Non-operative Management of Pediatric Solid Organ Injury · 2018. 5. 27. · non-operative...
Transcript of Non-operative Management of Pediatric Solid Organ Injury · 2018. 5. 27. · non-operative...
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NON-OPERATIVE MANAGEMENT OF PEDIATRIC SOLID ORGAN
INJURYJESSICA A. NAIDITCH, MD
TRAUMA MEDICAL DIRECTOR, DELL CHILDREN’S MEDICAL CENTER OF CENTRAL TEXAS
ASSISTANT PROFESSOR OF SURGERY AND PERIOPERATIVE CARE
UNIVERSITY OF TEXAS – AUSTIN
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NO DISCLOSURES
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PEDIATRIC TRAUMA IS COMMON
• 22 million children seek medical
care yearly
• 22,000 die annually
• Most common cause of childhood
mortality
• World-wide public health issue
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SOLID ORGAN INJURY IS COMMON IN CHILDREN
• Organs closely packaged
• Immature rib cage
• Less soft tissue padding
• Includes:
• Liver
• Spleen
• Kidney
• Pancreas
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MECHANISMS OF SOLID ORGAN INJURY
• Falls
• Playground injury
• Motor vehicle collisions
• Pedestrian vs motor vehicle
• Non-accidental trauma
• Recreational activities
• Bicycles
• Scooters
• Skateboards
• Sports
• Dirt bikes
• Hover boards
• ATV
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HOW DOES A CHILD WITH SOLID ORGAN INJURY PRESENT?
• History
• Blunt force trauma to the upper abdomen or chest
• Abdominal pain
• Children who can’t tell you
• In the absence of compromised mental status
• Shortness of breath
• Shoulder pain – referred
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HOW DOES A CHILD WITH SOLID ORGAN INJURY PRESENT?
• Exam
• Abdominal tenderness
• Abdominal wall findings
• Ecchymosis
• Abrasions
• Seat belt sign
• Handle bar marks
• Signs of shock
• Tachycardia
• Mental status changes
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LIVER AND SPLEEN INJURIES ARE THE MOST COMMON, POTENTIALLY LIFE
THREATENING, INTRA-ABDOMINAL INJURIES SUSTAINED IN CHILDREN.
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LIVER INJURY GRADE
Grade V Liver
Injury
Grade II Liver
Injury
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SPLEEN INJURY GRADE
Grade V Spleen
Injury
Grade III Spleen
Injury
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HOW DO WE TREAT THESE INJURIES?
• APSA Guidelines 1999
• Developed by Stylianos as part of APSA Trauma Committee
• Goal of >95% splenic salvage
• More details
• Days of Bed Rest = Injury Grade + 1
• Weeks to return to normal activity = Injury Grade + 2
• Ambitious plan, widely accepted
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• Unique aspect of APSA guideline was stratification of patients by CT injury
grade
• Guideline generally considered the standard
• Allowed a decrease in the resources used without a compromise in safety or
outcome
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• 44 patients with liver and/or spleen injury
• 40 excluded
• GCS < 13
• Thoracic injury
• Long-bone/pelvic fractures
• Hemodynamically abnormal
• 43 (97.7%) completed the pathway
• 1 developed a biloma
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• Protocol driven
• Changed the game
• Hemodynamics mattered more
• ICU utilization was decreased
• Decreased LOS without
complications
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THE SELECTION OF PATIENTS FOR NON-OPERATIVE MANAGEMENT SHOULD BE BASED UPON HEMODYNAMIC STABILITY
AND NOT THE GRADE OF INJURY.
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CRITERIA FOR NON-OPERATIVE MANAGEMENT OF BLUNT LIVER AND SPLEEN INJURY
• Hemodynamically stable
• Below blood transfusion threshold
• 50% of blood volume or 40cc/kg
• No other indication for an operation
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National Trauma Databank
• 413 patients
• High grade splenic injuries
• Non-operative management in
285
• 240 successfully
• 45 underwent delayed
operative management
Attempting non-operative
management is safe.
• Successful most of the time
• When it fails, operative outcomes
are similar to early operative
management.
