Management of Pediatric Splenic Injury
ABSTRACT & COMMENTARY
Synopsis: Two comparable groups of children with blunt splenic injury (BSI) were randomized to receive either "standard" management or a protocol involving shorter times in the hospital, as well as a reduced period of restricted activity at home. No differences were seen in clinical outcomes.
Source: Gandhi RR, et al. Pediatric splenic injury: Pathway to play? J Pediatr Surg 1999;34:55-59.
Gandhi and associates, pediatric surgeons at the children’s Hospital of Philadelphia (CHOP), conducted a study to see whether the "gold standard" management of BSI could be safely modified to reduce the duration of hospitalization and the period of restricted activity during outpatient convalescence (pathway protocol). Forty-nine children admitted to the CHOP during 1996-1997 were randomized to standard or "pathway" protocols. The groups were comparable with respect to age, injury mechanism, grade of splenic injury, length of ICU stay, or number of transfusions. Following transfer from the ICU, children on the standard protocol were kept at strict bed rest in the hospital for 6-7 days. They were then discharged and followed with physical examinations, complete blood counts (CBCs), and radiologic examinations at 2-4 weeks after discharge. When these were normal, the child was allowed to return to school, but resumption of full activity was not permitted until examinations 3-6 months later demonstrated resolution of splenic injury. In contrast, the "pathway" protocol permitted quiet activities on the third day after transfer from the ICU and discharge on day 4 if the hemoglobin level was steady. The children were then restricted to quiet activity at home for three weeks. If they were asymptomatic at this time, limited activity at home and school was permitted. At three months after injury, and if they were doing well, resumption of full activity (including sports) was allowed. The "pathway" patients’ length of hospital stay and medical costs were statistically less than the standard group. There were no complications or missed injuries in either group. Gandhi et al conclude that BSI in children can be treated safely with a four-day hospital stay followed by three weeks of quiet activity at home and three months of light activity before return to full, unrestricted activity. Repeat radiological studies were not performed in the "pathway" group before permitting full activity.
COMMENT BY ROBERT J. TOULOUKIAN, MD
The management of isolated BSI in children who remain hemodynamically stable is undergoing its second reappraisal in 25 years. The initial change to nonoperative management of BSI is now accepted as the standard of care and is possible in a great majority of cases of BSI and to a large extent is being applied to adult patients as well as children. The study by Gandhi et al addresses the issue as to whether shortening the period of in-hospital observation, reducing the quiet period at home, and eliminating postdischarge radiologic examinations has any adverse effect on full recovery. The data presented strongly support the concept that some modifications of our current treatment protocols are appropriate. However, the study group is small and these results must be substantiated by a larger, probably multi-institutional effort to confirm the results before major modifications can be fully accepted.
Gandhi et al’s study raises some further questions that should be addressed. How much farther can we "stretch the envelope" by further reducing mandatory monitoring and inactivity before an increased incidence of rebleeding or reinjury is noted? Does this kind of study send, to me, a worrisome signal that hospitals without pediatric trauma facilities or experienced pediatric surgeons will now be prepared to admit, evaluate, and manage children with splenic injury? Will trauma room focused abdominal sonographic testing (FAST), now commonly used in adult trauma centers, begin to be used as a cheaper substitute for our current and accurate diagnostic CT scans in children in order to reduce cost and "expedite" care? I am clearly in favor of further evaluating the recommendations proposed by Gandhi et al but we need to be cautious about other possible implications. Pediatricians should recognize the potentially serious risks associated with BSI and insist that these patients be managed by surgeons with expertise and experience in childhood injury. (Dr. Touloukian is Professor of Surgery and Chief of Pediatric Surgery at the Yale-New Haven Children’s Hospital.)