Over the years, we have slowly gotten wiser about solid organ injuries (SOI). Way back when, before CT and ultrasound, if there was a suspicion a patient had such an injury you were off to the operating room. We learned (from children, I might add) that these injuries, especially the minor ones, were not such a big deal.
However, we routinely admit adults and children with solid organ injury of any grade. Many centers have streamlined their practice guidelines so that these patients don’t spend very long in the hospital, but most are still admitted. A number of researchers from Level I pediatric centers in the US got together to see if this is really necessary.
They combed through 10 years worth of TQIP data for outcomes and timing of intervention in children with low-grade (grades 1 and 2) solid organ injury age 16 or less. Children with “trivial” extra-abdominal injuries were included to make the conclusions more generalizable. Penetrating injuries and burns were excluded, as were those with “risk of hemorrhage” or need for abdominal exploration for reasons other than the SOI. The risk of hemorrhage was defined as a pre-existing condition or other injury that made it more likely that a transfusion might be necessary for other causes.
Here are the factoids:
- A total of 1,019 children with low-grade SOI (liver, kidney, or spleen) were enrolled in the study, and 97% were admitted
- There was an even distribution across age groups. Many studies over-represent teenagers; this was not the case here.
- Median LOS was 2 days, and a quarter were admitted to the ICU
- Only 1.7% required an intervention, usually on the first hospital day (transfusion, angiography, or laparotomy)
- Pediatric trauma centers did not perform any of the 9 angiographic procedures, and they only performed 1 laparotomy of the 4 reported
The authors concluded that practice guidelines should be developed for adult centers caring for children to decrease the number of possibly unnecessary interventions, and that it may be feasible to manage many children with low-grade SOI outside of the hospital.
Bottom line: This is an intriguing study. The admission length and silly restrictions like bed rest, NPO, and multiple lab draws are finally approaching their end. Although this paper does have the usual limitations of using a large retrospective database, it was nicely done and thoughtfully analyzed.
It confirms that adverse events in this population are very uncommon, and that adult centers are still too aggressive in treating children like adults. The recommendation regarding practice guidelines is very poignant and this should be a high priority.
Individual centers should determine if they have the infrastructure to identify low-risk children who have reliable families and live in proximity to a hospital with a general surgeon, or better yet, near a trauma center. Hopefully this study will help accelerate the adoption of such guidelines and practices, moving treatment for many children to the outpatient setting.
Reference: Hospital-based intervention is rarely needed for children with low-grade blunt abdominal solid organ injury: An analysis of the Trauma Quality Improvement Program registry. JTrauma 91(4):590-598, 2021.