Missed Opportunities to Decrease Radiation Exposure in Children with Renal Trauma

Gaither, Thomas W.; Awad, Mohannad A.; Leva, Natalia; Murphy, G.P.; Breyer, Benjamin N.; Copp, Hillary L.

doi:10.1016/j.juro.2017.09.001

Cited by 22 publications

(9 citation statements)

References 21 publications

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“…20 However, other studies have shown that obtaining the delayed phase CT scans at initial imaging for any detected renal laceration may in fact reduce the number of follow up CT scans required. 21 This present study definitively argues for obtaining an on-table delayed excretory CT scan in the context of any renal laceration scored Grade 3 or higher, which captured all urine leaks in our larger series. Furthermore, we found that having CT imaging on arrival was closely associated with day one detection of urine leaks and more streamlined management.…”

Section: Discussionsupporting

confidence: 52%

“…Some have questioned the necessity of obtaining CT imaging in pediatric renal trauma, with one study demonstrating that outcomes were not different between patients who had on-table delayed excretory CT and those who did not 20 . However, other studies have shown that obtaining the delayed phase CT scans at initial imaging for any detected renal laceration may in fact reduce the number of follow up CT scans required 21 . This present study definitively argues for obtaining an on-table delayed excretory CT scan in the context of any renal laceration scored Grade 3 or higher, which captured all urine leaks in our larger series.…”

Section: Discussionmentioning

confidence: 99%

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Urine leaks in children sustaining blunt renal trauma

Ghani¹,

Snyder

et al. 2022

J Trauma Acute Care Surg

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BACKGROUND:Few consensus statements exist to guide the timely diagnosis and management of urine leaks in children sustaining blunt renal trauma (BRT). The aims of this study were to characterize kidney injuries among children who sustain BRT, evaluate risk factors for urine leaks, and describe the negative impact of urinoma on patient outcomes and resource consumption. METHODS:A retrospective review was performed of 347 patients, younger than 19 years, who presented with BRT to a single American College of Surgeons-verified Level I Pediatric Trauma Center between 2005 and 2020. Frequency of and risk factors for urine leak after BRT were evaluated, and impact on patient outcomes and resource utilization were analyzed. RESULTS:In total, 44 (12.7%) patients developed urine leaks, which exclusively presented among injury Grade 3 (n = 5; 11.4%), Grade 4 (n = 27; 61.4%), and Grade 5 (n = 12; 27.3%). A minority of urine leaks (n = 20; 45.5%) were discovered on presenting CT scan but all within 3 days. Kidney-specific operative procedures (nephrectomy, cystoscopy with J/ureteral stent, percutaneous nephrostomy) were more common among urine leak patients (n = 17; 38.6%) compared with patients without urine leaks (n = 3; 1.0%; p = 0.001). Patients with urine leak had more frequent febrile episodes during hospital stay (n = 24; 54.5%; p = 0.001) and showed increased overall 90-day readmission rates (n = 14; 33.3%; p < 0.001). Independent risk factors that associated with urine leak were higher grade (odds ratio [OR], 7.9; 95% confidence interval [CI], 2.6-24.3; p < 0.001), upper-lateral quadrant injuries (OR, 2.9; 95% CI, 1.2-7.1; p = 0.02), and isolated BRT (OR, 2.6; 95% CI, 1.0-6.5; p = 0.04). CONCLUSION:In a large cohort of children sustaining BRT, urine leaks result in considerable morbidity, including more febrile episodes, greater 90-day readmission rates, and increased operative or image-guided procedures. This study is the first to examine the relationship between kidney quadrant injury and urine leaks. Higher grade (Grade 4-5) injury, upper lateral quadrant location, and isolated BRT were independently predictive of urine leaks.

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Section: Discussionsupporting

confidence: 52%

Section: Discussionmentioning

confidence: 99%

Urine leaks in children sustaining blunt renal trauma

Ghani¹,

Snyder

et al. 2022

J Trauma Acute Care Surg

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“…The widely used ALARA (as low as reasonably achievable) principle is heavily emphasized in pediatrics to decrease unnecessary radiation exposure in all populations [11]. Regarding the reduction of radiation exposure in pediatric patients with renal trauma, evidence shows utilizing ultrasound for monitoring of renal trauma after obtaining diagnostic CT scan is an effective way to decrease radiation exposure [12,13]. In patients being treated for renal trauma at more than one institution by multiple providers, the ALARA principle may be compromised due to lower pediatric imaging protocol adherence or lack of outside hospital image transfer, leading to increased radiation exposure.…”

