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Pediatric blunt renal trauma practice management guidelines

Collaboration between the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society

Hagedorn, Judith C., MD; Fox, Nicole, MD; Ellison, Jonathan S., MD; Russell, Robert, MD; Witt, Cordelie E., MD; Zeller, Kristen, MD; Ferrada, Paula, MD; Draus, John M. Jr, MD

Journal of Trauma and Acute Care Surgery: May 2019 - Volume 86 - Issue 5 - p 916–925
doi: 10.1097/TA.0000000000002209
GUIDELINES
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BACKGROUND Injury to the kidney from either blunt or penetrating trauma is the most common urinary tract injury. Children are at higher risk of renal injury from blunt trauma than adults, but no pediatric renal trauma guidelines have been established. The authors reviewed the literature to guide clinicians in the appropriate methods of management of pediatric renal trauma.

METHODS Grading of Recommendations Assessment, Development and Evaluation methodology was used to aid with the development of these evidence-based practice management guidelines. A systematic review of the literature including citations published between 1990 and 2016 was performed. Fifty-one articles were used to inform the statements presented in the guidelines. When possible, a meta-analysis with forest plots was created, and the evidence was graded.

RESULTS When comparing nonoperative management versus operative management in hemodynamically stable pediatric patient with blunt renal trauma, evidence suggests that there is a reduced rate of renal loss and blood transfusion in patients managed nonoperatively. We found that in pediatric patients with high-grade American Association for the Surgery of Trauma grade III-V (AAST III-V) renal injuries and ongoing bleeding or delayed bleeding, angioembolization has a decreased rate of renal loss compared with surgical intervention. We found the rate of posttraumatic renal hypertension to be 4.2%.

CONCLUSION Based on the completed meta-analyses and Grading of Recommendations Assessment, Development and Evaluation profile, we are making the following recommendations: (1) In pediatric patients with blunt renal trauma of all grades, we strongly recommend nonoperative management versus operative management in hemodynamically stable patients. (2) In hemodynamically stable pediatric patients with high-grade (AAST grade III-V) renal injuries, we strongly recommend angioembolization versus surgical intervention for ongoing or delayed bleeding. (3) In pediatric patients with renal trauma, we strongly recommend routine blood pressure checks to diagnose hypertension. This review of the literature reveals limitations and the need for additional research on diagnosis and management of pediatric renal trauma.

LEVEL OF EVIDENCE Guidelines study, level III.

From the Department of Urology (J.C.H.), University of Washington, Seattle, Washington; Division of Pediatric Surgery, Department of Surgery (N.F.), Cooper University, Camden, New Jersey; Children's Hospital of Wisconsin and Medical College of Wisconsin (J.S.E.), Milwaukee, Wisconsin; Department of Surgery (R.R.), Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, Alabama; Department of Surgery (C.E.W.), University of Washington, Seattle, Washington; Department of Surgery (K.Z.), Section of Pediatric Surgery, Wake Forest School of Medicine, Wake Forest, North Carolina; Department of Surgery (P.F.), Virginia Commonwealth University, Richmond, Virginia; and Division of Pediatric Surgery, Department of Surgery (J.M.D.), University of Kentucky, Lexington, Kentucky.

Submitted: September 10, 2018, Revised: November 20, 2018, Accepted: December 24, 2018, Published online: Febuary 7, 2019.

Address for reprints: Judith C. Hagedorn, MD, Department of Urology, Harborview Injury Prevention and Research Center (HIPRC), University of Washington Harborview Medical Center, Box 359960, 325 9th Avenue, Seattle, WA 98104; email: judithch@uw.edu.

These guidelines were presented at the 31st EAST Annual Scientific Assembly, January 11-15th, 2018 in Lake Buena Vista, FL.

© 2019 Lippincott Williams & Wilkins, Inc.