Mahran Amr, Fernstrum Austin, Swindle Michael, Mishra Kirtishri, Bukavina Laura, Raina Richa, Narayanamurthy Vaishnavi, Ross Jonathan, Woo Lynn
Case Western Reserve School of Medicine, Cleveland, OH, USA; University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
Case Western Reserve School of Medicine, Cleveland, OH, USA.
J Pediatr Urol. 2020 Oct;16(5):658.e1-658.e9. doi: 10.1016/j.jpurol.2020.07.019. Epub 2020 Jul 24.
The pediatric kidney is the most common urinary tract organ injured in blunt abdominal trauma. Trauma care in the United States has been established into a hierarchical system verified by the American College of Surgeons (ACS). Literature evaluating management of pediatric renal trauma across trauma tier designations is scarce.
To examine the differences in the management and outcomes of renal trauma in the pediatric population based on trauma level designation across the United States.
We performed a review of the ACS - National Trauma Data Bank database. Pediatric patients (age 0-18 years) who were treated for renal injury between years 2011-2016 were identified. Our primary outcome was the difference in any complication rate amongst Level I versus Non-Level I trauma centers. Management strategies were evaluated as secondary outcomes. Propensity score matching (PSM) was utilized to adjust for baseline differences between cohorts. Multivariable regression analysis was performed to determine the independent effects of individual factors on complications, operative intervention, minimally invasive procedure, and blood transfusions.
Overall, 12,097 pediatric patients were diagnosed with renal trauma between 2011 and 2016 using target ICD-9 and AAST codes. After PSM, there was a total of 1623 subjects withing each group. No difference was identified between groups for occurrence on any complication [105 (6.5%) vs 114 (7.0%), p = 0.576. There were no differences in the rate of minimally invasive interventions [67 (4.1%) vs 48 (3.0%), p = 0.087], operative intervention [58 (3.6%) vs 68 (4.2%), p = 0.413], or nephrectomy [42 (2.6%) vs 47 (2.9%), p = 0.667] between Level I and Non-Level I trauma designations, respectively. Length of stay was longer in the Level I cohort compared to Non-Level I (days (SD)) [6.9 (8.8) vs 6.2 (7.9), p = 0.024. When specifically looking at risk factors associated with operative intervention, higher renal injury grade and injury severity score were highly correlated, whereas, trauma level designation was not found to be predictive for more aggressive management.
DISCUSSION & CONCLUSION: Our results corroborate with previous literature that renal injury grade and injury severity score are strong predictors of morbidity, invasive management, and complications. Pediatric renal trauma was managed similarly across trauma center designations, with the rate of complication and intervention more prevalent in patients with high grade renal injuries and concomitant injuries. Further studies are necessary to identify patients who will benefit most from transfer to a level I center.
小儿肾脏是钝性腹部创伤中最常受损的泌尿系统器官。美国的创伤护理已建立起一个由美国外科医师学会（ACS）验证的分级系统。评估不同创伤分级下小儿肾创伤管理的文献较少。
基于美国各地的创伤分级，研究小儿肾创伤管理及结局的差异。
我们对ACS - 国家创伤数据库进行了回顾。确定了2011年至2016年间接受肾损伤治疗的儿科患者（年龄0 - 18岁）。我们的主要结局是I级创伤中心与非I级创伤中心之间任何并发症发生率的差异。管理策略作为次要结局进行评估。倾向评分匹配（PSM）用于调整队列之间的基线差异。进行多变量回归分析以确定个体因素对并发症、手术干预、微创手术和输血的独立影响。
总体而言，2011年至2016年间，使用目标ICD - 9和AAST编码，共有12,097名儿科患者被诊断为肾创伤。PSM后，每组共有1623名受试者。两组之间在任何并发症的发生率上未发现差异[105（6.5%）对114（7.0%），p = 0.576]。I级与非I级创伤分级之间在微创手术率[67（4.1%）对48（3.0%），p = 0.087]、手术干预率[58（3.6%）对68（4.2%），p = 0.413]或肾切除术率[42（2.6%）对47（2.9%），p = （此处原文有误，应为0.667）]方面均无差异。I级队列的住院时间比非I级队列更长（天数（标准差））[6.9（8.8）对6.2（7.9），p = 0.024]。当具体查看与手术干预相关的危险因素时，较高的肾损伤分级和损伤严重程度评分高度相关，而创伤分级未被发现可预测更积极的管理。
我们的结果与先前的文献一致，即肾损伤分级和损伤严重程度评分是发病率、侵入性管理和并发症的有力预测指标。不同创伤中心分级对小儿肾创伤的管理相似，但并发症和干预率在高分级肾损伤和合并损伤的患者中更为普遍。有必要进行进一步研究以确定哪些患者将从转至I级中心中获益最大。
