Transfusion Requirements in Conservative Nonoperative Management of Blunt Splenic and Hepatic Injuries During Childhood By Catherine M. Cosentino, Susan R. Luck, Martha J. Barthel, Marleta Reynolds, and John G. Raffensperger Chicago, l Nonoperative management of splenic and hepatic injuries in children is safe, and the majority of those with isolated injuries do not require blood transfusion. Thirtyseven children were treated for blunt splenic or hepatic trauma from November 1983 to September 1989. There was one death in a patient with a lethal head injury. No operations were performed on those with isolated splenic or hepatic injuries. Three of those with multiple injuries underwent delayed laparotomy. Two had perirenal and retroperitoneal hematomas without active bleeding, and one had a bowel obstruction secondary to an intramural jejunal hematoma. There were no late complications re-
MATERIALS AND METHODS Thirty-seven children were admitted to the trauma service of the Children’s Memorial Medical Center, a level I trauma center, between November 1983 and September 1989 with the diagnosis of acute blunt splenic or hepatic injury. The medical records and all radiographic studies of each patient were reviewed retrospectively. Initial management included stabilization of vital signs, identification of injuries, and blood transfusion as indicated. All liver and spleen injuries with one exception were documented by computed axial tomography (CAT) scan, ultrasonography, or radionuclide imaging. No preoperative imaging studies were performed in a 4-year-old girl with a tender and distended abdomen 24 hours after injury. Surgical exploration showed a splenic laceration that was not bleeding and a perinephric hematoma.
lated to the splenic or hepatic injuries. Eight children (22%) required surgery for other injuries. Twelve children were not transfused, including the majority (8/l 1) of those with isolated splenic or hepatic injury. The hematocrit of four of these children fell to below 28% and this anemia was well-tolerated. Two children with bleeding disorders (factor VIII [antihemophilic factor] and factor XII [Hageman factor] deficiency) did not require packed red blood ceils transfusion. Two clinically distinct groups of children received blood transfusions: (I ) eight patients with multiple injuries were transfused during initial resuscitation when unstable or during early operation for other system trauma (mean, 62.0 mL blood/kg body weight): and (2) three hemodynamically stable patients with isolated injuries and 14 stable patients with multiple injuries were transfused empirically after initial resuscitation solely because of decreasing blood counts. They received an average of 16.5 and 21.1 mL blood/kg body weight, respectively. Transfusions should be limited or withheld in those who are hemodynamically stable after initial resuscitation. The hematocrit can decrease to 24% to 25% in these children without complications. @ 1990 by W.B. Saunders Company. INDEX WORDS:
RESULTS
Spleen, injury; liver, trauma.
B
LUNT SPLEEN and liver injuries can heal without surgery. However, some critics of nonoperative treatment believe that early operation will decrease complications and the need for blood transfusion.
From the Department of Surgery, The ChildrenS Memorial Medical Center. Northwestern University Medical School, Chicago, IL. Presented at the 38th Annual Meeting of the Surgical Section of the American Academy of Pediatrics. Chicago, Illinois, October 21-23, 1989. Address reprint requests to Susan R. Luck, MD, The Children’s Memorial Medical Center, Division of Pediatric Surgery, 2300 Children’s Plaza, Box 63, Chicago, IL 60614. o 1990 by W.B. Saunders Company. 0022-3468/90/2509-0006%03.00/0
950
Illinois
There were 23 boys and 14 girls with ages ranging from I1 months to 16 years 3 months (mean, 6 years 1 month). The most common cause of injury was a pedestrian motor vehicle accident (16/37, 43%) followed by falls (14/37, 38%) (Table 1). Thirty-three of 37 children (89%) were evaluated at this institution within 24 hours of their injuries. Two patients were transferred after 2 days of observation at other hospitals. Two others presented 3 and 4 days after injury with persistent upper abdominal pain. Twenty-three children had splenic trauma. This was the only injury in nine (Table 2). The liver was injured in 18 patients but was an isolated injury in only two. Four patients sustained both liver and spleen injuries and all of these had trauma to other systems as well. Twenty-six children had multisystem trauma (Table 3). There were no late complications related to the splenic or hepatic injuries. One child died 7 hours after a fall with a head injury. CAT scan showed a left parietal and basilar skull fracture, diffuse cerebral edema, a liver laceration, and a ruptured spleen. Intracranial pressure was equal to systemic blood pressure. No surgery was performed and medical support was withdrawn. Operation and administration of blood is correlated with the site and extent of trauma in Table 2. All 11 children with isolated liver or spleen trauma recovered without surgery. Three children with multiple injuries underwent delayed laparotomy. All three received blood products. One child underwent surgical exploration 24 hours after injury because of an acute abdomen and was found to have a splenic laceration that was not
Journal of Pediatric Surgery, Vol 25, No 9 (September). 1990: pp 950-954
951
TRANSFUSION IN SPLEEN AND LIVER TRAUMA
Table 3. Associated Injuries in 26 Multiply Injured Children
Table 1. Mechanism of Injury in 37 Children With Hepatic/Splenic Trauma
No. of
Pedestrian hit by motor vehicle
16 (43%)
Fall
14 (38%)
Body blow* Motor vehicle accident (passenger)
OCCUfWlCt3S
Type of Injury
No. (%)
Central nervous system (epidural hematoma, cerebral 13
contusion, skull fractures)
4(11%)
Genitourinary (renal contusions and rupture)
3 (8%)
Gastrointestinal (intramural hematomas)
12 2
Cardiothoracic (pneumothorax, rib fractures, aortic *Two
were
child abuse.
