Pleural effusion following blunt splenic injury in the pediatric trauma population ☆ , ☆☆ Afif N. Kulaylat a, c , Brett W. Engbrecht a , Carolina Pinzon-Guzman b , Vance L. Albaugh b , Susan E. Rzucidlo a , Jane R. Schubart c , Robert E. Cilley a, ⁎ a Division of Pediatric Surgery, Penn State Hershey Children's Hospital, Hershey, PA, USA b Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA c Department of Public Health Sciences, Penn State Hershey Medical Center, Hershey, PA, USA abstract article info Article history: Received 11 October 2013 Received in revised form 15 January 2014 Accepted 17 January 2014 Key words: Pediatric trauma Blunt splenic injury Splenic laceration Pleural effusion Nonoperative management Background: Pleural effusion is a potential complication following blunt splenic injury. The incidence, risk factors, and clinical management are not well described in children. Methods: Ten-year retrospective review (January 2000–December 2010) of an institutional pediatric trauma registry identified 318 children with blunt splenic injury. Results: Of 274 evaluable nonoperatively managed pediatric blunt splenic injures, 12 patients (4.4%) developed left-sided pleural effusions. Seven (58%) of 12 patients required left-sided tube thoracostomy for worsening pleural effusion and respiratory insufficiency. Median time from injury to diagnosis of pleural effusion was 1.5 days. Median time from diagnosis to tube thoracostomy was 2 days. Median length of stay was 4 days for those without and 7.5 days for those with pleural effusions (p b 0.001) and 6 and 8 days for those pleural effusions managed medically or with tube thoracostomy (p = 0.006), respectively. In multivariate analysis, high-grade splenic injury (IV–V) (OR 16.5, p = 0.001) was associated with higher odds of developing a pleural effusion compared to low-grade splenic injury (I–III). Conclusions: Pleural effusion following pediatric blunt splenic injury has an incidence of 4.4% and is associated with high-grade splenic injuries and longer lengths of stay. While some symptomatic patients may be successfully managed medically, many require tube thoracostomy for progressive respiratory symptoms. © 2014 Elsevier Inc. All rights reserved. The spleen is the most commonly injured solid organ in children following blunt abdominal trauma [1]. In both the adult and pediatric literature, selective nonoperative management (NOM) of hemody- namically stable splenic injuries has been adopted as the standard of care [2–8]. With a success rate approaching 90% in the pediatric population, NOM decreases the need for blood transfusions, is associated with shorter lengths of stay, and avoids the morbidity, mortality and costs of operative intervention, as well as the potential for immune-mediated complications such as overwhelming post- splenectomy sepsis [1,2,4,9–12]. Pleural effusion following blunt splenic injury has been described, but not well characterized and may contribute to morbidity and length of stay [12–16]. In children, a few small series have reported an incidence of 2.4% to 18.5% [14–16]. We reviewed our experience with 318 blunt splenic injuries to evaluate the mechanisms, diagnosis and management of pleural effusion in pediatric trauma patients. We hypothesized that pleural effusion would be associated with higher- grade splenic injuries. 1. Methods This retrospective study was approved by the Penn State Hershey College of Medicine Institutional Review Board (Hershey, PA) and was conducted at the Penn State Hershey Children's Hospital, a verified pediatric trauma center. All patients (ages 0–17 years old) with blunt traumatic spleen injuries were identified from our 2000–2010 institutional pediatric trauma registry. Patients undergoing explor- atory laparotomies for splenectomy or for other indications, those requiring urgent tube thoracostomy for pneumothorax or hemothorax, those with pancreatic lacerations or transections, as well as those who did not survive their initial trauma resuscitation were excluded from analysis. Injuries were identified using computed tomography (CT) scan and graded using the American Association for the Surgery of Trauma (AAST) Revised Organ Injury Scaling System [17]. Follow-up chest x-rays were performed at the discretion of the pediatric trauma surgeon using clinical criteria during hospitalization. Patients were considered positive for the development of a pleural effusion if chest x-ray confirmed the presence of pleural effusion and Journal of Pediatric Surgery 49 (2014) 1378–1381 ☆ Conflict of interest: All authors report no potential conflicts of interest. ☆☆ Financial support: No internal or external financial support was used for this report. ⁎ Corresponding author at: Division of Pediatric Surgery, Department of Surgery, Penn State Hershey Children's Hospital, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA. Tel.: + 1 717 531 8342; fax: + 1 717 531 4185. E-mail address: rcilley@hmc.psu.edu (R.E. Cilley). http://dx.doi.org/10.1016/j.jpedsurg.2014.01.002 0022-3468/© 2014 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg