Timeline to operative intervention for solid organ injuries in children

Nonoperative management of solid organ injuries (SOI) in children is now the standard of care. Little is know regarding the time to failure for those children requiring operative intervention. We sought to delineate this timeline to operative intervention for the subset of single solid organ injured patients requiring laparotomy.

The National Trauma Data Bank (NTDB) was queried for the period 1991 to 2003 for all children (age <15) with a single abdominal SOI (kidney, liver, spleen). Children with significant associated head injury (Abbreviated Injury Score; AIS >2) were excluded. Data abstracted included age, organ injury and severity (ICD-9, AIS), and operative procedures. Survival analysis methods were used to evaluate equality of hazard rates (indicating rate of operative intervention by hour).

For the period of review, the NTDB contained 2,013 children with a single SOI including 1,813 eligible for review. The mean age was 9.2 +/- 3.8 years with a mean Injury Severity Score (ISS) of 8.6 +/- 6.3. The study population included 224 (12.4%) kidney injuries, 488 (26.9%) liver injuries, and 1,101 (60.7%) splenic injuries. A total of 120 (6.6%) of the patients required an operation for their solid organ injury. The median time to operation was 2.4 hours with 61.7% undergoing surgery within 3 hours of arrival, 79.4% within 6 hours, and 89.7% within 24 hours. The operative intervention rate was greatest for splenic injuries (8.7%) followed by liver (3.5%) and kidney (3.1%) injuries. Hazard rates varied significantly by organ injured (p < 0.001) and peaked at 1.5 hours for liver, 2 hours for spleen, and 4.5 hours for kidney. Hazard rates varied significantly by injury severity (p < 0.001) with a peak time to surgery for all severity at 2 hours postadmission.

Although the patterns for peak time to operative intervention varied for the specific organs injured and injury severity, the need for operative intervention for children with an SOI is established for the vast majority of children within 24 hours of admission.