Davis DH, Localio, AR, Stafford, PW, Haelfaer, MA, Durbin, DR. Pediatrics. 2005;115(1):89-94.

INTRODUCTION

The approach to blunt splenic trauma in the pediatric patient has evolved in recent years, so that nonoperative management is the current standard of care. Nonoperative management of splenic injury has been associated with lower mortality, fewer complications, fewer blood transfusions, and a decreased length of stay. However, most studies demonstrating the safety and efficacy of nonoperative management have had limitations, including being conducted mainly in pediatric trauma centers. Surgeons in adult trauma centers or in nontrauma centers may have different criteria and management thresholds; in fact, there is evidence pointing to significant variations in practice patterns across hospital types. The authors of the article under review sought to describe the variation in management of pediatric blunt splenic injury within a regionalized trauma system, with different levels of pediatric resources, over a 10-year period. The information gained may be used to guide management strategies for this patient population.

ABSTRACT

The primary hypothesis proposed by the authors states that the proportion of children who were treated operatively would vary inversely with the level of pediatric resources of the hospitals. A secondary hypothesis proposed was that within hospitals of the same level of resources, operative management would decrease over time. The study population includes children who had a diagnosis of blunt splenic trauma and were hospitalized in the state of Pennsylvania during the 10-year study period. Statewide discharge data were obtained on each child, including age, gender, diagnosis codes, procedure codes, discharge status, length of stay, and a hospital identifier. Hospitals were stratified into 5 groups based on pediatric and trauma resources: pediatric trauma centers, level 1 trauma centers with additional qualifications in pediatrics, level 1 trauma centers, level 2 trauma centers, and nontrauma centers. The proportion of patients who were treated operatively was stratified by hospital type and adjusted for age and splenic injury severity.

A total of 3,245 children were included in the study, 23% of whom were managed operatively. Across hospital types, operative management increased as the resources for pediatric trauma care decreased. Those treated operatively were older and had a higher grade of splenic injury severity, a longer length of stay, and a higher mortality. Even after adjustment for age and injury severity, significant variation in practice patterns was seen both over time and across hospital types.

As hypothesized, the results of this study do indicate that nonoperative management was significantly higher and increased over time in those hospitals with larger volumes of pediatric patients. The authors do acknowledge limitations of this study that should be considered in interpreting its results. The decision on whether to operate on a child with blunt trauma to the spleen is complex and influenced by a number of factors. Many of these factors may not be available when conducting a retrospective study using an existing database. In this study, for example, data that may have influenced the decision on whether to operate, ie, hemoglobin levels, were not available from the data source and may have influenced outcomes.

COMMENTARY

The authors present a large-scale, comprehensive review demonstrating considerable variation in the management of blunt splenic trauma in the pediatric patient. Despite its retrospective approach, this study has significant implications for any nurse taking care of pediatric trauma patients. The importance of adopting standardized guidelines for this unique patient population is evident, especially considering the varying levels of pediatric resources within regionalized trauma systems. This study should raise awareness in all trauma nurses of the known benefits of nonoperative management in pediatric blunt splenic trauma, to promote its widespread utilization. The adoption of nonoperative management guidelines can assure the trauma team that they are providing optimal care for the pediatric patient.