Context The rates of appendiceal rupture and negative appendectomy in children remain high despite efforts to reduce them. Both outcomes are used as measures of hospital quality. Little is known about the factors that influence these rates. Objective To investigate the association between hospital-and patient-level characteristics and the rates of appendiceal rupture and negative appendectomy in children. Design, Setting, and Patients Retrospective review using the Pediatric Health Information System database containing information on 24 411 appendectomies performed on children aged 5 to 17 years at 36 pediatric hospitals in the United States between 1997 and 2002.

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Twenty-seven of 1,018 children evaluated with contrast material-enhanced computed tomography (CT) after blunt trauma demonstrated a characteristic hypoperfusion complex. This complex was usually seen in young children (median age, 2 years). CT findings in all 27 patients included a dilated, fluid-filled bowel and abnormally intense enhancement of the bowel wall, mesentery, kidneys, aorta, and inferior vena cava. Twenty-four percent of all children with a Trauma Score of 10 or less and 20% with a Glasgow Coma Score of 6 or less had the hypoperfusion complex. All 27 patients had a normal blood pressure immediately before CT, but five (19%) became hypotensive within 10 minutes of intravenous contrast material administration. Twenty-three children (85%) died. Of 16 children who survived 24 hours, four (25%) developed renal insufficiency. The intense multiorgan enhancement pattern seen in the hypoperfusion complex indicates tenuous hemodynamic stability. Recognition that the constellation of CT findings is due to hypovolemic shock and not to injured viscera helps avoid unnecessary laparotomy.

The authors describe a "hypoperfusion complex," seen on abdominal computed tomography, which consists of marked, diffuse dilatation of the intestine with fluid; abnormally intense contrast enhancement of the bowel wall, mesentery, kidneys, and/or pancreas; decreased caliber of the abdominal aorta and inferior vena cava; and moderate to large peritoneal fluid collections. This complex was present in three patients less than 2 years of age and was associated with severe injury and a poor outcome. Recognition of this constellation of findings may help direct attention to the patient's serious hemodynamic abnormality as much as to individual organ defects.

ObjectiveThe authors assessed the risks of nonoperative management of solid visceral injuries in children (age range, 4 months-14 years) who were consecutively admitted to a level pediatric trauma center during a 6-year period ending in 1991. MethodOne hundred seventy-nine children (5.0%) sustained injury to the liver or spleen. Nineteen children (1 1.2%) died. Of the 160 children who survived, 4 received emergency laparotomies; 156 underwent diagnostic computer tomography and were managed nonoperatively. The percentage of children who were successfully treated nonoperatively was 97.4%. Delayed diagnosis of enteric perforations occurred in two children. Fifty-three children (34.0%) received transfusions (mean volume 16.7 mL/kg); however, transfusion rates during the latter half of the study decreased from 50% to 19% in children with hepatic injuries, despite increasing grade of injury, and decreased from 57% to 23% in the splenic group with similar injury grade (p < 0.005, chi square test and Student's t test). ConclusionPediatric blunt hepatic and splenic trauma is associated with significant mortality. Nonoperative management based on physiologic parameters, rather than on computed tomography grading of organ injury, was highly successful, with few missed injuries and a low transfusion rate.It is common practice to forgo operative management of pediatric blunt hepatic and splenic injuries for more expectant therapy based on the physiologic status of the child rather than the anatomic nature of the injury. Previous reports have confirmed the efficacy of this approach,'16 but concerns remain about the ability of radiologic imaging to provide a diagnosis of all intraabdominal injuries. In addition, because of the growing Address reprint requests to Sheldon J. Bond, M.D., Division of Pediatric Surgery, Department of Surgery, University of Louisville, Louisville, KY 40292. Accepted for publication July 27, 1995. 286concern oftransmitting diseases through the use ofblood products, many question whether nonoperative management results in excessive transfusion rates. In an attempt to answer these questions and to examine the overall efficacy of treating blunt hepatic and splenic injuries in children nonoperatively, a review of our most recent experience was undertaken.

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