Tag Archives: Solid organ injury

General

Bedrest After Pediatric Liver/Spleen Injury? Really?

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A set of guidelines for management of blunt solid organ injury in children developed by the American Pediatric Surgical Association was originally published in 1999. One of the elements of the guideline was to place the child on bedrest for a period of time after the injury. Arbitrarily, this period was defined as the injury grade plus one day. So for a grade 3 spleen injury, the child would have to stay in bed for 4 days (!).

A paper published in 2013 looked at the impact of shortening this time interval. Over a 6 year period, all pediatric liver and spleen injuries from blunt trauma were identified and an abbreviated bedrest protocol was implemented. For low grade injuries (grade 1-2), children were kept in bed for 1 day, and for higher grade injuries this was extended to 2 days.

Here are the factoids:

  • 249 patients were enrolled (about 40 per year) with an average age of 10. “Bedrest was applicable for 199 patients, 80%.” Huh? Does that mean that 50 patients were excluded due to surgeon preference?
  • The organ injured was about 50:50 for spleen vs liver. Twelve children injured both.
  • Mean injury grade was 2.7, which is fairly high
  • Mean bedrest was 1.6 days, and mean hospital stay was 2.5
  • Bedrest was the limiting factor for hospital stay in 62% of cases
  • There were no delayed complications of the injury

Bottom line: Come on! Most centers don’t keep adult patients at bedrest this long, and we learned about solid organ injury management from kids! Children almost never fail nonop management, so why treat them more restrictively than adults? And have you ever tried to keep a child at bedrest? Impossible! This study is too underpowered to give real statistically valid results, but it certainly paints a good picture of what works. We recently updated our adult and pediatric protocols to eliminate bedrest and npo status. Let’s get rid of these anachronisms once and for all!

Reference: Follow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Ped Surg 48(12):2437-2441, 2013.

General

Updated Solid Organ Injury Protocol

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Over the past several days, I’ve been writing about updates to our solid organ injury protocol. It eliminates orders for bed rest and NPO diet status afterwards. After looking at our experience over the years, the number of early failures is practically zero. So how many days do you need to keep a patient in bed to make sure they have an empty stomach when they need to be whisked away to the OR. And does walking around really make your injured spleen fall apart?

The answers are none and no. So we’ve updated our protocol at Regions Hospital to reflect this. Feel free to download and modify to your heart’s content. If you want a copy of the Microsoft Publisher file, just email me!

Download the protocol here!

General

Bedrest After Pediatric Liver/Spleen Injury? Really?

Leave a comment

A set of guidelines for management of blunt solid organ injury in children developed by the American Pediatric Surgical Association was originally published in 1999. One of the elements of the guideline was to place the child on bedrest for a period of time after the injury. Arbitrarily, this period was defined as the injury grade plus one day. So for a grade 3 spleen injury, the child would have to stay in bed for 4 days (!).

Recent work looked at the impact of shortening this time interval. Over a 6 year period, all pediatric liver and spleen injuries from blunt trauma were identified and an abbreviated bedrest protocol was implemented. For low grade injuries (grade 1-2), children were kept in bed for 1 day, and for higher grade injuries this was extended to 2 days.

Here are the factoids:

  • 249 patients were enrolled (about 40 per year) with an average age of 10. “Bedrest was applicable for 199 patients, 80%.” Huh? Does that mean that 50 patients were excluded due to surgeon preference?
  • The organ injured was about 50:50 for spleen vs liver. Twelve children injured both.
  • Mean injury grade was 2.7, which is fairly high
  • Mean bedrest was 1.6 days, and mean hospital stay was 2.5
  • Bedrest was the limiting factor for hospital stay in 62% of cases
  • There were no delayed complications of the injury

Bottom line: Come on! Most centers don’t keep adult patients at bedrest this long, and we learned about solid organ injury management from kids! Children almost never fail nonop management, so why treat them more restrictively than adults? And have you ever tried to keep a child at bedrest? Impossible! This study is too underpowered to give real statistically valid results, but it certainly paints a good picture of what works. We’ve been keeping both adults and children at bedrest only overnight, and our average length of stay for isolated solid organs is about 1.5 days. But really, who says that staying in bed for any period of time avoids complications? There are lots of other evil things that can happen!

