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Home > Blogs > Trauma Research Blog > Variability in pediatric splenic injury care: results of a national survey of general surgeons.

PubMed ID: 21079092
Arch Surg. 2010 Nov;145(11):1048-53
Authors: Bowman SM, Bulger E, Sharar SR, Maham SA, Smith SD

Abstract:

BACKGROUND: Although nonoperative management is the standard of care for hemodynamically stable children with blunt splenic trauma, significant variation in practice exists. Little attention has been given to physician factors associated with management differences.

DESIGN: Nationally representative mail survey conducted in June 2008.

SETTING: United States.

PARTICIPANTS: Ten percent random sample of active, dues-paying fellows in the American College of Surgeons.

MAIN OUTCOME MEASURES: Knowledge, attitudes, and beliefs toward pediatric splenic injury management, including the role of clinical practice guidelines.

RESULTS: Almost all of the 375 responding surgeons (97.4%) agreed that surgical intervention is not immediately necessary for hemodynamically stable children. However, surgeons reported significant disagreement regarding whether blood should be administered before operative intervention for hemodynamically unstable children and whether explorative surgery is needed for stable patients with evidence of contrast extravasation on computed tomography. Only 18.7% of surgeons reported being very familiar with the clinical practice guidelines for the management of pediatric blunt splenic trauma from either the Eastern Association for the Surgery of Trauma or the American Pediatric Surgical Association. Surgeons who were very familiar with either guideline were significantly more likely to rate the guidelines as beneficial (90.0% vs 72.8%, P = .002).

CONCLUSIONS: General surgeons reported varying degrees of familiarity with and use of clinical practice guidelines for pediatric splenic injury management. Limited pediatric experience and lack of pediatric hospital resources may limit more widespread adoption of nonoperative management. Targeted educational interventions may help increase surgeon knowledge of guidelines and best practices.

Notes & Commentary:

I'm not normally a big fan of surveys of practice but it can be a useful exercise in highlighting deficiencies or discrepancies in care.  This is a case in point, where there are fundamental issues with the management of paediatric trauma.  Serious paediatric trauma is uncommon and most surgeons outside of paeditric trauma centres will see very few cases in their lifetime.  In a letter we wrote to the Annals of the Royal College of Surgeons of England we estimated that the average general surgeon in the UK would perform a paediatric splenectomy once every 25 years (and that as before the reduction of working hours!) (PMID: 12831498).

This study shows how low paediatric trauma is on the radar of general surgeons.  There is widespread understanding that the majority of paediatric splenic injuries can be managed non-operatively (over 90% in some series).  However this does not translate into ALL spleen injuries can be managed non-operatively.   Identifying the child with a spleen injury who is not responding to fluid resuscitation and making the decision to operate is extremely difficult when the condition is rare and the intervention even rarer - but these are the children whose lives can be saved by relatively simple immediate surgery.

Much has been written recently on the non-operative management of spleen injuries.  What needs to be focused on is operative management and specifically decision making in paediatric trauma.  

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