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Hemodilution in pediatric trauma: Defining the expected hemoglobin changes in patients with liver and/or spleen
Rachael L Stottlemyre1, David M Notrica2, Aaron S Cohen3
1Phoenix Children's, Phoenix, AZ 85016, United States; University of Miami Miller School of Medicine, Miami, FL 33136, United States.
Insights
Hemoglobin decreases are common in children with blunt liver and spleen injury, even without bleeding. Initial hemoglobin levels, not subsequent ones, predict non-operative management failure and transfusion needs.
Area of Science:
- Pediatric Traumatology
- Hepatobiliary and Splenic Injury Management
Background:
- Blunt liver and/or spleen injury (BLSI) in children often presents with hemoglobin decrease, irrespective of intra-abdominal bleeding.
- Understanding hemoglobin dynamics is crucial for managing these injuries.
Purpose of the Study:
- To analyze initial and follow-up hemoglobin values in pediatric BLSI patients.
- To determine the correlation between hemoglobin levels and intra-abdominal bleeding, transfusion needs, and non-operative management (NOM) outcomes.
Main Methods:
- Prospective cohort study of children (≤18 years) with BLSI.
- Analysis of hemoglobin levels in four groups: non-bleeding, bleeding without transfusion, bleeding with transfusion, and NOM failure.
- Statistical analysis of initial and follow-up hemoglobin data.
Main Results:
- A mean hemoglobin decrease of 0.83 g/dL was observed in non-bleeding patients.
- Initial hemoglobin levels >9.25 g/dL significantly reduced the odds of NOM failure (OR 14.2x less) and transfusion (OR 11.4x less).
- Follow-up hemoglobin levels did not correlate with NOM success or the need for transfusion.
Conclusions:
- Hemoglobin decrease post-trauma is expected, even without active bleeding.
- Initial hemoglobin measurement is valuable for predicting outcomes in pediatric BLSI.
- Routine rechecking of hemoglobin is not recommended; initial assessment is key.
Background:
Many children with blunt liver and/or spleen injury (BLSI) never bleed intraperitoneally. Despite this, decreases in hemoglobin are common. This study examines initial and follow up measured hemoglobin values for children with BLSI with and without evidence of intra-abdominal bleeding.
Methods:
Children ≤18 years of age with BLSI between April 2013 and January 2016 were identified from the prospective ATOMAC+ cohort. Initial and follow up hemoglobin levels were analyzed for 4 groups with BLSI: (1) Non bleeding; (2) Bleeding, non transfused (3) Bleeding, transfused, and (4) Bleeding resulting in non operative management (NOM) failure.
Results:
Of 1007 patients enrolled, 767 were included in one or more of four study cohorts. Of 131 non bleeding patients, the mean decrease in hemoglobin was 0.83 g/dL (+/-1.35) after a median of 6.3 [5.1,7.0] hours, (p = 0.001). Follow-up hemoglobin levels in patients with and without successful NOM were not different. For patients with an initial hemoglobin >9.25 g/dL, the odds ratio (OR) for NOM failure was 14.2 times less, while the OR for transfusion was 11.4 times less (p = 0.001).
Conclusion:
Decreases in hemoglobin are expected after trauma, even if not bleeding. A hemoglobin decrease of 2.15 g/dL [0.8 + 1.35] would still be within one standard deviation of a non bleeding patient. An initial low hemoglobin correlates with failure of NOM as well as transfusion, thereby providing useful information. By contrast, subsequent hemoglobin levels do not appear to guide the need for transfusion, nor correlate with failure of NOM. These results support initial hemoglobin measurement but suggest a lack of utility for routine rechecking of hemoglobin.
Level Of Evidence:
Level II Prognostic Study.
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