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Published on: February 2, 2021
Variable management of pediatric blunt renal trauma: A multicenter retrospective cohort study
Sindhu V Mannava1, Rodica Muraru, Jodi Raymond
1From the Department of Surgery (S.V.M.), and Department of Surgery (R.M.), Surgical Outcomes and Quality Improvement Center, Indiana University School of Medicine, Indianapolis, Indiana; Riley Hospital for Children (J.R.), Indiana University Health, Indianapolis, Indiana; Division of Pediatric Surgery, Department of Surgery (T.A.M., M.P.L.), Indiana University School of Medicine, Indianapolis, Indiana; Division of Pediatric Surgery (K.C.B., R.T.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio; Division of Pediatric Surgery (K.F.-O'.B., D.R.L., J.P.M.), Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Surgery (H.A.H., K.E.S., N.R.S.), University of Michigan School of Medicine, Ann Arbor, Michigan; Department of Surgery (S.D.S.P., M.E.), Children's Mercy Kansas City, University of Missouri-Kansas City, Kansas City, Missouri; Division of Pediatric Surgery (S.A.A., J.B.P.), Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois; Department of Surgery (K.C.), University of Chicago Pritzker School of Medicine, Chicago, Illinois; Division of Pediatric Surgery (S.C., D.F., T.W.), Norton Children's Hospital, University of Louisville, Louisville, Kentucky; Division of Pediatric Surgery (S.D.G.), Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Nationwide Children's Hospital (S.K.), Columbus, Ohio; Division of Pediatric General and Thoracic Surgery (M.K.), Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Pediatric Surgery, Department of Surgery (C.L.), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Division of Pediatric Surgery (G.Z.M.), Comer Children's Hospital, University of Chicago Pritzker School of Medicine, Chicago, Illinois; Division of Pediatric General and Thoracic Surgery (S.M.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Surgery (N.M.S.), St. Louis School of Medicine, Washington University, St. Louis, Missouri; Department of Surgery (M.S.), School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin; and Division of Pediatric Surgery (A.Y.), St. Louis School of Medicine, Washington University, St. Louis, Missouri.
Insights
Management of pediatric blunt renal injury varies widely, with no standard guidelines. This study found that while isolated injuries showed minimal outcome differences, polytrauma patients benefited from intensive care unit (ICU) admission.
Area of Science:
- Pediatric surgery
- Trauma surgery
- Nephrology
Background:
- Comprehensive management guidelines for pediatric blunt renal injury are lacking.
- Significant variation in care likely exists, impacting patient outcomes.
- This study aimed to describe current management practices and their association with adverse events.
Purpose of the Study:
- To describe contemporary management strategies for pediatric blunt renal trauma.
- To explore associations between clinical management and adverse outcomes.
- To identify areas for improved care standardization.
Main Methods:
- Retrospective review of 276 pediatric blunt renal injury patients from 11 Level I trauma centers (2020-2022).
- Categorization by injury grade (low: 1-3, high: 4-5) and type (isolated vs. polytrauma).
- Analysis of management strategies (bedrest, catheter, antibiotics, ICU, consults, labs/imaging) and outcomes (interventions, mortality, infection, readmission, hypertension, DVT).
Main Results:
- Management strategies like antibiotic use, ICU admission, and urinary catheterization varied across institutions.
- Adverse and intervention outcomes did not significantly differ based on bedrest, antibiotics, or post-discharge imaging.
- High-grade polytrauma patients with ICU admission had significantly higher adverse outcomes (55.6%) than those without (18.2%).
- Low-grade polytrauma patients with serial hemoglobin, renal labs, or inpatient imaging had better outcomes compared to those without.
Conclusions:
- Pediatric blunt renal injury management is inconsistent across institutions.
- Isolated renal injuries showed minimal outcome variation despite differing management.
- A consensus-based algorithm is needed to standardize care and improve outcomes, particularly for polytrauma patients.
Background:
There are no comprehensive management guidelines for pediatric blunt renal injury; therefore, we hypothesized that wide variation in care exists. We sought to describe contemporary management of pediatric blunt renal trauma and explore associations between clinical management strategies and adverse outcomes.
Methods:
We retrospectively evaluated blunt renal injury patients (younger than 18 years) treated at 11 pediatric level I trauma centers from 2020 to 2022. We categorized patients by the American Association for the Surgery of Trauma renal injury grade (low, grades 1-3; high, grades 4-5) and isolated renal injury versus polytrauma. Clinical management strategies included bedrest, urinary catheter use, antibiotic use, urology consult, intensive care unit (ICU) admission, and serial laboratory/imaging. We determined site-specific clinical management strategy frequencies and compared composite intervention outcomes (operations, interventional radiology procedures, blood transfusions) and composite adverse outcomes (mortality, infection, readmission, hypertension, deep venous thrombosis) between patients who did and did not undergo given clinical management strategies.
Results:
We analyzed 276 patients stratified by low-grade isolated (15.2%), low-grade polytrauma (51.1%), high-grade isolated (12%), and high-grade polytrauma (21.7%). Compared with other clinical management strategies, antibiotic use, ICU admission, and urinary catheter placement were less universally implemented across sites. Composite adverse and intervention outcomes did not vary significantly based on use of bedrest, antibiotics, and postdischarge serial renal imaging (all p > 0.05). Composite adverse outcomes varied significantly among high-grade polytrauma patients with and without ICU admission (55.6% vs. 18.2%, p = 0.003) and among low-grade polytrauma patients with and without serial hemoglobin laboratories (20.8% vs. 0%, p = 0.04), serial renal laboratories (26.3% vs. 10.1%, p = 0.02), and serial inpatient renal imaging (28.6% vs. 13%, p = 0.04).
Conclusion:
Pediatric blunt renal injury management varied across institutions. Patients with isolated renal injuries had minimal differences in interventions or adverse outcomes despite variable clinical management. This population would benefit from a consensus-based algorithm to minimize clinical management strategy variation.
Level Of Evidence:
Therapeutic/Care Management; Level IV.
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