Division of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, NY.
Division of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, NY.
J Pediatr Surg. 2020 Sep;55(9):1748-1753. doi: 10.1016/j.jpedsurg.2020.01.001. Epub 2020 Jan 16.
Nonoperative management (NOM) is commonly utilized in hemodynamically stable children with blunt splenic injuries (BSI). Guidelines published by the American Pediatric Surgical Association over the past 15 years support this approach. We sought to determine the rates and outcomes of NOM in pediatric BSI and compare trends between pediatric (PTC), mixed (MTC) and adult trauma centers (ATC).
This was a retrospective database analysis of the NTDB data from 2011 to 2015 including pediatric patients with BSI, as described by ICD-9-CM Codes 865.00-865.09. Patients with head injuries with AIS > 2, multiple intraabdominal injuries, and transfers-out were excluded. According to ACS and/or state designation, trauma facilities were defined as PTC (level I/II pediatric only), MTC (level I/II adult and pediatric) and ATC (level I/II adult only). OM group was defined as presence of procedure codes reflecting exploratory laparotomy/laparoscopy and/or any splenic procedures. NOM group consisted of patients who were observed, transfused or had transarterial embolization (TAE). Variables analyzed were age, ISS, spleen AIS, amount and type of blood products transfused, and intensive care unit (ICU) and hospital (H) length of stay (LOS).
5323 children met the inclusion criteria. 11.4% received care at PTC (NOM, 97%), 40.7% at MTC (NOM, 89.9%) and 47.8% at ATC (NOM, 83.8%) (P < 0.001). In NOM group, PTC patients had the highest spleen AIS (3.46 ± 0.95, P < 0.001). TAE was predominantly used at MTC and ATC (P = 0.001). MTC and ATC were more likely to transfuse than PTC (P = 0.002). MTC and ATC OM rates were lower in children aged ≤12 than in children aged >12 (P < 0.001). Splenectomy rate was 1.5% at PTC, 8.4% at MTC, and 14.4% at ATC (P < 0.001). In OM group, PTC patients had a higher ISS (P = 0.018) and spleen AIS (P = 0.048) than both MTC and ATC. The proportion of patients treated by NOM at ATC increased during the 5-year period studied (P = 0.015). Treatment at MTC or ATC increased the risk for OM by 3.89 and 5.36 times respectively (P < 0.001).
PTCs still outperform ATCs in NOM success rates despite higher ISS and splenic injury grades. From 2011 to 2015, ATC OM rates dropped from 17% to 12.4% suggesting increased adoption of the APSA guidelines. Further educational initiatives may help augment this trend.
II TYPE OF STUDY: Retrospective.
在血流动力学稳定的钝性脾损伤（BSI）患儿中，通常采用非手术治疗（NOM）。过去 15 年来，美国儿外科协会发布的指南支持这种方法。我们旨在确定儿科 BSI 中 NOM 的发生率和结果，并比较儿科（PTC）、混合（MTC）和成人创伤中心（ATC）之间的趋势。
这是对 2011 年至 2015 年 NTDB 数据的回顾性数据库分析，包括 ICD-9-CM 代码 865.00-865.09 描述的脾损伤患儿。排除头部损伤 AIS>2、多发腹内损伤和转出的患者。根据 ACS 和/或州指定，创伤机构被定义为 PTC（仅限 I/II 级儿科）、MTC（I/II 级成人和儿科）和 ATC（仅限 I/II 级成人）。OM 组定义为存在反映剖腹探查/腹腔镜和/或任何脾脏手术的程序代码。NOM 组包括接受观察、输血或接受经动脉栓塞（TAE）的患者。分析的变量包括年龄、ISS、脾脏 AIS、输血量和血制品类型，以及重症监护病房（ICU）和医院（H）的住院时间（LOS）。
5323 名儿童符合纳入标准。11.4%在 PTC 接受治疗（NOM，97%），40.7%在 MTC（NOM，89.9%）和 47.8%在 ATC（NOM，83.8%）（P<0.001）。在 NOM 组中，PTC 患者的脾脏 AIS 最高（3.46±0.95，P<0.001）。TAE 主要在 MTC 和 ATC 中使用（P=0.001）。MTC 和 ATC 比 PTC 更有可能输血（P=0.002）。≤12 岁儿童的 MTC 和 ATC 开放手术率低于>12 岁儿童（P<0.001）。PTC 的脾切除术率为 1.5%，MTC 为 8.4%，ATC 为 14.4%（P<0.001）。在 OM 组中，PTC 患者的 ISS（P=0.018）和脾脏 AIS（P=0.048）均高于 MTC 和 ATC。在研究期间，ATC 中采用 NOM 治疗的患者比例增加（P=0.015）。在 MTC 或 ATC 治疗会使 OM 的风险分别增加 3.89 和 5.36 倍（P<0.001）。
尽管 ISS 和脾脏损伤程度较高，PTC 在 NOM 成功率方面仍优于 ATC。从 2011 年到 2015 年，ATC 的 OM 率从 17%下降到 12.4%，表明 APSA 指南的采用率有所增加。进一步的教育举措可能有助于增加这一趋势。
II 型研究：回顾性。