11
disruption, myocardial or pulmonary contusion)
10
Musculoskeletal (long bone fractures)
bleeding and a nonexpanding perirenal hematoma. Another child with injuries that included an epidural hematoma, liver and spleen hematomas, multiple fractures, and pulmonary contusion underwent abdominal exploration 2 days after presentation. Increasing abdominal girth interfered with effective mechanical ventilation and the control of elevated intracranial pressure. Findings at exploration included the known liver and spleen injuries, which were not actively bleeding, and multiple retroperitoneal hematomas. A third child with a similar constellation of injuries underwent laparotomy 17 days after injury for a bowel obstruction secondary to an intramural jejunal hematoma. Eight children (22%) underwent operations to treat other system trauma. Twenty-five patients received blood transfusions (Table 4). Two clinically distinct groups could be identified. Eight patients with multiple injuries were transfused during initial resuscitation when unstable or during early operation for head or thoracic trauma (Table 5). These children received more transfused blood volume per body weight than the other patients. This group included three of four children with combined hepatic, splenic, and multisystemic trauma. The second major group was comprised of hemodynamitally stable patients (17/25) who were transfused after initial resuscitation only because of decreasing blood counts. Three patients had isolated hepatic or splenic injuries and 14 had multiple injuries. Twelve children received no transfusions (Table 6). This group included the majority of those with isolated Table 2. Treatment of 37 HepaticlSplenic Trauma Patients NCl. Receiving
No. With No. With
Operation or
No. of
Blood
Abdominal
Other Organ
Children
Transfusions
Exploration
Systems
Spleen
Pelvic fracture
2
Facial fracture
1
splenic or hepatic injuries (8/l 1). Hematocrits fell below 28% in four of these 12. An 1 l-year-old boy with a factor VIII (antihemophilic factor) deficiency had free fluid in the abdomen and a subscapular splenic hematoma documented by CAT scan. He was not transfused. One 4-year 7-month-old girl with a factor XII (Hageman factor) deficiency had free intraabdominal fluid and splenic rupture documented by CAT scan. Her hematocrit stabilized at 25%. and no transfusion was given. Illustrative Case Reports Case 1. J.V. was a 6-year 9-month-old boy pedestrian struck by a car. His injuries included: (1) a liver laceration of the right posterior lobe (Fig 1); (2) massive splenic disruption with free intraperitoneal blood; (3) left frontal cerebral contusions with right lateral ventricular hemorrhage; (4) right pulmonary contusion and pneumothorax; (5) a right pelvic wing fracture; and (6) a right femoral shaft fracture. He required tracheostomy, exploratory laparotomy for a small bowel obstruction secondary to an intramural jejunal hematoma at 17 days postinjury, femoral traction, and eventual external fixation. The total volume of blood transfused throughout his hospital stay was 57.8 mL packed red blood cells (PRBC)/kg body weight. A liver-spleen scan performed at 6 weeks postinjury showed a small irregular spleen. At discharge, he was neurologically intact and doing well. Case 2. J.L. was a 5-year 4-month-old girl pedestrian struck by a car. She had loss of consciousness at
Table 4. Volume of Blood Transfusion in 26 Children
Isolated
9
2
0
0
+ Other
10
8
1
4
Volume of PRBC Transfuaon ImLikg
Liver Isolated
2
1
0
0
+ Other
12
10
0
1
Liver/Spleen + Other
Type of Injury
Isolated spleen, liver Multiple (stable patient)
4
4
2
3
Multiple (unstable patient)
body weight)
NO.
