Variability in Pediatric Splenic Injury Care

Bowman, Stephen M.; Bulger, Eileen M.; Sharar, Sam R.; Maham, Sabrina A; Smith, Samuel D.

doi:10.1001/archsurg.2010.228

Cited by 18 publications

(8 citation statements)

References 17 publications

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“…4,18 Previous investigations have found benefit to instituting practice guidelines for splenic injury, 4,19,20 but have also shown that these guidelines are not widely known or used. 21 …”

Section: Discussionmentioning

confidence: 99%

Variation in intensive care unit utilization and mortality after blunt splenic injury

Kaufman

Wiebe²,

Martin³

et al. 2016

Journal of Surgical Research

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Background While trauma patients are frequently cared for in the ICU, admission triage criteria are unclear and may vary among providers and institutions. The benefits of close monitoring must be weighed against the economic and opportunity costs of an ICU admission. Materials and Methods We conducted a retrospective cohort study of patients treated for blunt splenic injuries at 30 level I and II Pennsylvania trauma centers, 2011–2014. We used multivariable logistic regression to assess the relationship between ICU admission and mortality, adjusting for patient characteristics, injury characteristics, and physiology. We calculated center-level observed-to-expected ratios for ICU utilization and mortality and evaluated correlations with Spearman’s rho. We compared the proportion of patients receiving critical care procedures, such as mechanical ventilation or central line placement, between high- and low-ICU-utilization centers. Results Of 2,587 patients with blunt splenic injuries, 63.9% (1,654) were admitted to the ICU. Median injury severity score (ISS) was 17 overall, 13 for non-ICU patients and 17 for ICU patients (p < 0.001). In multivariable logistic regression, ICU admission was not significantly associated with mortality. Center-level risk-adjusted ICU admission rates ranged from 17.9% to 87.3%. Risk-adjusted mortality rates ranged from 1.2% to 9.6%. There was no correlation between O:E ratios for ICU utilization and mortality (rs = −0.2595, p=0.2103). Proportionately fewer ICU patients at high-utilization centers received critical care procedures than at low-utilization centers. Conclusions Risk-adjusted ICU utilization rates for splenic trauma varied widely among trauma centers, with no clear relationship to mortality. Standardizing ICU admission criteria could improve resource utilization without increasing mortality.

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“…4,18 Previous investigations have found benefit to instituting practice guidelines for splenic injury, 4,19,20 but have also shown that these guidelines are not widely known or used. 21 …”

Section: Discussionmentioning

confidence: 99%

Variation in intensive care unit utilization and mortality after blunt splenic injury

Kaufman

Wiebe²,

Martin³

et al. 2016

Journal of Surgical Research

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“…Literature reports describe varying degrees of familiarity with and use of clinical practice guidelines for pediatric splenic injury management in the general surgeon group. Limited pediatric experience and a lack of pediatric hospital resources may limit the potential for a more widespread adoption of non-operative management approaches [10] . Especially in multi-trauma patients hemodynamic (in-) stability is not the only criterion for laparotomy.…”

Section: Discussion ▼mentioning

confidence: 99%

“…In the present series 32 % of laparotomies were performed for other indications than " hemodynamic instability " . But the term " hemodynamic instability " is also rather subjective [10] . The main challenge in the current management of the hemodynamically instable multi-trauma patient with intra-abdominal injury is defi ning the cause for the hemodynamic instability.…”

Section: Discussion ▼mentioning

confidence: 99%

Blunt Splenic Trauma in Children: Are We Too Careful?

et al. 2011

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Splenic injury in children is associated with substantial mortality. This is due to concomitant injuries and not to the splenic injury. Non-operative treatment is increasingly preferred to operative procedures when treating splenic injuries in hemodynamically, stable children. ICU and hospital stay have, despite the change from OT to NOT, remained the same. Complications after NOT are rare. We are still observing children in hospital for a longer period than is necessary.

