Title

Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis: A pediatric trauma society collaborative

Authors

Bindi J. Naik-Mathuria, Texas Children's Hospital Houston
Eric H. Rosenfeld, Texas Children's Hospital Houston
Ankush Gosain, Le Bonheur Children's Medical Center
Randall Burd, Childrens National Health System
Richard A. Falcone, Cincinnati Children's Hospital
Rajan Thakkar, Nationwide Children’s Hospital
Barbara Gaines, Mary Bridge Children's Hospital and Health Center
David Mooney, Texas Children's Hospital Houston
Mauricio Escobar, Texas Children's Hospital Houston
Mubeen Jafri, Randall Children's Hospital at Legacy Emanuel
Anthony Stallion, Texas Children's Hospital Houston
Denise B. Klinkner, Mayo Clinic
Robert Russell, Children's Health System
Brendan Campbell, Connecticut Children's Medical Center
Rita V. Burke, Children's Hospital Los Angeles
Jeffrey Upperman, Children's Hospital Los Angeles
David Juang, Nationwide Children’s Hospital
Shawn St Peter, Children's Mercy Hospitals and Clinics
Stephon J. Fenton, The University of Utah
Marianne Beaudin, Texas Children's Hospital Houston
Hale Wills, Hasbro Children's Hospital
Adam Vogel, St. Louis Children's Hospital
Stephanie Polites, Mayo Clinic
Adam Pattyn, Children's Hospital Boston
Christine Leeper, Mary Bridge Children's Hospital and Health Center
Laura V. Veras, Le Bonheur Children's Medical Center
Ilan Maizlin, Children's Health System
Shefali Thaker, Connecticut Children's Medical Center
Alexis Smith, Hasbro Children's Hospital
Megan Waddell, Carolinas HealthCare System
Joseph Drews, Children's Mercy Hospitals and Clinics
James Gilmore, Randall Children's Hospital at Legacy Emanuel
Lindsey Armstrong, Texas Children's Hospital Houston

Document Type

Journal Article

Publication Date

10-1-2017

Journal

Journal of Trauma and Acute Care Surgery

Volume

83

Issue

4

DOI

10.1097/TA.0000000000001576

Keywords

guideline; nonoperative management; pancreatic trauma; Pediatric pancreatic injury; practice variability; standard clinical pathway

Abstract

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. 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).

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