Nonoperative Management of Blunt Hepatic and Splenic Injury in Children

Abstract

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.

Management and treatment of liver injury in children

“…The liver is the second most commonly injured organ after blunt abdominal traumas. [1][2][3] The most common cause of liver injury is trauma to the upper right abdomen or right hemithorax. Injuries occur mostly in the right liver lobe because of its localization and size.…”

“…[5] The liver takes blood from the systemic and portal circulation, so injury to the liver can cause serious blood loss. [1,3] In hemodynamically stable patients, liver injuries are managed conservatively, but if there is hemodynamic instability, patients are managed surgically. [6] Surgery is required if patients need blood transfusions of over 40 ml/kg/day or if there are findings indicating peritoneal irritation or hollow organ perforation.…”

Pediatric Splenic Injury: Nonoperative Management First!

“…The finding that between 20 and 67% of splenic injuries will stop bleeding spontaneously at the time of laparotomy coupled with the risk of developing postsplenectomy sepsis led to the development of selective nonoperative management in hemodynamically stable children with BSI [7]. During the past couple of years, evidence-based guidelines were developed to serve as a framework for the nonoperative management of hemodynamically stable pediatric patients with isolated splenic injury [8][9][10].…”

Injuries to the Spleen

“…Nonoperative management is limited to patients who are hemodynamically stable upon admission or after initial resuscitation [12][13][14]. GCS score, age, and hypotension upon admission do not have a significant effect on the failure rate for nonoperative management [20].…”

“…The rate of successful nonoperative treatment of splenic injuries in children is about 95% [13]. Surgeons have been more reluctant to use this technique in adults although nonoperative management of splenic injuries with proper selection of patients is as safe and practicable in adults as in children [14].…”