The Failure of Nonoperative Management in Pediatric Solid Organ Injury: A Multi-institutional Experience

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Abstract
Nonoperative management (NOM) is the accepted treatment of most pediatric solid organ injuries (SOI) and, is typically successful. We sought to elucidate predictors of, and the time course to, failure in the subset of children suffering SOI who required operative intervention. A retrospective analysis was performed from January 1997 through December 2002 of all pediatric patients (age 0-20 years) with a SOI (liver, spleen, kidney, pancreas) from the trauma registries of seven designated, level I pediatric trauma centers. Failure of NOM was defined as the need for intra-abdominal operative intervention. Data reviewed included demographics, injury mechanism, injury severity (ISS, AIS, SOI grade, and GCS), and outcome. For the failures of NOM, time to operation and relevant clinical variables were also abstracted. A summary AIS (sAIS) was calculated for each patient by summing the AIS values for each SOI, to account for multiple SOI in the same patient. Univariate and multivariate analyses were employed, and significance was set at p < 0.05. A total of 1,880 children were identified. Of these, 62 sustained nonsurvivable head injuries that precluded assessment of NOM outcome and were thus excluded. The remaining 1,818 patients comprised the overall study population. There were 1,729 successful NOM patients (controls -- C) and 89 failures (F), for an overall NOM failure rate of 5%. For isolated organ injuries, the failure rates were: kidney 3%, liver 3%, spleen 4%, and pancreas 18%. There were 14 deaths in the failure group from nonsalvageable injuries (mean ISS = 54 +/- 15). The two groups did not differ with respect to mean age or gender. An MVC was the most common injury mechanism in both groups. Only bicycle crashes were associated with a significantly increased risk of failing NOM (RR = 1.76, 95% CI = 1.02-3.04, p < 0.05). Injury severity and organ specific injuries were associated with NOM failure. When controlling for ISS and GCS, multivariate regression analysis confirmed that a sAIS > or = 4, isolated pancreatic injury, and >1 organ injured were significantly associated with NOM failure (p < 0.01). The median time to failure was 3 hours (range, 0.5-144 hours) with 38% having failed by 2 hours, 59% by 4 hours, and 76% by 12 hours. Failure of NOM is un common (5%) and typically occurs within the first 12 hours after injury. Failure is associated with injury severity and multiplicity, as well as isolated pancreatic injuries.

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