Management Of Pediatric Renal Trauma Research Articles

Trends in Presentation and Management of Pediatric Renal Trauma

ObjectiveWe queried the Pediatric Health Information System (PHIS) to evaluate the presentation, management, and outcomes of renal trauma in children from birth to 18 years from 2007 to 2018. MethodsPatients were categorized as infants (0-1 year), toddlers (2-4 years), children (5-9 years), preteen (10-14 years), and teens (15-18 years) and patient demographics, grade of injury, and mechanism of injury including sports related trauma were collected. Each group was then evaluated for the level of management and patient outcome. ResultsWe identified 3720 patients with renal trauma. Our cohort was predominantly white (68.5%), male (68.6%), and required public insurance (38.5%). Most injuries were low grade (86.7%) and managed non-operatively (94.7%). The overall mortality was 51 (1.4%). Younger patients (infants, toddlers, children) were more likely to present with complex injuries and they were more likely to have been involved in a motor vehicle accident. They had higher blood transfusion rates, longer inpatient courses, higher levels of admission acuity, and higher mortality. Patients in the older age groups presented most after Sport Related Trauma (SRT). Across all age groups, the most common source of SRT was limited contact sports; however, when considering only teens, full contact sports were the primary offending activity. This review of the PHIS database provides insight to the rates and patterns of pediatric renal trauma in the United States. ConclusionOur data suggests an age-related differences in the presentation, management, and outcomes of pediatric renal trauma patients.

Management of pediatric renal trauma: Results from the American Association for Surgery and Trauma Multi-Institutional Pediatric Acute Renal Trauma Study.

Pediatric renal trauma is rare and lacks sufficient population-specific data to generate evidence-based management guidelines. A nonoperative approach is preferred and has been shown to be safe. However, bleeding risk assessment and management of collecting system injury are not well understood. We introduce the Multi-institutional Pediatric Acute Renal Trauma Study (Mi-PARTS), a retrospective cohort study designed to address these questions. This article describes the demographics and contemporary management of pediatric renal trauma at Level I trauma centers in the United States. Retrospective data were collected at 13 participating Level I trauma centers on pediatric patients presenting with renal trauma between 2010 and 2019. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Descriptive statistics were used to report on demographics, acute management, and outcomes. In total, 1,216 cases were included in this study. Of all patients, 67.2% were male, and 93.8% had a blunt injury mechanism. In addition, 29.3% had isolated renal injuries, and 65.6% were high-grade (American Association for the Surgery of Trauma Grades III-V) injuries. The mean Injury Severity Score was 20.5. Most patients were managed nonoperatively (86.4%), and 3.9% had an open surgical intervention, including 2.7% having nephrectomy. Angioembolization was performed in 0.9%. Collecting system intervention was performed in 7.9%. Overall mortality was 3.3% and was only observed in patients with multiple injuries. The rate of avoidable transfer was 28.2%. The management and outcomes of pediatric renal trauma lack data to inform evidence-based guidelines. Nonoperative management of bleeding following renal injury is a well-established practice. Intervention for renal trauma is rare. Our findings reinforce differences from the adult population and highlights opportunities for further investigation. With data made available through Mi-PARTS, we aimed to answer pediatric specific questions, including a pediatric-specific bleeding risk nomogram, and better understanding indications for interventions for collecting system injuries. Prognostic and Epidemiological; Level IV.

Pediatric renal trauma at a level 1 trauma center in a rural state: A 10-year institutional review and protocol implementation

Unintentional injury is a leading cause of mortality and morbidity in children. There is no consensus on the ideal, discrete management of pediatric renal trauma (PRT). Therefore, management protocols tend to be institution-specific. This study aimed to characterize PRT at a rural level-1 trauma center and subsequently develop a standardized protocol. A retrospective review of a prospectively maintained database of PRT at a rural level 1 trauma center between 2009 and 2019 was conducted. Injuries were characterized regarding renal trauma grade, associated multi-organ involvement and the need for intervention. The benefit of patient transfer from regional hospitals and length and cost of stay were evaluated. Of 250 patients admitted with renal trauma diagnosis 50 patients <18 years were analyzed. Of those, the majority (32/50, 64%) had low-grade (grade I-III) injuries. Conservative management was successful in all low-grade injuries. Of 18 high-grade PRT, 10 (55.6%) required intervention, one prior to transfer. Among patients with low-grade trauma, 23/32 (72%) were transferred from an outside facility. A total of 13 (26%) patients with isolated low-grade renal trauma were transferred from regional hospitals. All isolated, transferred low-grade renal trauma had diagnostic imaging before transfer and none required invasive intervention. Interventional management of renal injury was associated with a longer median LOS [7 (IQR=4-16.5) vs 4 (IQR=2-6) days for conservative management, p=0.019)] and an increased median total cost of $57,986 vs. $18,042 for conservative management (p=0.002). The majority of PRT, particularly low-grade, can be managed conservatively. A significant proportion of children with low-grade trauma are unnecessarily transferred to higher level centers. Review of pediatric renal trauma at our institution over a decade has allowed us to develop an institutional protocol which we believe allows for safe and effective patient monitoring. Isolated, low-grade PRT can be managed conservatively at regional hospitals without needing transfer to a level 1 trauma center. Children with high-grade injuries should be closely monitored and are more likely to need invasive intervention. Development of a PRT protocol will help to safely triage this population and identify those who may benefit from transfer to a tertiary care center.