Range
3
12.5-22.8
Mean
16.5
14
4.5-50.5
22.5
8
9.4-222.3
62.0
952
COSENTINO ET AL
Table 5. Transfusions Patient I.V.
Given to Eight Unstable Multiply Injured Patients
Liver/Spleen
Age 6yr9mo
Liver/spleen
Other Injuries Head injury, pulmonary contusion/
mL PRBC/kgBW 57.0
pneumothorax, pelvic fx, femur fx B.H.
5yrlmo
Spleen
Epidural hematoma
50.0
K.N.
llyr8mo
Spleen
Aortic disruption, renal injury, foot fx
31.9
I.C.
3yr2mo
Liver
Cardiac contusion, pneumatocele
A.K.
1 yr 11 mo
Liver/spleen
Retroperitoneal hematomas. pulmo-
9.4 223.3
nary contusion/hemothorax, pelvic fx, humerus fx, head injury R.A.
llyrlmo
Spleen
Pulmonary contusion, femur fx, hu-
37.3
merus fx I.M.
lyr2mo
Liver
Depressed skull fx
21.7
R.G.
4yrlmo
Liver/spleen
Diffuse cerebral edema, skull fxs
52.5
Abbreviations: PRBC, packed red blood cells; BW, body weight; fx, fracture.
the scene, but was alert with stable vital signs throughout evaluation. Her injuries included a fracture of the right lobe of the liver (Fig 2) and a right perinephric hematoma. She did not require surgery or transfusion. Her lowest hematocrit was 27.2%. She was discharged on hospital day 5 and has done well. Case 3. I.C. was an 8-year 2-month-old boy who sustained a 15foot fall from a bridge onto the street. CAT scan showed a rupture of the spleen (Fig 3) and laceration of the upper pole of the left kidney. His vital signs remained stable with appropriate fluid resuscitation and he was not transfused. The lowest hematocrit was 24.1%. Surgery was not indicated. He was discharged after 10 days and has done well in follow-up. DISCUSSION
Selective conservative management of blunt splenic and hepatic injuries in children has been widely advocated by pediatric surgeons. Many series illustrate the efficacy of this approach. ‘-’ Other authors caution that this approach is associated with the increased morbidity of transfusions as well as complications such as infected hematomas, hemobilia, bile peritonitis, and delayed splenic rupture.8,9 This review supports the conclusion that nonoperative management of blunt splenic and hepatic injuries in children is safe. No patient in this series required surgical exploration to treat a splenic or hepatic injury and none developed a late complication. There were no deaths related to these abdominal injuries. The condition of an acutely Table 6. Lowest Hematocrit InjuredOrgans Spleen isolated + Other Liver isolated + Other
in 12 Nontransfused
1/2 2/12
Children
Lowest Hematocrit
Nontransfused 719 2110
injured child with increasing intracranial pressure and/or pulmonary contusion may further deteriorate after an unnecessary anesthesia and surgery. The possible transfusion requirement of those children observed without surgery is a valid concern because of the risks of transmission of infectious disease with blood components. No screening test of blood products is available for non-A, non-B hepatitis. The current estimated risk per unit of blood transfused for non-A, non-B hepatitis is 1:lOO. Thirty percent to 50% of infected patients develop chronic active hepatitis and 10% of these develop cirrhosis.” In contrast, the estimated risk of transmission of the human immunodeficiency virus is between 1:40,000 and 1:250,000.1’ Other risks of transfusion include the transmission of hepatitis B, human T-cell lymphotropic virus 1, and cytomegalovirus. Hemodynamically stable children should not be transfused only because of a falling hematocrit. A hemoglobin of 7 g/dL or even less can provide an adequate oxygen-carrying capacity as long
26% to 36% (median, 31.7%) 24%and31% 23.6% 27% and 38%
Case 1. CAT scan demonstrating a liver laceration Fig 1. right posterior lobe end massive splenic disruption.
of the
TRANSFUSION
Fig 2. the liver.
IN SPLEEN AND LIVER TRAUMA
Case 2. CAT scan showing a fracture
of the right lobe of Fig 3.
as the patient’s intravascular volume is adequate.” Transfusions can be safely delayed in hemodynamitally stable patients until the hematocrit decreases to 25% or less. In this series, the majority of children with
Case 3. CAT scan depicting rupture of the spleen.
isolated splenic or require transfusion. the stable patients resuscitation would
hepatic injuries (8/ 11) did not In retrospect, as many as 30% of who were transfused after initial not be transfused by us today.
