. Variables included age, sex, associated major injuries, splenic procedures, intensive care unit (ICU) admissions, blood transfusions, and length of stay. Hospitals were coded as pediatric or nonpediatric. Univariate analysis and logistic regression were used to determine associations between hospital type and outcomes.ResultsOf 1284 cases, 654 were managed at pediatric hospitals and 630 at nonpediatric centers. Patients at pediatric centers tended to be younger and more likely to have associated major injuries. Controlling for covariates, including associated major injuries, patients managed at pediatric centers were less likely to undergo splenectomy compared with those managed at nonpediatric centers (odds ratio [OR], 0.2; 95% confidence interval, 0.1-0.4). The risk of receiving blood products, admission to the ICU, and staying in hospital for more than 5 days was associated only with having associated major injuries.ConclusionEven in the presence of other major injuries, successful NOM of blunt splenic injuries occurs more frequently in pediatric hospitals in Canada. This has policy relevance regarding education of adult surgeons about the appropriateness of NOM in children and developing guidelines on appropriate regional triaging of pediatric patients with splenic injury in Canada.     

Operative risk of splenic repair for isolated but complex splenic injuries due to blunt abdominal trauma]

Surgical repair for complex splenic trauma is often controversial, because the operative risk of splenic salvage may exceed the risk of overwhelming postsplenectomy infection (OPSI). To determine the operative risk of splenic salvage for such injuries, 19 cases of isolated but complex injuries among 73 cases of blunt splenic trauma were examined retrospectively. Shattered spleens were excluded from the study. Splenic repair was accomplished successfully in all 10 attempted cases. Prior to the repair, vascular isolation and temporal occlusion of splenic artery was done to control the bleeding from injured spleen. In another 9 cases, splenectomy was immediately performed after laparotomy. Total amount of blood loss and operative morbidity in each group were not different, and no death occurred in both groups. Operative time was longer in group of splenic repair (112 +/- 20 min) in comparison to splenectomy group (71 +/- 23 min). Postoperative peripheral platelet count, serum IgM level, and finding of RBC scan showed adequate functional activity of the repaired spleen. In conclusion, it is felt that surgical repair should be attempted for isolated but complex splenic injury, and that the spleen should be preferably repaired even with associated injuries, unless prolonged operative time does not increase operative risk to more than that of OPSI.     

Controversies in the management of splenic trauma

BackgroundThe technologic innovations of the last three decades, coupled with a deeper understanding of the immunologic role of the spleen, have significantly shifted the management of splenic injuries towards non-operative approaches. However, there continuous to be a wide range of practice patterns related to the non-operative management of splenic injuries, from which the authors infer a gap between the best available evidence and its translation into practice. We sought to explore ongoing areas of controversy in the non-operative management of splenic trauma with the aim of further elucidating why these controversies continue to exist.MethodsWe explored areas of ongoing controversy in the management of splenic injury though a series of iterative surveys. We invited 70 experts in trauma care from ten countries around the world to participate. Areas of controversy explored included: indications and frequency for in-hospital and follow-up imaging, definitions of failure of non-operative management, indications for angioembolisation and non-operative management in special populations (i.e. elderly, concomitant traumatic brain injury, penetrating trauma).ResultsA 49% response rate was obtained. Even though a wide range of practice patterns were identified, no controversies were identified in areas that do not involve the adoption of new technologies. In areas where practice pattern variation was observed, the strong influence of the local environment was constantly identified as an impediment to changes in practice.ConclusionsWe have identified that barriers present within local practice environments are the major driving forces behind controversies in the non-operative management of splenic injuries.     

Physiologically focused triage criteria improve utilization of pediatric surgeon-directed trauma teams and reduce costs

Introduction

Pediatric surgeon-directed trauma teams (STTs) provide lifesaving treatment but at a high cost. We used physiologically based criteria to improve STT utilization.

