National Trends in Pediatric Blunt Spleen and Liver Injury Management and Potential Benefits of An Abbreviated Bed Rest Protocol

Sunday, October 27, 2013: 10:24 AM
Windermere Ballroom W (Hyatt Regency Orlando, formerly the Peabody)
Christopher Dodgion, MD, MBA, MSPH1, Ankush Gosain, MD, PhD2, Andrew Rogers, MD1, Shawn D St Peter, MD3, Peter F. Nichol, MD2 and Daniel J. Ostlie, MD2, (1)University of Wisconsin Hospitals and Clinics, Madison, WI, (2)Surgery, University of Wisconsin, American Family Children's Hospital, Madison, WI, (3)Pediatric Surgery, Children's Mercy Hospitals and Clinics, Kansas City, MO

Purpose

Non-operative management has become standard of care for blunt spleen and liver injury (BSLI) in the pediatric population.  Current American Pediatric Surgical Association (APSA) guidelines recommend a length of bed rest equal to the grade of injury plus one day.  Recent single-institution studies and a randomized control trial suggest that an abbreviated bed rest protocol (ABRP) may safely reduce length of stay (LOS) and resource utilization. Specifically, patients with less than grade II (AIS 2) injury may be observed for one day of bed rest, and patients with grade III (AIS 3) or higher injury may be observed for two days of rest.  This study evaluates national temporal trends in BLSI non-operative management and estimates national reduction in LOS using an abbreviated protocol.

Methods

Pediatric patients (<=17yo) sustaining BLSI were identified by ICD-9 diagnosis code in the Kids’ Inpatient Database from 2000, 2003, 2006, and 2009. Yearly rates of injury and operative intervention were examined and stratified by type of injury.  Temporal trends were evaluated for significance using Mantel-Haenszel chi-square, accounting for clustering within hospitals.  Both the APSA guidelines and the reported ABRP were applied to the isolated organ injury cohorts based on abbreviated injury score (AIS) and compared with actual LOS.

Results

23,314 patients (mean age=12.1y(+/-4.7), mean injury severity score (ISS)=15.1(+/-10.4)) were identified as having a BSLI. 14,759 patients sustained splenic injuries (mean AIS=2.8(+/- 1.1)). 10,276 patients sustained hepatic injury (mean AIS=2.3(+/- 0.65)). Operative rates showed significant declines from 2000 to 2009 (Spleen: 21% to 12% (p<0.0001) and Liver: 13% to 9.5% (p=0.0009)).  Similarly, overall mortality in BSLI patients declined from 4.4% to 3.1% over that same time period (p=0.001). LOS was determined for isolated organ injuries; isolated splenic injury mean LOS=3.2d(+/-2.5) (n=2052), and isolated liver injury mean LOS=2.7d(+/- 2.0) (n=707).  Comparison over time (2000-2009) revealed that only isolated splenic injury LOS declined significantly (p=0.016).  If APSA guidelines were followed for all patients with isolated organ injury, the mean LOS=3.8d(+/-1.1) for splenic injury and 3.4d (+/-0.7) for those with liver injury. The application of the ABRP would result in a mean LOS=1.3d(+/-0.5) for splenic injury and mean LOS=1.3d(+/-0.5) for those with liver injuries.   Overall the use of the ABRP would result in 1.8 potential hospital days saved/patient, or 25,585 patient hospital days nationally.

Conclusion

The results of this study confirm a significant national decrease in rate of operative intervention, with a simultaneous decrease in overall mortality in patients with BSLI from 2000-2009. Additionally, it appears that providers are following a shorter observation period than the currently recommended APSA guidelines, however, the implementation of ABRP holds potential in further reducing LOS and resource utilization.