REFERENCES KT, Guice KS, Rychman F, et al: Blunt liver injury in childhood: Evolution of therapy and current perspective. Surgery 100:542-549, 1986 1. Oldam
2. Giacomantino M, Filler RM, Rich RH: Blunt hepatic trauma in children: Experience with operative and nonoperative management. J Pediatr Surg 19:519-522, 1984 3. Karp MP, Cconey DR. Pros GA, et al: The nonoperative management of pediatric hepatic trauma. J Pediatr Surg 18:512518,1983 4. Grisoni ER, Gauderer MWL, Ferron J, et al: Nonoperative management of liver injuries following blunt abdominal trauma in children. J Pediatr Surg 19515518,1984 5. Pearl RH, Wesson DE, Spence LJ, et al: Splenic injury: A 5-year update with improved results and changing criteria for conservative management. J Pediatr Surg 24:121-125, 1989
6. Wesson DE, Filler RM, Ein SH, et al: Ruptured spleenWhen to operate? J Pediatr Surg 16:324-326, 1981 7. Ein SH, Shandling B, Simpson JS, et al: Nonoperative management of traumatized spleen in children: How and why? J PediatrSurg 13:117-119, 1978 8. Bass BL, Eichelberger MR, Schisgall R, et al: Hazards of nonoperative therapy of hepatic injury in children. J Trauma 241978-982, 1984 9. Luna GK, Dellinger EP: Nonoperative observation therapy for splenic injuries: A safe therapeutic option? Am J Surg 153:462-468, 1987 10. Office of Medical Applications of Research, National Institute of Health: Perioperative red cell transfusion. JAMA 260:27002703.1988 11. Department of Health and Human Services: Use of blood components. FDA Drug Bull 19:14- 15, 1989
Discussion M. Nahmad (Miami, FL): How long are you keeping your patients with isolated hepatic or splenic trauma in the hospital and how are you monitoring them other than the obvious hematocrit counts while in the hospital? If, in fact, you are doing some ultrasound studies or CAT scans of the abdomen, what did the three patients that you took to surgery show on CAT scanning that made you take them to surgery in the first place. C. Cosentino (response): The length of hospitalization varied depending on each patient. Their stays were determined by their clinical course. Some of the
patients were observed in the intensive care units, others were not. We usually followed them with serial hematocrits and serial examinations. We did not routinely get follow-up CAT scans or ultrasounds while they were in the hospital. It all depended on their clinical course. As far as the patients that we took to the operating room, one patient did not have any preoperative imaging studies and was taken to the operating room with the diagnosis of an acute abdomen and probable bowel injury. We found that patient to have a splenic laceration that was not bleeding. One patient went to the operating room for a small bowel
954
obstruction secondary to an intramural jejunal hematoma. The other patient was taken to the operating room more for increasing abdominal girth, which was interfering with mechanical ventilation and control of intracranial pressure. When we explored that patient, there was no active bleeding from the spleen or liver injuries. R. Powell (Mobile, AL): All of your data and the data in other publications regarding transfusion requirements in the nonoperative management of liver and splenic injuries, report the requirements in mL per kg. As you stated, the main risk involved is per transfusion. Do you have data on the per unit or different units required by these patients? C. Cosentino (response): Yes I do, but I don’t have that information available right now. Most patients received anywhere from 1 to 4 units, although there were patients on the opposite end of the spectrum that received blood transfusions from multiple donors. For example, the patient that received 233 mL/kg received multiple transfusions. B. Beaver (Baltimore, MD): I’d like to congratulate the authors on a very nice assimilation of their experience in Chicago and I think nationwide we should all seriously look at our changing trend with transfusion. In Maryland, we have found that an hematocrit of 25 is perfectly acceptable with appropriate reticulocyte
COSENTINO ET AL
counts. The patient who is hemodynamically stable and has no clinical symptomatology whatsoever does not require routine transfusion posttrauma. Another point I’d like to bring up is of the three patients that had delayed laparotomy, were any of those involved with lap-belt injury? C. Cosentino (response): One was a fall and the other two were pedestrian motor vehicle accidents. J. Randolph (Washington, DC): When you get to be my age, you get to make historical comments, and I want to make two. One is that it is interesting the way the wheel goes around because it was exactly 10 years ago that Benji Brooks gave us the first comments about saving the spleen at APSA, and we almost laughed her out of the room and here we are all having adopted this way. Second historical comment. There are occasionally other indications for operation. We had a patient in our series where we, too, had tried very hard not to operate. She was a 13-year-old girl who had fallen off a horse and her father was the outside linebacker and defensive captain for the Washington Redskins, and was not a small person. We had a lot of conversations about wanting to save the spleen and that we just hung the blood and then we hung another blood. I remember talking to him and he said, “yeah, yeah, Dr Randolph, I understand all that stuff, but don’t let anything happen to my little girl.” So we operated on her.
