Nonoperative management of blunt liver and spleen injury in children

Abstract

Expert opinion, guideline, grades I to IV.

Factores asociados a falla en el manejo no operatorio de lesiones hepáticas o esplénicas secundarias a trauma abdominal cerrado en niños

“…Similar to what was previously reported in other series 1,3,6,7,15,23,27 , pedestrian-like traffic accidents are the predominant trauma mechanism in the hepatic and splenic injuries due to closed trauma in our study group, followed by falls from high heights in second place and others less common causes, as trauma on bicycle or skateboards, trauma with blunt objects among others. The most affected group was the 5 to 10 years old children.…”

“…Multiple studies are in agreement with what is found in our series of patients, although most of these are focused on determining cut points to move from NOM to surgical management and not to establish factors that act as predictors of this outcome or to prevent the complications associated with the delay of these 6,7,23,27 . These findings may have a especial significance when using pediatric abdominal trauma algorithms 23 , since they allow us to anticipate the patient's clinical condition, in order to reduce the associated morbidity and mortality. The majority of algorithms used as a cutoff point for surgical intervention are a requirement for serial transfusions that exceed half of the blood volume, 40 cc/kg or 4 RBCU during the 24 hours after the injury.…”

“…The NOM complications are low, with an overall morbidity rate of 25% and mortality < 5%, counting among the advantages 1,6,7,[20][21][22][23] : less hospital and ICU stay, lower incidence of infections and less need for transfusion compared to conventional surgical management. The main complications reported are 1,4,7,11,[18][19][20][21][22] : bleeding, biliary leakage (biliary fistula, bilioma) 24 , arterial pseudoaneurysm with hemobilia, abdominal compartment syndrome, presence of other inadvertent visceral lesions, hepatic, gallbladder or splenic necrosis, hepatic or splenic abscess and left pleural effusion in splenic lesions 25 .…”

“…However, other series have shown that 61-86% of grade IV lesions and 32-77% of grade V lesions (in the absence of hemodynamic instability) have been treated conservatively 6,7,[12][13][14][15]22 , and it does not matter the age, gender, mechanism of trauma and degree of injury 13,17 , because it is hemodynamic instability the one that does not show improvement after 6 hours of adequate resuscitation, which predicts almost a 100% of correlation between the need for laparotomy and splenectomy in children with closed trauma spleen 29 . The above is clear, a periodic evaluations by trained personnel are necessary in order to allow the early detection of the surgical interventions need and to identify patients at high risk, avoiding failure of NOM 6,7,[12][13][14][15]23,27,[29][30][31] . The primary indication for surgical intervention in hemodynamically stable children is the requirement for serial transfusions exceeding half the blood volume or 40 cc/kg for 24 hours after injury 1,9,14,15,17 .…”

“…The included patient should present hemodynamic stability, absence of signs of peritoneal irritation 1,4,9,10,12,13,18,19,23,28,29 , whose age were between 0-14 years old, with an initial NOM for hepatic or splenic trauma, no trauma to other solid organs or other voids rather than liver or spleen, which has required to proceed with surgery; patients who present evidence of tomographic images for classification of hepatic or splenic trauma and evidence of clinical and paraclinical data (Hb levels) in clinical history.…”