MP53-02 PEDIATRIC RENAL TRAUMA AT A LEVEL-1 TRAUMA CENTER IN RURAL STATE: 10-YEAR INSTITUTIONAL REVIEW AND PROTOCOL IMPLEMENTATION

You have accessJournal of UrologyCME1 Apr 2023MP53-02 PEDIATRIC RENAL TRAUMA AT A LEVEL-1 TRAUMA CENTER IN RURAL STATE: 10-YEAR INSTITUTIONAL REVIEW AND PROTOCOL IMPLEMENTATION Zachary Werner, Luke O'Connor, Ahmed Abdelhalim, and Osama Al-Omar Zachary WernerZachary Werner More articles by this author , Luke O'ConnorLuke O'Connor More articles by this author , Ahmed AbdelhalimAhmed Abdelhalim More articles by this author , and Osama Al-OmarOsama Al-Omar More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003301.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There is no consensus on the ideal management of pediatric renal trauma (PRT); therefore protocols tend to be institution-specific. This study aimed to characterize PRT at a rural level-1 trauma center and to develop a standardized protocol. METHODS: We retrospectively reviewed a prospectively maintained database of PRT at our institution from 2009-2019. Injuries were characterized based on renal trauma grade, associated multi-organ involvement and need for intervention. We subsequently appraised the benefit of patient transfer from regional hospitals and the impact of follow-up imaging on patient care. RESULTS: Of the 250 patients admitted with a diagnosis of renal trauma, 50 were under the age of eighteen. Of those, 32/50 (68%) patients had low-grade (grade I-III) injuries with the remaining 18/50 (32%) diagnosed with high grade (IV-V) injuries. All grade I-III injuries were managed conservatively without requiring invasive intervention. Among patients with low-grade trauma, 21/32 (65.5%) were transferred from an outside facility. For patients with high grade injuries, 9/18 (50%) required surgical intervention. Of the patient with high grade injuries, 2/18 (11%) had their management escalated as a result of follow up imaging. Based on data from our institution, we developed pediatric-specific renal trauma protocol which was implemented in early 2021 (Figure 1). CONCLUSIONS: Isolated, low-grade PRT can be managed conservatively at regional hospitals without needing transfer to a Level 1 Trauma Center. However, those with high-grade injuries should be monitored closely as these patients may require intervention. Development of PRT protocol will help to safely triage this population and identify those that require transfer to tertiary care center. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e712 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Zachary Werner More articles by this author Luke O'Connor More articles by this author Ahmed Abdelhalim More articles by this author Osama Al-Omar More articles by this author Expand All Advertisement PDF downloadLoading ...

Impact of trauma center designation in pediatric renal trauma: National Trauma Data Bank analysis

The pediatric kidney is the most common urinary tract organ injured in blunt abdominal trauma. Trauma care in the United States has been established into a hierarchical system verified by the American College of Surgeons (ACS). Literature evaluating management of pediatric renal trauma across trauma tier designations is scarce. To examine the differences in the management and outcomes of renal trauma in the pediatric population based on trauma level designation across the United States. We performed a review of the ACS - National Trauma Data Bank database. Pediatric patients (age 0-18 years) who were treated for renal injury between years 2011-2016 were identified. Our primary outcome was the difference in any complication rate amongst Level I versus Non-Level I trauma centers. Management strategies were evaluated as secondary outcomes. Propensity score matching (PSM) was utilized to adjust for baseline differences between cohorts. Multivariable regression analysis was performed to determine the independent effects of individual factors on complications, operative intervention, minimally invasive procedure, and blood transfusions. Overall, 12,097 pediatric patients were diagnosed with renal trauma between 2011 and 2016 using target ICD-9 and AAST codes. After PSM, there was a total of 1623 subjects withing each group. No difference was identified between groups for occurrence on any complication [105 (6.5%) vs 114 (7.0%), p=0.576. There were no differences in the rate of minimally invasive interventions [67 (4.1%) vs 48 (3.0%), p=0.087], operative intervention [58 (3.6%) vs 68 (4.2%), p=0.413], or nephrectomy [42 (2.6%) vs 47 (2.9%), p=0.667] between Level I and Non-Level I trauma designations, respectively. Length of stay was longer in the Level I cohort compared to Non-Level I (days (SD)) [6.9 (8.8) vs 6.2 (7.9), p=0.024. When specifically looking at risk factors associated with operative intervention, higher renal injury grade and injury severity score were highly correlated, whereas, trauma level designation was not found to be predictive for more aggressive management. Our results corroborate with previous literature that renal injury grade and injury severity score are strong predictors of morbidity, invasive management, and complications. Pediatric renal trauma was managed similarly across trauma center designations, with the rate of complication and intervention more prevalent in patients with high grade renal injuries and concomitant injuries. Further studies are necessary to identify patients who will benefit most from transfer to a level I center.