MATERIALS AND METHODS Thirty-seven children were admitted to the trauma service of the Children’s Memorial Medical Center, a level I trauma center, between November 1983 and September 1989 with the diagnosis of acute blunt splenic or hepatic injury. The medical records and all radiographic studies of each patient were reviewed retrospectively. Initial management included stabilization of vital signs, identification of injuries, and blood transfusion as indicated. All liver and spleen injuries with one exception were documented by computed axial tomography (CAT) scan, ultrasonography, or radionuclide imaging. No preoperative imaging studies were performed in a 4-year-old girl with a tender and distended abdomen 24 hours after injury. Surgical exploration showed a splenic laceration that was not bleeding and a perinephric hematoma.
lated to the splenic or hepatic injuries. Eight children (22%) required surgery for other injuries. Twelve children were not transfused, including the majority (8/l 1) of those with isolated splenic or hepatic injury. The hematocrit of four of these children fell to below 28% and this anemia was well-tolerated. Two children with bleeding disorders (factor VIII [antihemophilic factor] and factor XII [Hageman factor] deficiency) did not require packed red blood ceils transfusion. Two clinically distinct groups of children received blood transfusions: (I ) eight patients with multiple injuries were transfused during initial resuscitation when unstable or during early operation for other system trauma (mean, 62.0 mL blood/kg body weight): and (2) three hemodynamically stable patients with isolated injuries and 14 stable patients with multiple injuries were transfused empirically after initial resuscitation solely because of decreasing blood counts. They received an average of 16.5 and 21.1 mL blood/kg body weight, respectively. Transfusions should be limited or withheld in those who are hemodynamically stable after initial resuscitation. The hematocrit can decrease to 24% to 25% in these children without complications. @ 1990 by W.B. Saunders Company. INDEX WORDS:
RESULTS
Spleen, injury; liver, trauma.
B
LUNT SPLEEN and liver injuries can heal without surgery. However, some critics of nonoperative treatment believe that early operation will decrease complications and the need for blood transfusion.
From the Department of Surgery, The ChildrenS Memorial Medical Center. Northwestern University Medical School, Chicago, IL. Presented at the 38th Annual Meeting of the Surgical Section of the American Academy of Pediatrics. Chicago, Illinois, October 21-23, 1989. Address reprint requests to Susan R. Luck, MD, The Children’s Memorial Medical Center, Division of Pediatric Surgery, 2300 Children’s Plaza, Box 63, Chicago, IL 60614. o 1990 by W.B. Saunders Company. 0022-3468/90/2509-0006%03.00/0
950
Illinois
There were 23 boys and 14 girls with ages ranging from I1 months to 16 years 3 months (mean, 6 years 1 month). The most common cause of injury was a pedestrian motor vehicle accident (16/37, 43%) followed by falls (14/37, 38%) (Table 1). Thirty-three of 37 children (89%) were evaluated at this institution within 24 hours of their injuries. Two patients were transferred after 2 days of observation at other hospitals. Two others presented 3 and 4 days after injury with persistent upper abdominal pain. Twenty-three children had splenic trauma. This was the only injury in nine (Table 2). The liver was injured in 18 patients but was an isolated injury in only two. Four patients sustained both liver and spleen injuries and all of these had trauma to other systems as well. Twenty-six children had multisystem trauma (Table 3). There were no late complications related to the splenic or hepatic injuries. One child died 7 hours after a fall with a head injury. CAT scan showed a left parietal and basilar skull fracture, diffuse cerebral edema, a liver laceration, and a ruptured spleen. Intracranial pressure was equal to systemic blood pressure. No surgery was performed and medical support was withdrawn. Operation and administration of blood is correlated with the site and extent of trauma in Table 2. All 11 children with isolated liver or spleen trauma recovered without surgery. Three children with multiple injuries underwent delayed laparotomy. All three received blood products. One child underwent surgical exploration 24 hours after injury because of an acute abdomen and was found to have a splenic laceration that was not
Journal of Pediatric Surgery, Vol 25, No 9 (September). 1990: pp 950-954
951
TRANSFUSION IN SPLEEN AND LIVER TRAUMA
Table 3. Associated Injuries in 26 Multiply Injured Children
Table 1. Mechanism of Injury in 37 Children With Hepatic/Splenic Trauma
No. of
Pedestrian hit by motor vehicle
16 (43%)
Fall
14 (38%)
Body blow* Motor vehicle accident (passenger)
OCCUfWlCt3S
Type of Injury
No. (%)
Central nervous system (epidural hematoma, cerebral 13
contusion, skull fractures)
4(11%)
Genitourinary (renal contusions and rupture)
3 (8%)
Gastrointestinal (intramural hematomas)
12 2
Cardiothoracic (pneumothorax, rib fractures, aortic *Two
were
child abuse.
