Nonoperative Management of Solid Organ Injuries in Children Results in Decreased Blood Utilization By David A. Partrick, Denis D. Bensard, Ernest E. Moore, and Frederick M. Karrer Denver, Colorado 6ackground:The administration of blood products to injured children has been recognized as a potential risk of nonopera- tive management. The purpose of this study was to evaluate blood utilization in the management of solid organ injuries in pediatric blunt abdominal trauma victims. Methods: One hundred sixty-one children (516 years old) with solid organ injuries over an 8-year study period (1990 through 1997) were identified from the trauma registries at 2 urban regional trauma centers. Results: Mean age of the study patients was 7.9 2 0.4 years, 95 (59%) were boys, and their mean injury severity score (ISS) was 17.8 2 1.2. Patients were divided into 4-year study cohorts (1990 through 1993 and 1994 through 1997) to examine changes in operative management and blood utiliza- tion. For each time period examined, those treated nonopera- N ONOPERATIVE MANAGEMENT of children who sustain blunt abdominal trauma (BAT) has become commonly accepted as the standard of care. Indeed, this expectant management of injured children has repeatedly been proven to have a very high rate of success while avoiding operative morbidity and mortality. Guidelines for such conservative management have been established in the literature for splenic, hepatic, and renal injuries.lm3 Patients who have evidence of massive bleeding should undergo prompt laparotomy. In the child who is hemody- namically stable with a solid organ injury documented by computed tomography (CT) scan, however, nonoperative management with close monitoring by an experienced surgical team has become the standard. The current recommendation is to proceed with nonoperative manage- ment until the child requires transfusion of more than half of their blood volume (40 rrL/kg) within 24 hours of injury.1,2,4 Investigators have reported a 2-fold risk of mortality for patients who require exploration after failed observation, which may be partially explained by their increased transfusion requirements.5 The purpose of this study was to evaluate blood utilization in the manage- ment of solid organ injuries in children sustaining BAT. MATERIALS AND METHODS Patients All patients 516 years of age admitted to the trauma service at Denver Health Medical Center (DHMC) or The Children’s Hospital of Denver with documented solid organ injuries over an &year period tively received fewer blood transfusions (46% v9% and 44% v 13%, P < .05 by Fisher’s Exact test), and the hospital length of stay was shorter (12.3 ? 2.1 v 5.0 2 0.7 and 7.8 ? 1.9 v 4.2 ? 0.4 days, P< .OOOl by analysis of variancelscheffe’s) compared with the laparotomy cohort. Conclusions: The appropriate nonoperative management of injured children actually reduces the risks of receiving blood transfusion and decreases the length of hospital stay com- pared with aggressive operative intervention. Blood transfu- sion should be reserved only for those injured children with solid organ injuries who are hemodynamically unstable. J Pediatr Surg 34:1695-1699. Copyright o 1999 by W. 6. Saunders Company. INDEX WORDS: Trauma, transfusion, blood, nonoperative, pedestrian, automobile. (1990 to 1997) were identified by the trauma registry at each institution. Children with other intraahdominal injuries requiring exploratory laparotomy were excluded from the analysis (ie, hollow viscus, pancreatic, or diaphragmatic injuries), thus attempting to accrue a relatively homogeneous patient population with isolated solid organ injuries. Criteria for laparotomy included hemodynamically unstable children with evidence of massive bleeding on presentation and children who required transfusion of more than half of their blood volume (40 mLJkg) within 24 hours of injury. The medical records of the pediatric trauma patients identified in the trauma registry as requiring laparotomy or transfusion of packed red blood cells were reviewed to confirm details of the operation performed and the indications for transfusion. The data recorded include age, gender, injury severity score (ISS),6 injury mechanism, admitting diagnoses, any operative procedures performed in the emergency department or operating room, and arrival and discharge dates. Data were available from DHMC over the entire study period. Data from TCH only includes the period from 1994 to 1997 because patients from 1990 to 1993 are not included in the registry. DHMC functions as a level I regional trauma center with pediatric commitment for the city of Denver and the state of Colorado. The Children’s Hospital functions as a designated pediatric regional trauma center for the same encatchment area. At DHMC, injured patients (pediatric and adult) are evaluated in the emergency department by the From the Department of Pediatric Surgery The Children’s Hospital, University of Colorado Health Sciences Centel; and the Department of Surgery, Denver Health Medical Center; Denver CO. Presented at the 32nd Annual Meeting of the Pact@ Association of Pediatric Surgeons, May 9-14, 1999, Beijing, China. Address reprint requests to Denis D. Bensard, MD, The Children’s Hospital, 1950 Ogden St, B-323, Denver; CO 80218. Copyright 0 1999 by WB. Saunders Company 0022-3468/99/3411-0026$03.00/O Journalof Pediatric Surgery,Vol34, No 11 (November), 1999: pp 16951699 1695