PEDIATRIC HEPATIC-TRAUMA - DOES CLINICAL COURSE SUPPORT INTENSIVE-CARE UNIT STAY

Purpose: The objective of this study is to determine if grade of liver injury predicts outcome after blunt hepatic trauma in children and to initiate analysis of current management practices to optimize resourc e utilization without compromising patient care. Methods: A retrospect ive review of 36 children who had blunt hepatic trauma treated at a pe diatric trauma center from 1989 to present was performed. Hepatic inju ries graded (AAST Organ Injury Scaling) ranged from grade I to IV. Inj ury Severity Score (ISS), Glasgow Coma Score (GCS), transfusion requir ements, liver transaminase levels, associated injuries, intensive care unit (ICU) length of stay, and survival were analyzed. Results: Mean (+/-SEM) age was 6.6 +/- 0.8 years, mean grade of hepatic injury was 2 .4 +/- 0.2, mean ISS was 17 +/- 2.6, mean GCS was 13 +/- 1, and mean t ransfusion was 15.4 mL/kg of packed red blood cells (PRBC). There were three deaths with a mean ISS of 59 +/- 9 and a mean GCS of 3 +/- 0. D eath was not associated with a high-grade liver injury, survivors vers us nonsurvivors, 2.3 +/- 0.2 Versus 2.7 +/- 0.3, but was associated wi th ISS, 13 +/- 1.4 Versus 59 +/- 9 (P = .005) and GCS, 14 +/- 1 versus 3 +/- 0 (P = .005). Only one patient (grade ill, ISS = 43) underwent surgery. There were no differences in mean ISS or GCS between grades I to IV patients. The hepatic injury grades of patients requiring transf usion versus no transfusion were significantly different, 3.4 +/- 0.2 versus 2.2 +/- 0.2 (P = 0.04). Abused patients had high-grade hepatic injuries and significant laboratory and clinical findings. Alanine ami notransferase (ALT) and aspartate aminotransferase (AST) were signific antly higher in grade III and IV injuries than in grades I and II, 1,1 57 +/- 320 versus 333 +/- 61 (P = .02) and 1,176 +/- 299 versus 516 +/ - 86 (P = .04), respectively. No children with grade I or II injury ha d a transfusion requirement or surgical intervention. There were no li ver-related complications. Conclusions: Mortality and morbidity rates in pediatric liver injuries, grades I to IV, correlate with associated injuries not the degree of hepatic damage. ALT, AST, and transfusion requirements are significantly related to degree of liver injury. Low- grade and isolated high-grade liver injuries seldom require transfusio n. Blunt liver trauma rarely requires surgical intervention. In retros pect, the need for expensive ICU observation for low-grade and isolate d high-grade hepatic injuries is questionably warranted. Copyright (C) 1998 by W.B. Saunders Company.