11
disruption, myocardial or pulmonary contusion)
10
Musculoskeletal (long bone fractures)
bleeding and a nonexpanding perirenal hematoma. Another child with injuries that included an epidural hematoma, liver and spleen hematomas, multiple fractures, and pulmonary contusion underwent abdominal exploration 2 days after presentation. Increasing abdominal girth interfered with effective mechanical ventilation and the control of elevated intracranial pressure. Findings at exploration included the known liver and spleen injuries, which were not actively bleeding, and multiple retroperitoneal hematomas. A third child with a similar constellation of injuries underwent laparotomy 17 days after injury for a bowel obstruction secondary to an intramural jejunal hematoma. Eight children (22%) underwent operations to treat other system trauma. Twenty-five patients received blood transfusions (Table 4). Two clinically distinct groups could be identified. Eight patients with multiple injuries were transfused during initial resuscitation when unstable or during early operation for head or thoracic trauma (Table 5). These children received more transfused blood volume per body weight than the other patients. This group included three of four children with combined hepatic, splenic, and multisystemic trauma. The second major group was comprised of hemodynamitally stable patients (17/25) who were transfused after initial resuscitation only because of decreasing blood counts. Three patients had isolated hepatic or splenic injuries and 14 had multiple injuries. Twelve children received no transfusions (Table 6). This group included the majority of those with isolated Table 2. Treatment of 37 HepaticlSplenic Trauma Patients NCl. Receiving
No. With No. With
Operation or
No. of
Blood
Abdominal
Other Organ
Children
Transfusions
Exploration
Systems
Spleen
Pelvic fracture
2
Facial fracture
1
splenic or hepatic injuries (8/l 1). Hematocrits fell below 28% in four of these 12. An 1 l-year-old boy with a factor VIII (antihemophilic factor) deficiency had free fluid in the abdomen and a subscapular splenic hematoma documented by CAT scan. He was not transfused. One 4-year 7-month-old girl with a factor XII (Hageman factor) deficiency had free intraabdominal fluid and splenic rupture documented by CAT scan. Her hematocrit stabilized at 25%. and no transfusion was given. Illustrative Case Reports Case 1. J.V. was a 6-year 9-month-old boy pedestrian struck by a car. His injuries included: (1) a liver laceration of the right posterior lobe (Fig 1); (2) massive splenic disruption with free intraperitoneal blood; (3) left frontal cerebral contusions with right lateral ventricular hemorrhage; (4) right pulmonary contusion and pneumothorax; (5) a right pelvic wing fracture; and (6) a right femoral shaft fracture. He required tracheostomy, exploratory laparotomy for a small bowel obstruction secondary to an intramural jejunal hematoma at 17 days postinjury, femoral traction, and eventual external fixation. The total volume of blood transfused throughout his hospital stay was 57.8 mL packed red blood cells (PRBC)/kg body weight. A liver-spleen scan performed at 6 weeks postinjury showed a small irregular spleen. At discharge, he was neurologically intact and doing well. Case 2. J.L. was a 5-year 4-month-old girl pedestrian struck by a car. She had loss of consciousness at
Table 4. Volume of Blood Transfusion in 26 Children
Isolated
9
2
0
0
+ Other
10
8
1
4
Volume of PRBC Transfuaon ImLikg
Liver Isolated
2
1
0
0
+ Other
12
10
0
1
Liver/Spleen + Other
Type of Injury
Isolated spleen, liver Multiple (stable patient)
4
4
2
3
Multiple (unstable patient)
body weight)
NO.
Range
3
12.5-22.8
Mean
16.5
14
4.5-50.5
22.5
8
9.4-222.3
62.0
952
COSENTINO ET AL
Table 5. Transfusions Patient I.V.