Section: Discussionmentioning

confidence: 99%

“…Renal trauma in the pediatric population is unique compared to adults. Increased risk for injury and complications due to the relative size and lack of rib protection of the pediatric kidneys, increased likelihood of undiagnosed congenital urogenital tract anomalies leading to complications, and the task of minimizing pediatric radiation exposure can present challenges in management [12,[14][15][16][17]. Although challenges differ from the those faced in the adult population, the 2019 Eastern Association for the Surgery of Trauma (EAST) pediatric blunt renal trauma practice management guidelines recommend nonoperative management with close monitoring for post-traumatic renal hypertension as the gold standard management for both adults and pediatrics [17,18].…”

Section: Discussionmentioning

confidence: 99%

Renal Trauma in Pediatric Patients Transferred to Tertiary Care Center

LaCouture

Sandridge

Halstead

et al. 2022

Preprint

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PURPOSE:Patients with traumatic kidney injuries often require transfer to tertiary trauma centers. The purpose of our study is to describe the outcomes of pediatric patients who were transferred from an outside hospital versus those presenting initially to our level 1 pediatric trauma center.METHODS: We performed a retrospective chart review of patients 0-18 years-olds seen at our level 1 pediatric trauma center following acute renal trauma after external trauma of any AAST grade and any mechanism of injury. Data collected included clinical complications, number of follow-up visits, long-term sequelae, and imaging techniques used. Statistical analyses using Fisher’s Exact and Kruskal-Wallis tests were performed. RESULTS:26 transferred and 9 non-transferred patients met inclusion criteria. There were no statistically significant differences in repeat imaging, immediate complications, follow-up visits, or long-term adverse outcomes for transferred vs. non-transferred patients. When comparing patients who transferred <50 miles versus >=50 miles, there was a non-significant increase in immediate complications in the >=50 miles group. CONCLUSIONS: Transferred patients receive similar radiation exposure and may not be at increased risk for immediate or long-term complications. Future studies are needed to determine optimal criteria for transfer of renal trauma pediatric patients to level 1 trauma centers.

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“…Future research may reveal that repeat imaging of collecting system injury can be reasonably followed by ultrasound as urinoma is frequently picked up on ultrasonography. Indeed, a recent study investigating renal trauma in pediatric patients suggests that ultrasonography may be useful in evaluating renal trauma and beneficial in reducing unnecessary radiation [19]. In addition to limiting radiation, transition from CT scan to ultrasound could also reduce health care costs.…”

mentioning

confidence: 99%

Does routine repeat imaging change management in high-grade renal trauma? Results from three level 1 trauma centers

et al. 2018

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Purpose Guidelines call for routine reimaging of Grade 4-5 renal injuries at 48-72 h. The aim of the current study is to evaluate the clinical utility of computed tomography (CT) reimaging in high-grade renal injuries. Materials and methods We assembled data on 216 trauma patients with high-grade renal trauma at three level 1 trauma centers over a 19-year span between 1999 and 2017 in retrospectively collected trauma database. Demographic, radiographic, and clinical characteristics of patients were retrospectively reviewed. Results In total, 151 cases were Grade 4 renal injuries, and 65 were Grade 5 renal injuries. 53.6% (81) Grade 4 and 15.4% (10) Grade 5 renal injuries were initially managed conservatively. Of the 6 asymptomatic cases where repeat imaging resulted in intervention, 100% had collecting system injuries at initial imaging. Collecting system injuries were only present in 42.9% of cases where routine repeat imaging did not trigger surgical intervention. Collecting system injury at the time of initial imaging was a statistically significant predictor of routine repeat imaging triggering surgical intervention (p = 0.022). Trauma grade and the presence of vascular injury were not significant predictors of intervention after repeat imaging in asymptomatic patients. Conclusion In asymptomatic patients with high-grade renal trauma, the number needed to image is approximately one in eight (12.5%) to identify need for surgical intervention. There is potentially room to improve criteria for routine renal imaging in high-grade renal trauma based on the more predictive imaging finding of collecting system injury.

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Missed Opportunities to Decrease Radiation Exposure in Children with Renal Trauma

Cited by 22 publications

References 21 publications

Urine leaks in children sustaining blunt renal trauma

Urine leaks in children sustaining blunt renal trauma

Renal Trauma in Pediatric Patients Transferred to Tertiary Care Center

Does routine repeat imaging change management in high-grade renal trauma? Results from three level 1 trauma centers

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