Related posts:

Reference: Follow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Ped Surg 48(12):2437-2441, 2013.

General

Phlebotomy And Pediatric Solid Organ Injury

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I recently wrote about this journal article from a couple of pediatric trauma programs in New York. The article tried to focus on reducing the rate of phlebotomy in children who are being observed for solid organ injury. I was more excited about the overall protocol being used to manage liver and spleen injury, as it was a great advance over the original APSA guideline. But let’s look at the phlebotomy part as well.

This is an interestingly weird study, and you’ll see what I mean shortly. Two New York trauma hospitals that take care of pediatric patients pooled 4 years of registry records on children with isolated blunt liver and/or spleen injuries. Then they did a tabletop excercise, looking at “what if” they had applied the APSA guideline, and “what if” they had applied their new, proposed guideline.

Interestingly, this implies that they were using neither! I presume they are trying to justify (and push all their partners) to move to the new protocol from (probably) random, individual choice.

Here are the factoids:

  • 120 records were identified across the 2 hospitals that met criteria
  • Late presentation to the hospital, contrast extravasation, comorbidities, lack of imaging, operative intervention at an outside hospital excluded 59 patients, leaving 61 for analysis. Three of those patients became unstable and were also excluded.
  • None of the remaining patients required operation or angioembolization
  • Use of the “new” (proposed) protocol would reduce ICU admissions by 65%, reduce blood draws by 70%, and reduce hospital stay by 37%
  • Conclusion: use of the protocol would eliminate the need for serial phlebotomy (huh?)

Bottom line: Huh? All this to justify decreasing blood draws? I know, kids hate needles, but the data on decreased length of stay in the hospital and ICU is much more important! We’ve been using a protocol similar to their “new” one at Regions Hospital, which I’ve shared below. We’ve been enjoying decreased resource utilization, blood draws, and very short lengths of stay for over a decade. And our analysis showed that we save $1000 for every patient entering the protocol, compared to the old-fashioned and inefficient way we used to manage them.

Related posts:

Reference: Reducing scheduled phlebotomy in stable pediatric patients with liver or spleen injury. J Ped Surg 49(5):759-762, 2014.

General

The FAST Exam in Children

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FAST is a helpful adjunct to the initial evaluation of adult trauma patients. Unfortunately, due to small numbers the usefulness is not as clear in children. In part, this is due to the fact that many children (particularly small children < 10 years old) have a small amount of fluid in the abdomen at baseline. This makes interpreting a FAST exam after trauma more difficult.

Despite this, use of FAST in children is widespread. A survey of 124 US trauma hospitals in 2007 showed an interesting pattern of ultrasound usage. In adult-only institutions 96% use FAST, and at hospitals that see both adults and kids, 85% use it. Most of these centers that use FAST have no lower age limit, and the physician most commonly performing the exam was a surgeon. However, only 15% of children’s hospitals do FAST exams, and they were usually done by nonsurgeons! The reasons for this are not clear. It appears that the pediatric surgeons have not embraced this technology as much as their adult counterparts.

What about that confusing bit of fluid found in kids? Several groups have looked at this (retrospectively). Fluid in the pelvis alone appears to be okay, but fluid anywhere else is a good predictor of solid organ injury. Fluid seen outside the pelvis had a 90% sensitivity and 97% specificity for injury, and positive and negative predictive values were 87% and 97% respectively.

Bottom line: FAST exam is useful in pediatric victims of blunt abdominal trauma. Fluid in the pelvis alone is normal in most children, but fluid seen anywhere else indicates a high probability of solid organ injury.

References: 

  1. Use of focused abdominal sonography for trauma at pediatric and adult trauma centers: a survey. J Pediatric Surgery 44:1746-1749, 2009.
  2. Minimal pelvic fluid in blunt abdominal trauma in children: the significance of this sonographic finding. J Pediatric Surgery 36(9):1387-1389, 2001.
  3. Clinical importance of ultrasonographic pelvic fluid in pediatric patients with blunt abdominal trauma. Ulus Travma Acil Cerrahi Derg 16(2):155-159, 2010.