TY - JOUR
T1 - Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis
T2 - A pediatric trauma society collaborative
AU - Naik-Mathuria, Bindi J.
AU - Rosenfeld, Eric H.
AU - Gosain, Ankush
AU - Burd, Randall
AU - Falcone, Richard A.
AU - Thakkar, Rajan
AU - Gaines, Barbara
AU - Mooney, David
AU - Escobar, Mauricio
AU - Jafri, Mubeen
AU - Stallion, Anthony
AU - Klinkner, Denise B.
AU - Russell, Robert
AU - Campbell, Brendan
AU - Burke, Rita V.
AU - Upperman, Jeffrey
AU - Juang, David
AU - St Peter, Shawn
AU - Fenton, Stephon J.
AU - Beaudin, Marianne
AU - Wills, Hale
AU - Vogel, Adam
AU - Polites, Stephanie
AU - Pattyn, Adam
AU - Leeper, Christine
AU - Veras, Laura V.
AU - Maizlin, Ilan
AU - Thaker, Shefali
AU - Smith, Alexis
AU - Waddell, Megan
AU - Drews, Joseph
AU - Gilmore, James
AU - Armstrong, Lindsey
AU - Sandler, Alexis
AU - Moody, Suzanne
AU - Behrens, Brandon
AU - Carmant, Laurence
N1 - Publisher Copyright:
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
PY - 2017/10/1
Y1 - 2017/10/1
N2 - BACKGROUND Guidelines for nonoperative management (NOM) of high-grade pancreatic injuries in children have not been established, and wide practice variability exists. The purpose of this study was to evaluate common clinical strategies across multiple pediatric trauma centers to develop a consensus-based standard clinical pathway. METHODS A multicenter, retrospective review was conducted of children with high-grade (American Association of Surgeons for Trauma grade III-V) pancreatic injuries treated with NOM between 2010 and 2015. Data were collected on demographics, clinical management, and outcomes. RESULTS Eighty-six patients were treated at 20 pediatric trauma centers. Median age was 9 years (range, 1-18 years). The majority (73%) of injuries were American Association of Surgeons for Trauma grade III, 24% were grade IV, and 3% were grade V. Median time from injury to presentation was 12 hours and median ISS was 16 (range, 4-66). All patients had computed tomography scan and serum pancreatic enzyme levels at presentation, but serial enzyme level monitoring was variable. Pancreatic enzyme levels did not correlate with injury grade or pseudocyst development. Parenteral nutrition was used in 68% and jejunal feeds in 31%. 3Endoscopic retrograde cholangiopancreatogram was obtained in 25%. An organized peripancreatic fluid collection present for at least 7 days after injury was identified in 59% (42 of 71). Initial management of these included: observation 64%, percutaneous drain 24%, and endoscopic drainage 10% and needle aspiration 2%. Clear liquids were started at a median of 6 days (IQR, 3-13 days) and regular diet at a median of 8 days (IQR 4-20 days). Median hospitalization length was 13 days (IQR, 7-24 days). Injury grade did not account for prolonged time to initiating oral diet or hospital length; indicating that the variability in these outcomes was largely due to different surgeon preferences. CONCLUSION High-grade pancreatic injuries in children are rare and significant variability exists in NOM strategies, which may affect outcomes and effective resource utilization. A standard clinical pathway is proposed. LEVEL OF EVIDENCE Therapeutic/care management, level V (case series).
AB - BACKGROUND Guidelines for nonoperative management (NOM) of high-grade pancreatic injuries in children have not been established, and wide practice variability exists. The purpose of this study was to evaluate common clinical strategies across multiple pediatric trauma centers to develop a consensus-based standard clinical pathway. METHODS A multicenter, retrospective review was conducted of children with high-grade (American Association of Surgeons for Trauma grade III-V) pancreatic injuries treated with NOM between 2010 and 2015. Data were collected on demographics, clinical management, and outcomes. RESULTS Eighty-six patients were treated at 20 pediatric trauma centers. Median age was 9 years (range, 1-18 years). The majority (73%) of injuries were American Association of Surgeons for Trauma grade III, 24% were grade IV, and 3% were grade V. Median time from injury to presentation was 12 hours and median ISS was 16 (range, 4-66). All patients had computed tomography scan and serum pancreatic enzyme levels at presentation, but serial enzyme level monitoring was variable. Pancreatic enzyme levels did not correlate with injury grade or pseudocyst development. Parenteral nutrition was used in 68% and jejunal feeds in 31%. 3Endoscopic retrograde cholangiopancreatogram was obtained in 25%. An organized peripancreatic fluid collection present for at least 7 days after injury was identified in 59% (42 of 71). Initial management of these included: observation 64%, percutaneous drain 24%, and endoscopic drainage 10% and needle aspiration 2%. Clear liquids were started at a median of 6 days (IQR, 3-13 days) and regular diet at a median of 8 days (IQR 4-20 days). Median hospitalization length was 13 days (IQR, 7-24 days). Injury grade did not account for prolonged time to initiating oral diet or hospital length; indicating that the variability in these outcomes was largely due to different surgeon preferences. CONCLUSION High-grade pancreatic injuries in children are rare and significant variability exists in NOM strategies, which may affect outcomes and effective resource utilization. A standard clinical pathway is proposed. LEVEL OF EVIDENCE Therapeutic/care management, level V (case series).
KW - Pediatric pancreatic injury
KW - guideline
KW - nonoperative management
KW - pancreatic trauma
KW - practice variability
KW - standard clinical pathway
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U2 - 10.1097/TA.0000000000001576
DO - 10.1097/TA.0000000000001576
M3 - Article
C2 - 28930953
AN - SCOPUS:85020240834
SN - 2163-0755
VL - 83
SP - 589
EP - 596
JO - Journal of Trauma and Acute Care Surgery
JF - Journal of Trauma and Acute Care Surgery
IS - 4
ER -