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Can we safely decrease intensive care unit admissions for children with high grade isolated solid organ injuries?
Mary Arbuthnot1, Lindsey Bendure Armstrong1, David P Mooney1
1Boston Children's Hospital, Department of Surgery, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115, United States.
Insights
Pediatric blunt solid organ injuries can be safely managed by limiting intensive care unit (ICU) admission to children with an elevated shock index for pediatric age-adjusted (SIPA) or low hematocrit. This approach reduces ICU admissions by two-thirds.
Area of Science:
- Pediatric Surgery
- Trauma Management
- Critical Care Medicine
Background:
- Established guidelines recommend intensive care unit (ICU) admission for pediatric patients with grade IV blunt liver and splenic injuries.
- There is a need to refine criteria for ICU admission in children with isolated solid organ injuries (SOI).
Purpose of the Study:
- To identify predictors of ICU-level interventions in children with isolated blunt SOI.
- To determine if the shock index for pediatric age-adjusted (SIPA) and hematocrit can guide ICU admission decisions.
Main Methods:
- A retrospective review of pediatric patients with isolated liver, spleen, or kidney injuries admitted to the ICU between November 2003 and August 2015.
- ICU-level interventions included transfusion, vasopressor use, intubation, and operative/procedural intervention.
- Sensitivity and negative predictive values (NPV) were calculated for elevated SIPA or hematocrit <30%.
Main Results:
- 133 children met inclusion criteria; 19% required ICU-level intervention.
- An elevated SIPA or hematocrit <30% was present in 95% of the intervention group versus 22% of the non-intervention group.
- The sensitivity was 95% and the NPV was 99% for these criteria.
Conclusions:
- Limiting ICU admission to children with isolated SOI and either an elevated SIPA or hematocrit <30% can significantly reduce ICU admission rates.
- This strategy can decrease ICU admissions by two-thirds while maintaining patient safety.
- SIPA and hematocrit are valuable tools for predicting the need for ICU-level intervention in pediatric SOI.
Background:
In 2000, the American Pediatric Surgical Association (APSA) disseminated consensus practice guidelines for the management of blunt liver and splenic injury which included intensive care unit (ICU) admission for children with grade IV injuries. We sought to determine if we could better predict which children with isolated solid organ injuries (SOI) underwent an ICU-level intervention, thus necessitating ICU admission.
Methods:
Children with isolated liver, spleen, or kidney injuries admitted to the ICU from November 2003 to August 2015 were identified in our trauma registry, and data were extracted from the medical record. ICU-level interventions were defined as transfusion, vasopressor use, intubation, and operative/procedural intervention. Shock index and pediatric age-adjusted (SIPA) was calculated for all patients. The sensitivity and negative predictive values (NPV) were determined.
Results:
133 children met inclusion criteria. 19 (14.3%) required ICU-level intervention, and 114 (85.1%) did not. 95% (n=18) of the intervention group had either an elevated SIPA or a hematocrit <30% on admission compared to 22% (n=25) of patients in the no intervention group. Sensitivity was 95%, and NPV was 99%.
Conclusions:
Limiting ICU admission in children with isolated SOI to those with an elevated SIPA or hematocrit <30% would reduce the ICU admission rate by two-thirds while maintaining patient safety.
Type Of Study:
Diagnostic study.
Level Of Evidence:
III.