Given to Eight Unstable Multiply Injured Patients
Liver/Spleen
Age 6yr9mo
Liver/spleen
Other Injuries Head injury, pulmonary contusion/
mL PRBC/kgBW 57.0
pneumothorax, pelvic fx, femur fx B.H.
5yrlmo
Spleen
Epidural hematoma
50.0
K.N.
llyr8mo
Spleen
Aortic disruption, renal injury, foot fx
31.9
I.C.
3yr2mo
Liver
Cardiac contusion, pneumatocele
A.K.
1 yr 11 mo
Liver/spleen
Retroperitoneal hematomas. pulmo-
9.4 223.3
nary contusion/hemothorax, pelvic fx, humerus fx, head injury R.A.
llyrlmo
Spleen
Pulmonary contusion, femur fx, hu-
37.3
merus fx I.M.
lyr2mo
Liver
Depressed skull fx
21.7
R.G.
4yrlmo
Liver/spleen
Diffuse cerebral edema, skull fxs
52.5
Abbreviations: PRBC, packed red blood cells; BW, body weight; fx, fracture.
the scene, but was alert with stable vital signs throughout evaluation. Her injuries included a fracture of the right lobe of the liver (Fig 2) and a right perinephric hematoma. She did not require surgery or transfusion. Her lowest hematocrit was 27.2%. She was discharged on hospital day 5 and has done well. Case 3. I.C. was an 8-year 2-month-old boy who sustained a 15foot fall from a bridge onto the street. CAT scan showed a rupture of the spleen (Fig 3) and laceration of the upper pole of the left kidney. His vital signs remained stable with appropriate fluid resuscitation and he was not transfused. The lowest hematocrit was 24.1%. Surgery was not indicated. He was discharged after 10 days and has done well in follow-up. DISCUSSION
Selective conservative management of blunt splenic and hepatic injuries in children has been widely advocated by pediatric surgeons. Many series illustrate the efficacy of this approach. ‘-’ Other authors caution that this approach is associated with the increased morbidity of transfusions as well as complications such as infected hematomas, hemobilia, bile peritonitis, and delayed splenic rupture.8,9 This review supports the conclusion that nonoperative management of blunt splenic and hepatic injuries in children is safe. No patient in this series required surgical exploration to treat a splenic or hepatic injury and none developed a late complication. There were no deaths related to these abdominal injuries. The condition of an acutely Table 6. Lowest Hematocrit InjuredOrgans Spleen isolated + Other Liver isolated + Other
in 12 Nontransfused
1/2 2/12
Children
Lowest Hematocrit
Nontransfused 719 2110
injured child with increasing intracranial pressure and/or pulmonary contusion may further deteriorate after an unnecessary anesthesia and surgery. The possible transfusion requirement of those children observed without surgery is a valid concern because of the risks of transmission of infectious disease with blood components. No screening test of blood products is available for non-A, non-B hepatitis. The current estimated risk per unit of blood transfused for non-A, non-B hepatitis is 1:lOO. Thirty percent to 50% of infected patients develop chronic active hepatitis and 10% of these develop cirrhosis.” In contrast, the estimated risk of transmission of the human immunodeficiency virus is between 1:40,000 and 1:250,000.1’ Other risks of transfusion include the transmission of hepatitis B, human T-cell lymphotropic virus 1, and cytomegalovirus. Hemodynamically stable children should not be transfused only because of a falling hematocrit. A hemoglobin of 7 g/dL or even less can provide an adequate oxygen-carrying capacity as long
26% to 36% (median, 31.7%) 24%and31% 23.6% 27% and 38%
Case 1. CAT scan demonstrating a liver laceration Fig 1. right posterior lobe end massive splenic disruption.
of the
TRANSFUSION
Fig 2. the liver.
IN SPLEEN AND LIVER TRAUMA
Case 2. CAT scan showing a fracture
of the right lobe of Fig 3.
as the patient’s intravascular volume is adequate.” Transfusions can be safely delayed in hemodynamitally stable patients until the hematocrit decreases to 25% or less. In this series, the majority of children with
Case 3. CAT scan depicting rupture of the spleen.
isolated splenic or require transfusion. the stable patients resuscitation would
hepatic injuries (8/ 11) did not In retrospect, as many as 30% of who were transfused after initial not be transfused by us today.