Methods

We reviewed 152 consecutive STT activations at one center, comparing standard and physiologically focused criteria and 24-hour hospital costs/charges for overtriaged patients vs level 2 (emergency department managed) blunt trauma patients matched for age, Injury Severity Score (ISS), and necessity for operation.

Results

Our cohort (73.0% male; 86.8% blunt; median age, 8.0 [interquartile range, 4.0-14.0] years) had 10 deaths (6.6%) and 18 (11.8%) emergent operations. Twenty-nine patients met neither standard nor physiologic criteria (group 1), 25 met standard but not physiologic criteria (overtriaged, group 2), and 98 met physiologic criteria (group 3). Group 3 had higher median ISS (19.0 [10.0-33.0] vs 10.0 [4.0-17.0] and 5.5 [5.0-16.75] for groups 1 and 2, P = .001), more intensive care unit admissions (67.2% vs 31.0% and 52.0%, P = .001), longer hospitalization (5.0 [3.0-9.25] days vs 3.0 [1.0-5.0] and 4.0 [2.0-5.0] days, P = .002), and all patients who died or required emergent operation (P < .001). Physiologic criteria maintained 100% sensitivity but improved specificity (49.2% vs 23.0%). Overtriaged patients (n = 18) had 78.2% higher charges ($4700; 95% confidence interval, 13.3%-180.1%; P = .013) and 53.4% higher costs ($800; 95% confidence interval, 1.8%-131.2%; P = .041) than level 2 patients (n = 259) after adjusting for age, ISS, and need for operation, largely because of computed tomography and emergency department charges (66% of overtriaged charges).

Conclusions

Physiologic STT activation criteria would have saved 25 activations, $20,000 in costs, and $120,000 in charges annually without compromising patient safety.     

Adherence to APSA activity restriction guidelines and 60-day clinical outcomes for pediatric blunt liver and splenic injuries (BLSI)

Background

After NOM for BLSI, APSA guidelines recommend activity restriction for grade of injury + 2 in weeks. This study evaluates activity restriction adherence and 60?day outcomes.

Management of adult blunt splenic injuries: comparison between level I and level II trauma centers

BACKGROUND: The factors important in determining outcome when managing adult blunt splenic injuries continue to be debated. Whether trauma center level designation (Level I versus Level II) affects patient management has not been evaluated. STUDY DESIGN: We conducted a retrospective analysis of prospectively gathered data from the Pennsylvania Trauma Outcome Study database that collected information from 27 statewide trauma centers (Level I [15], Level II [17]). Adult patients (ages > or = 16 years) with blunt splenic injuries (ICD-9-CM 865) were evaluated. Demographic data, injury data, and trauma center level designation were collected, and patient management, length of stay, and mortality were analyzed. RESULTS: There were 2,138 adult patients who suffered blunt splenic injuries during the study period (1998-2000). Patients treated at Level II trauma centers (n = 772) had a higher rate of operative treatment (38.2% versus 30.7%) (p < 0.001), but a shorter mean length of stay (10.1 +/- 0.4 versus 12.0 +/- 0.4 days) (p < 0.01) compared with patients in Level I trauma centers (n = 1,366). The rate of failure of nonoperative treatment was lower at Level II trauma centers (13.0% versus 17.6%) (p < 0.05), but the mortality for patients managed nonoperatively was higher (8.4% versus 4.5%) (p < 0.05). Splenorrhaphy was performed more frequently in Level I trauma centers. CONCLUSIONS: Management differences exist in the treatment of adult blunt splenic injuries between institutions of different trauma center level designation. Multicenter studies should account for this finding in design and implementation.     

