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Davis DH, Localio AR, Stafford PW, et al. Trends in operative management of pediatric splenic injury in a regional trauma system

Department of Pediatrics, The Children's Hospital of Philadelphia, Filadelfia, Pennsylvania, United States
PEDIATRICS (Impact Factor: 5.3). 02/2005; 115(1):89-94. DOI: 10.1542/peds.2004-0508
Source: PubMed

ABSTRACT Selective nonoperative management of pediatric blunt splenic injury became the standard of care in the late 1980s. The extent to which this practice has been adopted in both trauma centers and nontrauma hospitals has been investigated sporadically. Several studies have demonstrated significant variations in practice patterns; however, most published studies capture only a selective population over a relatively short time interval, often without simultaneous adjustment for confounding variables. The objective of this study was to characterize the variation in operative versus nonoperative management of blunt splenic injury in children in nontrauma hospitals and in trauma centers with varying resources for pediatric care within a regionalized trauma system in the past decade.
The study population included all children who were younger than 19 years and had a diagnosis of blunt injury to the spleen (International Classification of Diseases code 865.00-865.09) and were admitted to each of the 175 acute care hospitals in Pennsylvania between 1991 and 2000. The proportion of patients who were treated operatively was stratified by trauma-level certification and adjusted for age and splenic injury severity. Multivariable logistic regression models were used to generate probabilities of splenectomy by age, injury severity, and hospital type.
From 1991 through 2000 in Pennsylvania, 3245 children sustained blunt splenic injury that required hospitalization; 752 (23.2%) were treated operatively. Generally, as age and splenic injury severity increased, the proportion of patients who were treated operatively increased. Compared with pediatric trauma centers, the relative risk (with associated 95% confidence interval) of splenectomy was 4.4 (3.0-6.3) for level 1 trauma centers with additional qualifications in pediatrics; 6.2 (4.4-8.7) for level 1 trauma centers, 6.3 (5.3-7.4) for level 2 trauma centers, and 5.0 (4.2-5.9) for nontrauma centers. Significant variation in practice pattern was seen among hospital types and over time even after adjustment for age and injury severity.
The operative management of splenic injury in children varied significantly by hospital trauma status and over time during the past decade in Pennsylvania. Given the relative benefits of nonoperative treatment for children with blunt splenic injury, these results highlight the need for more widespread and standardized adoption of this treatment, particularly in hospitals without a large volume of pediatric trauma patients.

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    • "Blunt trauma comprises 92% of all pediatric splenic injuries [2]. Selective NOM of blunt splenic injury in hemodynamically stable pediatric trauma patients has been adopted as the standard of care [2] [3] [4]. Accordingly, nationwide, from 2000–2008, splenectomy rates dropped from 18.3% to 10.9% [16]. "
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    ABSTRACT: 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 10-year retrospective review (January 2000-December 2010) of an institutional pediatric trauma registry identified 318 children with blunt splenic injury. Results Of 274 evaluable non-operatively managed pediatric blunt splenic injures, 12 patients (4.4%) developed left-sided pleural effusions. 7 of 12 patients (58%) 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, highgrade 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.
    Journal of Pediatric Surgery 09/2014; 49(9). DOI:10.1016/j.jpedsurg.2014.01.002 · 1.31 Impact Factor
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    • "For years, surgery has been advised for those with evidence of pancreatic ductal injury on the grounds that this can reduce morbidity, mortality as well as the length of hospital stay [2,4–6]. With the success of non-operative management of injuries to solid organs such as the liver, spleen and kidney, a lot of changes were seen in the management of blunt abdominal trauma [7] [8]. There is strong evidence from paediatric [4,9–15] as well as a few adult patients [16] [17] that even those with severe pancreatic contusion and ductal injury can be managed conservatively with good outcome. "
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    ABSTRACT: Background Pancreatic injury remains uncommon and the majority occurs in association with injury of other organs. For years, surgery has been advised for those with evidence of pancreatic duct damage. However, a lot of changes were seen in the management of blunt abdominal trauma, with strong support for non-operative management of solid organ injuries. There is strong evidence from pediatric patients that those with severe pancreatic contusion and ductal injury can be managed conservatively. Patients and Method: We present our cases of severe blunt pancreatic injury with ductal damage that were successfully managed non-operatively. We reviewed the literature to find evidence to support this management strategy. Result Our case report and the literature showed that majority of pancreatic ductal injury have been successfully managed non-operatively without increased morbidity or mortality. Conclusion Non-operative management of blunt pancreatic injury with ductal damage allows the formation of a pseudocyst for delayed drainage safely. This strategy of “induced pseudocyst” is particularly applicable to cases that present late and those with concomitant injuries of other organs. The majority of pseudocysts will subside by themselves. The use of embolization may decrease the need for urgent operation and timely percutaneous drainage may help relieve early symptoms.
    Injury Extra 05/2014; 45(5). DOI:10.1016/j.injury.2014.02.026
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    • "The impact of designated pediatric trauma centers (PTC) on the outcome of pediatric trauma patients compared with adult trauma centers (ATC) has been investigated using a large trauma database, with variable results [11] [12]. Care at PTC is known to be significantly associated with lower operative intervention for blunt splenic injury than at ATC [9] [11] [13]. There are scarce data comparing operative rates for blunt liver or kidney injury between ATC and PTC [11] [14]. "
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    ABSTRACT: BACKGROUND: Optimal management of adolescent trauma patients with blunt abdominal solid organ injury (SOI) remains controversial. The purpose of this study was to identify management differences in adolescents with SOI treated at adult trauma centers (ATC) versus pediatric trauma centers (PTC). We hypothesized that adolescents with SOI would undergo different treatment at ATC and PTC. MATERIALS AND METHODS: Retrospective review of the Pennsylvania Trauma Systems Foundation database from 2005-2010 was performed. Adolescent patients (13-18 y old) with SOI (spleen, liver, and kidney injury) were included. Patient baseline characteristics and care processes for each injury were compared between ATC and PTC. RESULTS: A total of 1532 patients with at least one SOI were identified: 946 patients had a splenic injury, 505 had a liver injury, and 424 had a kidney injury. Spleen and liver procedures were performed more often at ATC than at PTC irrespective of injury grade (respectively, 16.1% versus 3.2%, 5.9% versus 0%; P < 0.01). Transarterial embolization for splenic injury was more frequently performed at ATC (2.8% versus 0.6%; P = 0.02). After adjusting for potential confounding factors, care at PTC was significantly associated with lower odds of splenic procedure for patients with splenic injury (OR: 0.16, 95% CI: 0.08-0.36, P < 0.001). In a subgroup analysis of nontransfer patients, care at PTC remained significantly associated with lower odds of splenic procedure (OR: 0.24, 95% CI: 0.10-0.59, P = 0.002) despite higher median injury severity score than ATC. CONCLUSIONS: Significant differences in the management of adolescents with SOI were identified in Pennsylvania. Operative intervention for SOI was more often performed at ATC than at PTC. Further study will be needed to address the impact of these disparities on patient outcomes.
    Journal of Surgical Research 03/2013; 183(2). DOI:10.1016/j.jss.2013.02.050 · 2.12 Impact Factor
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