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Failure of nonoperative management of pediatric blunt liver and spleen injuries: A prospective Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium study

Linnaus, Maria E. MD; Langlais, Crystal S. MPH; Garcia, Nilda M. MD; Alder, Adam C. MD; Eubanks, James W. III MD; Maxson, R. Todd MD; Letton, Robert W. MD; Ponsky, Todd A. MD; St. Peter, Shawn D. MD; Leys, Charles MD; Bhatia, Amina MD; Ostlie, Daniel J. MD; Tuggle, David W. MD; Lawson, Karla A. PhD; Raines, Alexander R. MD; Notrica, David M. MD

Journal of Trauma and Acute Care Surgery: April 2017 - Volume 82 - Issue 4 - p 672–679
doi: 10.1097/TA.0000000000001375
AAST Plenary Papers
Editor's Choice

BACKGROUND: Nonoperative management (NOM) is standard of care for most pediatric blunt liver and spleen injuries (BLSI); only 5% of patients fail NOM in retrospective reports. No prospective studies examine failure of NOM of BLSI in children. The aim of this study was to determine the frequency and clinical characteristics of failure of NOM in pediatric BLSI patients.

METHODS: A prospective observational study was conducted on patients 18 years or younger presenting to any of 10 Level I pediatric trauma centers April 2013 and January 2016 with BLSI on computed tomography. Management of BLSI was based on the Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium pediatric guideline. Failure of NOM was defined as needing laparoscopy or laparotomy.

RESULTS: A total of 1008 patients met inclusion; 499 (50%) had liver injury, 410 (41%) spleen injury, and 99 (10%) had both. Most patients were male (n = 624; 62%) with a median age of 10.3 years (interquartile range, 5.9, 14.2). A total of 69 (7%) underwent laparotomy or laparoscopy, but only 34 (3%) underwent surgery for spleen or liver bleeding. Other (nonexclusive) operations were for 21 intestinal injuries; 15 hematoma evacuations, washouts, or drain placements; 9 pancreatic injuries; 5 mesenteric injuries; 3 diaphragm injuries; and 2 bladder injuries. Patients who failed were more likely to receive blood (52 of 69 vs. 162 of 939; p < 0.001) and median time from injury to first blood transfusion was 2.3 hours for those who failed versus 5.9 hours for those who did not (p = 0.002). Overall mortality rate was 24% (8 of 34) in those who failed NOM due to bleeding.

CONCLUSION: NOM fails in 7% of children with BLSI, but only 3% of patients failed for bleeding due to liver or spleen injury. For children failing NOM due to bleeding, the mortality was 24%.

LEVEL OF EVIDENCE: Therapeutic study, level II.

From the Level I Pediatric Trauma Center, Phoenix Children's Hospital (M.E.L., C.S.L., D.M.N.), Phoenix, AZ; Pediatric Trauma Center, Dell Children’s Medical Center (N.M.G., K.A.L., D.W.T.), Austin, TX; Pediatric Surgery Department, Children's Medical Center (A.C.A.), Dallas, TX; Department of Pediatric Surgery, Le Bonheur Children's Hospital (J.W.E.), Memphis, TN; Department of Pediatric Surgery, Arkansas Children's Hospital (R.T.M.), Little Rock, AR; Department of Surgery, The Children’s Hospital at OU Medical Center (R.W.L., A.R.R.), Oklahoma City, OK; Department of Pediatric Surgery, Akron Children’s Hospital (T.A.P.), Akron OH; Pediatric Surgery, Mercy Children’s Hospital (S.D.S.), Kansas City, MO; Pediatric Surgery, American Family Children’s Hospital (C.L.), Madison WI; Department of Pediatric Surgery, Children’s Healthcare of Atlanta (A.B.), Atlanta GA; and Department of Surgery, Phoenix Children’s Hospital, Phoenix AZ & American Family Children's Hospital (D.J.O.), Madison WI.

Submitted: September 1, 2016, Revised: November 20, 2016, Accepted: December 19, 2016, Published online: January 17, 2017.

This study was presented at the 76th annual meeting of the American Association for the Surgery of Trauma, September 13–16, 2016, in Waikoloa, Hawaii.

Address for reprints: David M. Notrica, MD, Division of Pediatric Surgery and Level I Pediatric Trauma Center, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016; email: dnotrica@phoenixchildrens.com.

© 2017 Lippincott Williams & Wilkins, Inc.