Linnaus Maria E, Langlais Crystal S, Garcia Nilda M, Alder Adam C, Eubanks James W, Maxson R Todd, Letton Robert W, Ponsky Todd A, St Peter Shawn D, Leys Charles, Bhatia Amina, Ostlie Daniel J, Tuggle David W, Lawson Karla A, Raines Alexander R, Notrica David M
From the Level I Pediatric Trauma Center, Phoenix Children's Hospital (M.E.L., C.S.L., D.M.N.), Phoenix, AZ; Pediatric Trauma Center, Dell Children's Medical Center (N.M.G., K.A.L., D.W.T.), Austin, TX; Pediatric Surgery Department, Children's Medical Center (A.C.A.), Dallas, TX; Department of Pediatric Surgery, Le Bonheur Children's Hospital (J.W.E.), Memphis, TN; Department of Pediatric Surgery, Arkansas Children's Hospital (R.T.M.), Little Rock, AR; Department of Surgery, The Children's Hospital at OU Medical Center (R.W.L., A.R.R.), Oklahoma City, OK; Department of Pediatric Surgery, Akron Children's Hospital (T.A.P.), Akron OH; Pediatric Surgery, Mercy Children's Hospital (S.D.S.), Kansas City, MO; Pediatric Surgery, American Family Children's Hospital (C.L.), Madison WI; Department of Pediatric Surgery, Children's Healthcare of Atlanta (A.B.), Atlanta GA; and Department of Surgery, Phoenix Children's Hospital, Phoenix AZ & American Family Children's Hospital (D.J.O.), Madison WI.
J Trauma Acute Care Surg. 2017 Apr;82(4):672-679. doi: 10.1097/TA.0000000000001375.
Nonoperative management (NOM) is standard of care for most pediatric blunt liver and spleen injuries (BLSI); only 5% of patients fail NOM in retrospective reports. No prospective studies examine failure of NOM of BLSI in children. The aim of this study was to determine the frequency and clinical characteristics of failure of NOM in pediatric BLSI patients.
A prospective observational study was conducted on patients 18 years or younger presenting to any of 10 Level I pediatric trauma centers April 2013 and January 2016 with BLSI on computed tomography. Management of BLSI was based on the Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium pediatric guideline. Failure of NOM was defined as needing laparoscopy or laparotomy.
A total of 1008 patients met inclusion; 499 (50%) had liver injury, 410 (41%) spleen injury, and 99 (10%) had both. Most patients were male (n = 624; 62%) with a median age of 10.3 years (interquartile range, 5.9, 14.2). A total of 69 (7%) underwent laparotomy or laparoscopy, but only 34 (3%) underwent surgery for spleen or liver bleeding. Other (nonexclusive) operations were for 21 intestinal injuries; 15 hematoma evacuations, washouts, or drain placements; 9 pancreatic injuries; 5 mesenteric injuries; 3 diaphragm injuries; and 2 bladder injuries. Patients who failed were more likely to receive blood (52 of 69 vs. 162 of 939; p < 0.001) and median time from injury to first blood transfusion was 2.3 hours for those who failed versus 5.9 hours for those who did not (p = 0.002). Overall mortality rate was 24% (8 of 34) in those who failed NOM due to bleeding.
NOM fails in 7% of children with BLSI, but only 3% of patients failed for bleeding due to liver or spleen injury. For children failing NOM due to bleeding, the mortality was 24%.
Therapeutic study, level II.
非手术治疗（NOM）是大多数小儿钝性肝脾损伤（BLSI）的标准治疗方法；回顾性报告显示，只有5%的患者非手术治疗失败。尚无前瞻性研究探讨儿童BLSI非手术治疗的失败情况。本研究的目的是确定小儿BLSI患者非手术治疗失败的频率及临床特征。
对2013年4月至2016年1月期间在10个I级小儿创伤中心之一就诊、经计算机断层扫描诊断为BLSI的18岁及以下患者进行前瞻性观察研究。BLSI的治疗基于亚利桑那-德克萨斯-俄克拉荷马-孟菲斯-阿肯色联盟小儿指南。非手术治疗失败定义为需要进行腹腔镜检查或剖腹手术。
共有1008例患者符合纳入标准；499例（50%）有肝损伤，410例（41%）有脾损伤，99例（10%）两者均有。大多数患者为男性（n = 624；62%），中位年龄为10.3岁（四分位间距，5.9，14.2）。共有69例（7%）接受了剖腹手术或腹腔镜检查，但只有34例（3%）因脾或肝出血接受手术。其他（非排他性）手术包括21例肠损伤；15例血肿清除、冲洗或置管引流；9例胰腺损伤；5例肠系膜损伤；3例膈肌损伤；2例膀胱损伤。治疗失败的患者更有可能接受输血（69例中的52例 vs. 939例中的162例；p < 0.001），治疗失败患者从受伤到首次输血的中位时间为2.3小时，未失败患者为5.9小时（p = 0.002）。因出血导致非手术治疗失败的患者总体死亡率为24%（34例中的8例）。
7%的小儿BLSI患者非手术治疗失败，但只有3%的患者因肝或脾损伤出血导致治疗失败。因出血导致非手术治疗失败的儿童死亡率为24%。
治疗性研究，II级。