Variation in treatment of pediatric spleen injury at trauma centers versus nontrauma centers: a call for dissemination of American Pediatric Surgical Association benchmarks and guidelines

BACKGROUND: American Pediatric Surgical Association consensus guidelines for children with blunt spleen injuries have been defined and validated in children's hospitals, but large administrative data sets indicate that only 10% to 15% of children with blunt spleen injuries are treated at children's hospitals. We sought to identify the frequency and compare the treatment of children with spleen injury in hospitals with and without recognized trauma expertise, with the aim of identifying a meaningful target for dissemination of benchmarks and consensus guidelines. STUDY DESIGN: State health departments' administrative data sets from California, Florida, New Jersey, and New York were analyzed for 2000, 2001, and 2002. All children with head injury or other nonspleen abdominal injuries requiring surgery were excluded. Injury Severity Scores were determined by ICDMAP-90. RESULTS: There were 3,232 patients with blunt spleen injury. Trauma centers had a significantly lower rate of operation for both multiply injured patients (15.3% versus 19.3%, p < 0.001) and those with isolated injury (9.2% versus 18.5%, p < 0.0001) when compared with nontrauma centers. The operative rates at both trauma centers and nontrauma centers exceed published American Pediatric Surgical Association benchmarks for all children with spleen injury (5% to 11%) and the subset with isolated spleen injury (0% to 3%). Independent risk factors for splenectomy included ages 15 to 19 years (p < 0.002), spleen injury severity (p < 0.0001), and presence of multiple injuries (p < 0.04). Adjusted odds ratio for risk of splenic operation in all patients with spleen injury was 2.122 (95% CI:1.455- 3.096) when treated at a nontrauma center (p < 0.0001). CONCLUSIONS: These multistate discharge data indicate that treatment of children with blunt spleen injury differs significantly when comparing trauma centers and nontrauma centers. Because nearly two-thirds of these children were treated at trauma centers, dissemination of American Pediatric Surgical Association guidelines and benchmarks through state or regional trauma systems may reduce the number of children having operations for splenic injury.     

Safety of selective nonoperative management for blunt splenic trauma: the impact of concomitant injuries

Background

Nonoperative management for blunt splenic injury is the preferred treatment. To improve the outcome of selective nonoperative therapy, the current challenge is to identify factors that predict failure. Little is known about the impact of concomitant injury on outcome. Our study has two goals. First, to determine whether concomitant injury affects the safety of selective nonoperative treatment. Secondly we aimed to identify factors that can predict failure.

Methods

From our prospective trauma registry we selected all nonoperatively treated adult patients with blunt splenic trauma admitted between 01.01.2000 and 12.21.2013. All concurrent injuries with an AIS?≥?2 were scored. We grouped and compared patients sustaining solitary splenic injuries and patients with concomitant injuries. To identify specific factors that predict failure we used a multivariable regression analysis.

Results

A total of 79 patients were included. Failure of nonoperative therapy (n =?11) and complications only occurred in patients sustaining concomitant injury. Furthermore, ICU-stay as well as hospitalization time were significantly prolonged in the presence of associated injury (4 versus 13?days,p <?0.05). Mortality was not seen. Multivariable analysis revealed the presence of a femur fracture and higher age as predictors of failure.

Conclusions

Nonoperative management for hemodynamically normal patients with blunt splenic injury is feasible and safe, even in the presence of concurrent (non-hollow organ) injuries or a contrast blush on CT. However, associated injuries are related to prolonged intensive care unit- and hospital stay, complications, and failure of nonoperative management. Specifically, higher age and the presence of a femur fracture are predictors of failure.

     

The management of splenic trauma in a trauma system

Large teaching centers have reported splenic salvage rates of 40% to 50% in adults after splenic trauma. It is unknown whether similar salvage rates can be achieved safely in community trauma centers with a lower volume of patients and less experience. Between August 1984 and August 1988, 117 patients with splenic injury were treated at a level I center and 311 were treated at four level II centers. Splenectomy was performed in 252 patients (59%), splenorrhaphy was performed in 160 patients (37%), and 16 patients (4%) were observed. While the splenic salvage rate was higher at the level I center (50% vs 38%), selective splenorrhaphy was successful in the level II centers where the volume of splenic injury was lower (15 to 25 cases per year).