Pediatric blunt abdominal injury: age is irrelevant and delayed operation is not detrimental
Monika Tataria1, Michael L Nance, James H Holmes
1Lucille Packard Children's Hospital, Stanford University, Palo Alto, California, USA.
Insights
For pediatric solid organ injuries, immediate operation versus failed nonoperative management shows no difference in outcomes like blood transfusions or mortality. The timing of surgery is not detrimental when indicated by patient physiology.
Area of Science:
- Pediatric Trauma Surgery
- Solid Organ Injury Management
- Surgical Outcomes Research
Background:
- Pediatric solid organ injury management has largely shifted to nonoperative approaches over 40 years.
- Characterizing children requiring operative intervention is crucial for understanding outcomes.
- Investigating potential disparities between immediate operation and failed nonoperative management is important.
Purpose of the Study:
- To characterize pediatric patients who require operative intervention for solid organ injuries.
- To compare outcomes between immediate operation (IO) and failed nonoperative management (F-NOM).
- To determine if F-NOM increases risks of mortality or morbidities.
Main Methods:
- Retrospective analysis of 2,944 pediatric trauma patients with blunt splenic, hepatic, renal, or pancreatic injuries from seven Level I trauma centers (1993-2002).
- Identified 140 patients (4.8%) requiring operation, divided into IO (laparotomy ≤3 hours) and F-NOM (laparotomy >3 hours).
- Collected data included demographics, hemodynamics, blood transfusions, Glasgow Coma Scale, Injury Severity Score, and lengths of stay (LOS).
Main Results:
- No age differences were found between IO and F-NOM cohorts.
- IO patients had worse hemodynamics, Injury Severity Score, and Glasgow Coma Scale score; liver injuries were associated with IO.
- Pancreatic injuries were associated with F-NOM; however, controlling for injury severity showed equivalent blood transfusions, ICU LOS, hospital LOS, and mortality between IO and F-NOM.
Conclusions:
- Immediate operation and failed nonoperative management are rare and age-independent in pediatric solid organ injury.
- The timing of surgical intervention for pediatric solid organ injury is not detrimental when indicated by patient physiology.
- Outcomes regarding blood transfusion, mortality, and LOS are comparable between IO and F-NOM when surgery is appropriately timed.
Background:
During the past 40 years, management of solid organ injury in pediatric trauma patients has shifted to highly successful nonoperative management. Our purpose was to characterize children requiring operative intervention. We hypothesized that older children would be more likely to require operative intervention. In particular, we wanted to examine potential outcome disparities between children who were operated upon immediately and those in whom attempted nonoperative management failed. Additionally, we asked whether attempted nonoperative management, when failed, put children at higher risk for mortality or morbidities such as increased blood product transfusions or lengths of stays.
Methods:
Retrospective cohorts from seven Level I pediatric trauma centers were identified. Blunt splenic, hepatic, renal, or pancreatic injuries were documented in 2,944 children <1 to 19 years of age from January 1993 to December 2002. Data collected included demographics, hemodynamics, blood transfusions, Glasgow Coma Scale score, Injury Severity Score, hospital length of stay (LOS), intensive care unit (ICU) LOS, and mortality. Analysis involved 140 (4.8%) of 2,944 patients requiring operation. Two cohorts were characterized: (1) immediate operation (IO), defined as laparotomy 3 hours after arrival (n = 59; 42%).
Results:
Comparing the two cohorts, no age differences were found. Compared with F-NOM, IO had significantly worse hemodynamics, Injury Severity Score, and Glasgow Coma Scale score and was associated with liver injuries. Pancreatic injuries were significantly associated with F-NOM. While controlling for injury severity to compare IO versus F-NOM, linear regression revealed equivalent blood transfusions, ICU LOS, hospital LOS, and mortality rates.
Conclusion:
IO and F-NOM are rare events and independent of age. When operated upon for appropriate physiology, the timing of operation in pediatric solid organ injury is irrelevant and not detrimental with respect to blood transfusion, mortality, ICU and hospital LOS, and resource utilization.
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