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Management of pediatric liver injuries: a 13-year experience at a pediatric trauma center
Insights
Most pediatric liver injuries (LI) can be managed nonoperatively. Hemodynamic instability, indicated by significant blood transfusion needs, signals major hepatic vascular injury (MHVI) and a higher risk of mortality in children.
Area of Science:
- Pediatric Surgery
- Trauma Surgery
- Hepatobiliary Surgery
Background:
- Traumatic liver injuries (LI) are a significant concern in pediatric trauma.
- Effective management strategies are crucial for improving outcomes.
Purpose of the Study:
- To review the management of pediatric traumatic liver injuries.
- To identify key indications for surgical intervention in these cases.
Main Methods:
- A retrospective analysis of 11,761 pediatric admissions over 13 years.
- Inclusion of patients with identified traumatic liver injuries.
Main Results:
- 328 children sustained liver injuries, with common causes including vehicle accidents and falls.
- Nonoperative management was successful in 72% of cases.
- Hemodynamic instability (requiring >25 mL/kg transfusion in 2 hours) indicated major hepatic vascular injury (MHVI) and was associated with increased mortality.
Conclusions:
- The majority of pediatric liver injuries do not require surgery and can be managed nonoperatively.
- Hemodynamic instability is a critical indicator for potential MHVI and necessitates careful surgical consideration.
Purpose:
This study of traumatic liver injuries (LI) in children reviews the authors' management and identifies the indications for surgical intervention.
Methods:
A total of 11,761 admissions over 13 years to a regional pediatric trauma center were surveyed.
Results:
LI were identified in 328 children. Mechanisms included 39% pedestrians struck by a vehicle, 34% motor vehicle occupants, 13% falls or discrete blows to the abdomen, 5% bicycle injuries, 5% child abuse, and 4% penetrating injuries. Eighty-seven of patients with LI were treated nonoperatively with a mortality rate of 17%. Six percent of deaths were attributed to the LI and massive hemorrhage, all of which presented with cardiopulmonary resuscitation (CPR) in progress, with the remainder of deaths attributed to massive head, neck, or chest injuries (HNCI, 90%) and sepsis (4%). Surgery was performed in 13% of all LI and included major hepatic vascular injury (MHVI) repairs (34%), hepatorrhaphies (34%), lobectomies (27%), and biliary repairs (4%). Excluding the nonoperative group deaths, the need for blood transfusion of more than 25 mL/kg in the first 2 hours as an indicator of surgical necessity or a MHVI had, respectively, a sensitivity of 34% and 67%, specificity of 98% and 97%, positive predictive value of 79% and 53%, negative predictive value of 89% and 98%, and prediction accuracy of 88% and 95%. In the surgical management group, the mortality rate was 23% with 40% of deaths attributed to MHVI, 30% a combination of MHVI and HNCI, 20% massive HNCI, and 10% sepsis.
Conclusions:
The majority of pediatric LI are not associated with hemodynamic instability and can be successfully managed nonoperatively (72%). Hemodynamic instability, as defined by the need for blood transfusion in excess of 25 mL/kg within the first 2 hours, was a strong indicator of a MHVI, which was often a lethal injury (70%).