REFERENCES KT, Guice KS, Rychman F, et al: Blunt liver injury in childhood: Evolution of therapy and current perspective. Surgery 100:542-549, 1986 1. Oldam
2. Giacomantino M, Filler RM, Rich RH: Blunt hepatic trauma in children: Experience with operative and nonoperative management. J Pediatr Surg 19:519-522, 1984 3. Karp MP, Cconey DR. Pros GA, et al: The nonoperative management of pediatric hepatic trauma. J Pediatr Surg 18:512518,1983 4. Grisoni ER, Gauderer MWL, Ferron J, et al: Nonoperative management of liver injuries following blunt abdominal trauma in children. J Pediatr Surg 19515518,1984 5. Pearl RH, Wesson DE, Spence LJ, et al: Splenic injury: A 5-year update with improved results and changing criteria for conservative management. J Pediatr Surg 24:121-125, 1989
6. Wesson DE, Filler RM, Ein SH, et al: Ruptured spleenWhen to operate? J Pediatr Surg 16:324-326, 1981 7. Ein SH, Shandling B, Simpson JS, et al: Nonoperative management of traumatized spleen in children: How and why? J PediatrSurg 13:117-119, 1978 8. Bass BL, Eichelberger MR, Schisgall R, et al: Hazards of nonoperative therapy of hepatic injury in children. J Trauma 241978-982, 1984 9. Luna GK, Dellinger EP: Nonoperative observation therapy for splenic injuries: A safe therapeutic option? Am J Surg 153:462-468, 1987 10. Office of Medical Applications of Research, National Institute of Health: Perioperative red cell transfusion. JAMA 260:27002703.1988 11. Department of Health and Human Services: Use of blood components. FDA Drug Bull 19:14- 15, 1989
Discussion M. Nahmad (Miami, FL): How long are you keeping your patients with isolated hepatic or splenic trauma in the hospital and how are you monitoring them other than the obvious hematocrit counts while in the hospital? If, in fact, you are doing some ultrasound studies or CAT scans of the abdomen, what did the three patients that you took to surgery show on CAT scanning that made you take them to surgery in the first place. C. Cosentino (response): The length of hospitalization varied depending on each patient. Their stays were determined by their clinical course. Some of the
patients were observed in the intensive care units, others were not. We usually followed them with serial hematocrits and serial examinations. We did not routinely get follow-up CAT scans or ultrasounds while they were in the hospital. It all depended on their clinical course. As far as the patients that we took to the operating room, one patient did not have any preoperative imaging studies and was taken to the operating room with the diagnosis of an acute abdomen and probable bowel injury. We found that patient to have a splenic laceration that was not bleeding. One patient went to the operating room for a small bowel
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obstruction secondary to an intramural jejunal hematoma. The other patient was taken to the operating room more for increasing abdominal girth, which was interfering with mechanical ventilation and control of intracranial pressure. When we explored that patient, there was no active bleeding from the spleen or liver injuries. R. Powell (Mobile, AL): All of your data and the data in other publications regarding transfusion requirements in the nonoperative management of liver and splenic injuries, report the requirements in mL per kg. As you stated, the main risk involved is per transfusion. Do you have data on the per unit or different units required by these patients? C. Cosentino (response): Yes I do, but I don’t have that information available right now. Most patients received anywhere from 1 to 4 units, although there were patients on the opposite end of the spectrum that received blood transfusions from multiple donors. For example, the patient that received 233 mL/kg received multiple transfusions. B. Beaver (Baltimore, MD): I’d like to congratulate the authors on a very nice assimilation of their experience in Chicago and I think nationwide we should all seriously look at our changing trend with transfusion. In Maryland, we have found that an hematocrit of 25 is perfectly acceptable with appropriate reticulocyte
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counts. The patient who is hemodynamically stable and has no clinical symptomatology whatsoever does not require routine transfusion posttrauma. Another point I’d like to bring up is of the three patients that had delayed laparotomy, were any of those involved with lap-belt injury? C. Cosentino (response): One was a fall and the other two were pedestrian motor vehicle accidents. J. Randolph (Washington, DC): When you get to be my age, you get to make historical comments, and I want to make two. One is that it is interesting the way the wheel goes around because it was exactly 10 years ago that Benji Brooks gave us the first comments about saving the spleen at APSA, and we almost laughed her out of the room and here we are all having adopted this way. Second historical comment. There are occasionally other indications for operation. We had a patient in our series where we, too, had tried very hard not to operate. She was a 13-year-old girl who had fallen off a horse and her father was the outside linebacker and defensive captain for the Washington Redskins, and was not a small person. We had a lot of conversations about wanting to save the spleen and that we just hung the blood and then we hung another blood. I remember talking to him and he said, “yeah, yeah, Dr Randolph, I understand all that stuff, but don’t let anything happen to my little girl.” So we operated on her.