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DOES BEDREST REALLY HELP?
• APSA recommended strict bed rest for Grade+1 days
• Is ambulation associated with bleeding?
• Is bedrest really treatment?
• Limitless numbers of cases treated with bedrest
• No evidence
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• 740 children with blunt abdominal trauma
• Blunt splenic injury in 270
• Contrast blush in 47
• No embolizations
• Contrast blush vs absence
• LOS: 5.1 vs 4.1days
• Blood transfusion: 25% vs 21%
• Need for splenectomy: 2% vs 4%
• Mortality: 4% vs 3%
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WHY SHOULDN’T WE JUST TAKE OUT THE SPLEEN?
• Overwhelming post-splenectomy infection (OPSI)
• Encapsulated organisms, most often Streptococcus
pneumoniae
• Meningitis and/or septicemia
• Rare, rapidly fatal infection
• 4.4% rate of OPSI with 50% mortality if < 16 years
• 0.9% rate of OPSI with 94% mortality if >16 years
• 2% will get OPSI after trauma splenectomy, half of these will
die
Holdsworth et al. Br. J. Surg. Vol 78 1991
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• Formed 7 years ago with 6 Level I Pediatric Trauma Centers
• Purpose was to do multicenter trauma research
• Arizona, Phoenix (PCH) – David Notrica
• Texas, Austin – Nilda Garcia
• Texas, Dallas – Steve Megison
• Oklahoma – Bob Letton and David Tuggle
• Memphis (Le Bonheur) – Trey Eubanks
• Arkansas – Todd Maxson
• Consortium
ATOMAC
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• 18 months developing an evidence-based algorithm for SOI
• Modified Delphi method
• Each center reviewed it with retrospective cases
• Started using the algorithm at version 7.4
• Revised it a few more times
• Other centers started asking for it
DEVELOPED AN ALGORITHM FOR THE TREATMENT OF SOLID ORGAN INJURY
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• Look at the evidence
• Make new recommendations based on studies already done
• Find the unanswered question
• Work together to answer those questions
PURPOSE
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NONOPERATIVE MANAGEMENT OF BLUNT LIVER AND SPLEEN INJURY IN CHILDREN: EVALUATION OF THE ATOMAC GUIDELINE
USING GRADE• 27 clinical questions
• Six 1A recommendations:
• Management based on hemodynamic status rather than grade
• Support for abbreviated period of bed rest
• Transfusion thresholds of 7g/dL
• Exclusion of peritonitis from a guideline
• Accounting for local resources and concurrent injuries in the management of children failing to stabilize
• Use of a guideline in patients with multiple injuries
• Two 1B recommendations
• Use of 40mL/kg of 4 units of blood to define end points for the guideline
• Discharging stable patients before 24 hours
Notrica et al. J Trauma Acute Care Surg 2015
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FAILURE OF NONOPERATIVE MANAGEMENT OF PEDIATRIC BLUNT LIVER AND SPLEEN
INJURIES
• 1008 patients
• 499 liver injury
• 410 spleen injury
• 99 both
• 34 (3%) underwent laparotomy or laparoscopy for spleen or liver bleeding
• Patients who failed:
• More likely to receive blood (52/69 vs 162/939; p < 0.001)
• Median time from injury to first blood transfusion: 2.3 hours vs 5.9 hours (p= 0.002)
• Mortality 24% in those who failed NOM due to bleeding
Linnaus et al. J Trauma Acute Care Surg 2017
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CONCLUSIONS
• Solid organ injuries, specifically splenic and liver, are common in pediatric
patients
• The vast majority can be managed non-operatively with good outcomes
• The outcomes are similar between those undergoing early operative
management and delayed operative management
• Delayed splenic hemorrhage is rare and not effected by day of mobilization
• Contrast blush is not an indication for operation or angiographic
intervention
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QUESTIONS?Jessica A. Naiditch, MD
Trauma Medical Director, Dell Children’s Medical Center of Central Texas
Assistant Professor of Surgery and Perioperative Care
University of Texas – Austin