Contemporary management of pediatric high grade renal trauma: 10 year experience at a level 1 trauma centre

Current guidelines advocating the conservative management of renal injuries in children are primarily extrapolated from adult series due to a dearth of evidence in the pediatric population. The aim of this study was to review our experience in the management of pediatric high-grade renal trauma and to clarify the role of conservative management in this cohort of patients. The Alberta Trauma Registry (ATR) is a comprehensive web-based registry which functions to prospectively collect data on all trauma patients in the province who sustain a severe injury (i.e. Injury Severity Score (ISS) ≥12). The ATR was used to identify all pediatric patients who attended hospitals within the Edmonton region with high grade renal injuries (grade III-V) between January 2006 and December 2018. Hospital records and imaging were reviewed to identify patient demographics, mechanism of injury, AAST grade, haemodynamic stability, associated injuries, management, length of hospital stay (LOS), complications, and follow-up outcomes. A total of 53 children (38 boys, 15 girls) were identified with a mean age of 13 years (1-16). The mechanism of injury was blunt trauma in 92.5% (49/53) of cases (Supplementary Table). AAST grade distribution was 37.8% Grade III (20/53), 49% Grade IV (26/53) and 13.2% Grade V (7/53). All Grade III injuries were successfully managed conservatively. Overall 11 patients with Grade IV/V injuries required urological intervention (ureteral stenting (5 patients), angioembolization (4 patients), bladder washout with clot evacuation (1 patient), emergency nephrectomy (3 patients)). The overall renal salvage rate was 92.4% (49/53). Our series confirms the safety of expectant management in high grade pediatric renal trauma. All grade III injuries in our study were managed conservatively without the need for intervention. This suggests that these injuries may be managed safely outside of designated trauma centres. One third of children with grade IV/V injuries required intervention. Therefore we recommend that patients with these injuries are transferred to specialized units with the capacity to provide such procedures if required. This study supports the conservative management of pediatric renal trauma in the setting of high-grade injury. Expectant management was associated with acceptable rates of intervention and excellent renal salvage rates.

Does contrast-enhanced ultrasound have a role in evaluation and management of pediatric renal trauma? A preliminary experience

BackgroundTo report our initial experience using intravenous contrast-enhanced ultrasound (CEUS) in pediatric renal trauma with the potential for substantial radiation reduction. MethodsA retrospective review of all patients who underwent intravenous CEUS at our institution between May 2015 and January 2018 for the suspicion of blunt renal trauma. CEUS was obtained either as an immediate or short-term comparison to contrast-enhanced computed tomography (CECT), or in outpatient follow-up. ResultsCEUS was performed on 7 patients (9 kidneys) with age range 2 months to 16 years old. CEUS was utilized as a comparison to CECT in 4 of 7 patients for initial evaluation, clinical change, or short-term follow-up. CEUS alone was used in one patient with low suspicion for renal injury. In the remaining two patients, CEUS was obtained as a follow-up study weeks after the initial CECT, following conservative management. All patients with confirmed renal injury by CECT (n = 5) underwent a follow-up CEUS at 1–2 months. ConclusionsIn an era of conservative management for renal trauma in which operative intervention is dictated more often by the clinical course than radiographic findings, it is reasonable to consider alternative imaging methods such as CEUS in stable patients to decrease radiation exposure. Level of Evidence RatingIV

Pediatric blunt renal trauma: Its conservative management and patterns of associated injuries

Objectives To review the conservative management of pediatric renal trauma and investigate the significance of associated nonrenal injuries. Methods We performed a retrospective review of 63 pediatric patients with blunt renal injury who were treated expectantly. A comparison was made between operative and nonoperative management, mechanism of injury, treatment complications, requirement for blood transfusion, length of hospital stay, associated injuries, and incidence of pre-existing urologic conditions. Results The renal injury grade was grade I in 31 patients, grade II in 12, grade III in 8, grade IV in 10, and grade V in 2. Two patients underwent acute surgical exploration; one for nonrenal causes and one (2%) for life-threatening renal bleeding (grade V injury). Renorrhaphy was not performed, and 98% of patients were initially treated nonoperatively. Three patients (5%) underwent delayed renal surgery: one nephrectomy for Wilms’ tumor, one partial nephrectomy for nonhealing grade IV injury, and one attempted repair of a renal pelvis injury with subsequent nephrectomy. Excluding 1 patient who died and one nephrectomy for tumor control, our renal salvage rate was 97% (59 of 61). The overall mean hospital stay was 7.7 days and was similar across all grades (grade I, 7.7 days; grade II, 7.8; grade III, 6.1; grade IV, 9.2; and grade V, 10.5 days). Conclusions The results of our study have shown that pediatric patients with blunt nonexsanguinating renal injuries treated conservatively do well. The length of hospital stay did not increase with worsening severity of renal injury and, instead, was determined by the severity of the nonrenal associated injuries. This report adds to a growing body of published data that suggest that conservative management of pediatric blunt renal trauma is safe.