Tataria Monika, Nance Michael L, Holmes James H, Miller Charles C, Mattix Kelly D, Brown Rebeccah L, Mooney David P, Scherer L R Tres, Groner Jon I, Scaife Eric R, Spain David A, Brundage Susan I
Lucille Packard Children's Hospital, Stanford University, Palo Alto, California, USA.
J Trauma. 2007 Sep;63(3):608-14. doi: 10.1097/TA.0b013e318142d2c2.
During the past 40 years, management of solid organ injury in pediatric trauma patients has shifted to highly successful nonoperative management. Our purpose was to characterize children requiring operative intervention. We hypothesized that older children would be more likely to require operative intervention. In particular, we wanted to examine potential outcome disparities between children who were operated upon immediately and those in whom attempted nonoperative management failed. Additionally, we asked whether attempted nonoperative management, when failed, put children at higher risk for mortality or morbidities such as increased blood product transfusions or lengths of stays.
Retrospective cohorts from seven Level I pediatric trauma centers were identified. Blunt splenic, hepatic, renal, or pancreatic injuries were documented in 2,944 children <1 to 19 years of age from January 1993 to December 2002. Data collected included demographics, hemodynamics, blood transfusions, Glasgow Coma Scale score, Injury Severity Score, hospital length of stay (LOS), intensive care unit (ICU) LOS, and mortality. Analysis involved 140 (4.8%) of 2,944 patients requiring operation. Two cohorts were characterized: (1) immediate operation (IO), defined as laparotomy </=3 hours after arrival (n = 81; 58%) and (2) failed nonoperative management (F-NOM), defined as laparotomy >3 hours after arrival (n = 59; 42%).
Comparing the two cohorts, no age differences were found. Compared with F-NOM, IO had significantly worse hemodynamics, Injury Severity Score, and Glasgow Coma Scale score and was associated with liver injuries. Pancreatic injuries were significantly associated with F-NOM. While controlling for injury severity to compare IO versus F-NOM, linear regression revealed equivalent blood transfusions, ICU LOS, hospital LOS, and mortality rates.
IO and F-NOM are rare events and independent of age. When operated upon for appropriate physiology, the timing of operation in pediatric solid organ injury is irrelevant and not detrimental with respect to blood transfusion, mortality, ICU and hospital LOS, and resource utilization.
在过去40年中，小儿创伤患者实体器官损伤的管理已转向非常成功的非手术治疗。我们的目的是描述需要手术干预的儿童特征。我们假设年龄较大的儿童更有可能需要手术干预。特别是，我们想研究立即接受手术的儿童与非手术治疗失败的儿童之间潜在的结局差异。此外，我们询问非手术治疗失败时，是否会使儿童面临更高的死亡风险或诸如增加血制品输注量或住院时间等并发症风险。
确定了来自7个一级小儿创伤中心的回顾性队列。记录了1993年1月至2002年12月期间2944名1至19岁儿童的钝性脾、肝、肾或胰腺损伤情况。收集的数据包括人口统计学、血流动力学、输血情况、格拉斯哥昏迷量表评分、损伤严重度评分、住院时间（LOS）、重症监护病房（ICU）住院时间和死亡率。分析涉及2944例患者中140例（4.8%）需要手术治疗的患者。分为两个队列：（1）立即手术（IO），定义为到达后≤3小时行剖腹手术（n = 81；58%）和（2）非手术治疗失败（F-NOM），定义为到达后>3小时行剖腹手术（n = 59；占42%）。
比较两个队列，未发现年龄差异。与F-NOM相比，IO的血流动力学、损伤严重度评分和格拉斯哥昏迷量表评分明显更差，且与肝损伤有关。胰腺损伤与F-NOM显著相关。在控制损伤严重程度以比较IO与F-NOM时，线性回归显示输血、ICU住院时间、住院时间和死亡率相当。
IO和F-NOM是罕见事件，且与年龄无关。当因适当的生理状况进行手术时，小儿实体器官损伤的手术时机无关紧要，且在输血、死亡率、ICU和住院时间以及资源利用方面并无不利影响。
