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Does time to operating room affect outcomes after pediatric blunt hollow viscus injury? A Trauma Quality Improvement
William R Johnston1, Allison L Mak Croughan, Rosa Hwang
1From the Department of General, Thoracic, and Fetal Surgery (W.R.J., A.L.M.C., R.H., M.A., M.L.N., G.N.), Children's Hospital of Philadelphia; and Department of General Surgery (W.R.J.), Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
Insights
Delayed surgery for pediatric blunt hollow viscus injuries (HVIs) does not increase infection or mortality risks. While longer hospital stays are noted, outcomes remain similar for patients with blunt hollow viscus injuries.
Area of Science:
- Pediatric Surgery
- Trauma Surgery
- Gastrointestinal Surgery
Background:
- Blunt hollow viscus injuries (HVIs) are uncommon and challenging to diagnose in children.
- The impact of delayed operative intervention on pediatric blunt HVI outcomes is not well-established.
Purpose of the Study:
- To investigate the association between delayed surgery and outcomes in pediatric patients with blunt hollow viscus injuries.
- To analyze multicenter data to determine if delayed operative intervention affects patient outcomes.
Main Methods:
- A query of the Trauma Quality Improvement Program database (2016-2020) for pediatric patients (<18 years) with blunt HVI requiring surgery.
- Exclusion of patients with solid organ injury or other major thoracic/abdominal operations.
- Categorization of patients based on time from emergency department arrival to operating room (1-72 hours) and analysis of outcomes.
Main Results:
- 1,700 pediatric patients with blunt HVI were identified; 9% experienced delayed operations (>24 hours).
- Delayed surgery patients had higher Injury Severity Scores and longer hospital/ICU stays but no increased risk of surgical site infection, sepsis, or mortality.
- Delayed operations were associated with less frequent full-thickness injury identification and more concomitant orthopedic injuries.
Conclusions:
- Delayed diagnosis and surgery for blunt HVIs can occur, particularly with distracting injuries or without full-thickness perforation.
- Despite more severe injury profiles and longer hospitalizations, delayed operative intervention for pediatric blunt HVI does not appear to worsen key adverse outcomes.
- This suggests a potential window for non-operative management or delayed surgical intervention in select pediatric blunt HVI cases.
Background:
Blunt hollow viscus injuries (HVIs) are relatively rare and difficult to diagnose. Whether a delay in operative intervention impacts outcomes for pediatric patients with blunt HVI has not been investigated via analysis of multicenter databases.
Methods:
We queried the Trauma Quality Improvement Program database from 2016 to 2020 for patients younger than 18 years who underwent an operation of the stomach, small intestine, large intestine, or rectum within 72 hours of emergency department arrival after blunt injury. We excluded patients with solid organ injury and additional extra-intestinal abdominal or thoracic operations. Patients were categorized by the time from emergency department presentation to operating room arrival: 1 to 5, 5 to 12, 12 to 24, and 24 to 72 hours. We analyzed baseline characteristics and outcomes between groups.
Results:
We identified 1,700 patients, including 147 (9%) who were operated on >24 hours after arrival. Patients with delayed operations demonstrated higher Injury Severity Scores and higher Abbreviated Injury Scale scores for the head, face, and upper extremities and were more likely to require an orthopedic operation. Patients who received a delayed operation were less likely to have full-thickness injury noted in the operating room and demonstrated longer hospital and intensive care unit stays. However, there was no difference in superficial surgical site infection (SSI), deep SSI, organ space SSI, severe sepsis, or mortality between groups.
Conclusion:
Diagnosis and operative intervention for blunt HVI may be delayed in the presence of distracting injuries and in the absence of full-thickness perforation. While these patients typically have a more severe injury profile and require longer hospital stays, they do not appear to have increased rates of SSI, sepsis, or mortality.
Level Of Evidence:
Therapeutic/Care Management; Level IV.
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