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“…5–7,13,14,16 Despite the high grades of organ injury and substantial overall injury in the HMC solid organ injury population, the overall splenectomy frequency of 4.0% among all pediatric splenic injury patients at HMC from 2005 to 2012 falls below published benchmarks of 5% to 11% in a nonisolated injury population. 1,19 This suggests that there may be opportunity for further reducing splenectomy frequency, particularly among severely injured patients.…”

Section: Discussionmentioning

confidence: 99%

“…Review of this experience has led to the publication of benchmarks of a splenectomy frequency of no more than 3% in children with isolated splenic injuries and of 5% to 11% in all children with splenic injury. 1 This goal seems to be achievable in a variety of care settings 2–4 without subjecting patients to increased risk of transfusion, urgent surgery, late complications, or mortality. 4–12 In nonoperatively managed patients, subsequent efforts aimed to decrease resource use showed that most may be successfully managed with relatively short intensive care unit (ICU) stays, relatively short hospital stays, limited laboratory draws, and limited repeat imaging tests.…”

mentioning

confidence: 99%

Pediatric solid organ injury operative interventions and outcomes at Harborview Medical Center, before and after introduction of a solid organ injury pathway for pediatrics

Dervan

King

Cuschieri

et al. 2015

Journal of Trauma and Acute Care Surgery

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BACKGROUND Although nonoperative management has become the standard of care for solid organ injury, variability exists in the care patients receive, and there are limited data regarding nonoperative management in patients with high grades of organ injury and substantial overall injury. We aimed to evaluate operative intervention frequency, including splenectomy, and patient outcomes before and after institution of the pediatric solid organ injury pathway at Harborview Medical Center (HMC) in 2005. METHODS This is a retrospective cohort study conducted at HMC for all pediatric solid organ injury patients from 2001 to 2012. Patients were identified in the Harborview Trauma Registry via DRG International Classification of Diseases—9th Rev. (ICD-9) codes for the presence of liver and spleen injuries. Demographic information, clinical characteristics, and ICD-9 procedure codes were also obtained from the trauma registry. Outcomes including splenectomy, a related abdominal surgery (exploratory laparotomy, spleen or liver repair, or splenectomy), mortality, and length of stay were compared between periods before and after 2005, adjusted for Injury Severity Score (ISS). RESULTS The pediatric solid organ injury population at HMC (n = 712) has a high frequency of high-grade injury (35% Grade IV or V) and a high level of overall injury severity (median ISS, 21). Splenectomy was rare and remained stable over time despite an increase in severity of injury (from 2.4% to 0.8%, p = 0.44, among patients with isolated injury and from 4.0% to 3.3%, p = 0.78, among patients with nonisolated injury). Other abdominal surgeries also remained stable over time. Mortality decreased among patients with nonisolated injury (from 11.2% to 4.8%, p = 0.01). Length of stay decreased among patients with isolated organ injury, from a median of 4 days (interquartile range, 3–5 days) to 2 days (interquartile range, 2–3 days) (p < 0.0005) as well as within the lower ISS strata among patients with nonisolated organ injury (from a median of 4 days to 2 days among ISS < 12, p = 0.007; from 5 days to 3 days among ISS of 12–20, p = 0.0001; and from 7 days to 4 days among ISS of 21–33, p = 0.003). CONCLUSION Care in the recent period (2005–2012) was associated with a stable, low frequency of splenectomy; decreased mortality for patients with nonisolated injury; and decreased hospital length of stay among most subsets of patients, suggesting improved care despite an increase in patients’ severity of injury. LEVEL OF EVIDENCE Therapeutic study, level IV; epidemiologic study, level III.

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Variability in Pediatric Splenic Injury Care

Cited by 18 publications

References 17 publications

Variation in intensive care unit utilization and mortality after blunt splenic injury

Variation in intensive care unit utilization and mortality after blunt splenic injury

Blunt Splenic Trauma in Children: Are We Too Careful?

Pediatric solid organ injury operative interventions and outcomes at Harborview Medical Center, before and after introduction of a solid organ injury pathway for pediatrics

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