Nonoperative management of blunt liver and spleen injury in children: evaluation of the ATOMAC guideline using GRADE

BACKGROUND: Nonoperative management of liver and spleen injury should be achievable for more than 95% of children. Large national studies continue to show that some regions fail to meet these benchmarks. Simultaneously, current guidelines recommend hospitalization for injury grade + 2 (in days). A new treatment algorithm, the ATOMAC guideline, is in clinical use at many centers but has not been prospectively validated. METHODS: A literature review conducted through MEDLINE identified publications after the American Pediatric Surgery Association guidelines using the search terms blunt liver trauma pediatric, blunt spleen trauma pediatric, and blunt abdominal trauma pediatric. Decision points in the new algorithm generated clinical questions, and GRADE [Grading of Recommendations, Assessment, Development, and Evaluations] methodology was used to assess the evidence supporting the guideline. RESULTS: The algorithm generated 27 clinical questions. The algorithm was supported by six 1A recommendations, two 1B recommendations, one 2B recommendation, eight 2C recommendations, and ten 2D recommendations. The 1A recommendations included management based on hemodynamic status rather than grade of injury, support for an abbreviated period of bed rest, transfusion thresholds of 7.0 g/dL, exclusion of peritonitis from a guideline, accounting for local resources and concurrent injuries in the management of children failing to stabilize, as well as the use of a guideline in patients with multiple injuries. The use of more than 40 mL/kg or 4 U of blood to define end points for the guideline, and discharging stable patients before 24 hours received 1B recommendations. CONCLUSION: The original American Pediatric Surgery Association guideline for pediatric blunt solid organ injury was instrumental in improving care, but sufficient evidence now exists for an updated management guideline.(AU)

Admission base deficit in pediatric trauma: a study using the National Trauma Data Bank.

BACKGROUND: The base deficit, an important indicator of physiologic derangement after severe injury in adults, has not been specifically examined in the pediatric trauma population. The purpose of this study was to assess the ability of the admission base deficit to predict injury severity and outcome in the pediatric trauma population. METHODS: The study group included all patients in the National Trauma Data Bank over a 2-year period aged 0 to 12 years with a base deficit (0 to -30 mEq/L) recorded from the emergency department. Age, presence of a severe closed head injury, and base deficit were analyzed with respect to mortality and other indicators of injury severity. RESULTS: A total of 515 patients constituted the study group. Base deficit less than -4 mEq/L (p < 0.001) and the presence of a closed head injury (odds ratio, 3.8; p < 0.05) were predictors of mortality. For the group, an admission base deficit of -8 mEq/L corresponded to a probability of mortality of 25%. Significant correlations were found between base deficit and emergency department systolic blood pressure, Injury Severity Score, and Revised Trauma Score. There was no relationship between age and mortality. CONCLUSION: In injured children, the admission base deficit reflects injury severity and predicts mortality. The probability of mortality increases precipitously in children with a base deficit less than -8 mEq/L, and should alert the clinician to the presence of potentially lethal injuries or uncompensated shock.

Neonatal lipid utilization increases with injury severity: recombinant human growth hormone versus placebo.

Increased lipid oxidation has been observed in injured adult and pediatric patients who receive growth hormone (GH). In infants, whose bodies make fat more readily (de novo lipogenesis), this effect has not been tested. After surgery for necrotizing enterocolitis or gastroschisis, 22 neonates (average gestational age, 35 weeks; average postnatal age, 7 days) were provided basal protein-calorie parenteral repletion, and were prospectively randomized to receive either recombinant human GH (rhGH, 0.2 mg/kg/d) or placebo for 6 days. Injury severity was established by serial serum C-reactive protein (CRP) levels (high v low stress: CRP > or = 6.0 mg/dL v < 6.0 mg/dL). Indirect calorimetry was used to measure energy expenditure (MEE), respiratory quotient (RQ), net lipid oxidation (Fe), and lipid oxidative O2 consumption (VO2f). Among the GH+ group, MEE, Fe, and VO2f were significantly higher for the high-stress patients (MEE: 52.87 +/- 13.35 v 42.57 +/- 9.47 kcal/kg/d; P < .03: Fe; 18.32 +/- 27.74 v 0.81 +/- 13.47 kcal/kg/d; P < .02; VO2f: 7.21 +/- 9.86 v 0.01 +/- 7.42 L/d, P < .02), and RQnp was significantly lower in the high-stress patients (RQnp: 0.93 +/- 0.14 v 1.05 +/- 0.11; P < .02). In addition, Fe and RQnp were directly proportional to carbohydrate intake (CHO) in the high-stress patients (CHO to Fe: Pearson r = -.701; CHO to RQnp: Pearson r = .714; P < .05). Lipid oxidation was directly proportional to stress severity, was higher in the GH group (18.32 v 11.91 kcal/kg/d for the placebo group), and was depressed in response to increased CHO intake in all groups. Lipid is an important energy source in acutely injured, especially severely stressed neonates. Lipid substrate utilization is improved with GH supplementation during acute metabolic stress. In addition, excess carbohydrate delivery reduces the amount of lipid utilized for energy metabolism. An appropriately balanced, mixed-fuel formula should be used for caloric repletion in this infant population.

Stratification of injury severity using energy expenditure response in surgical infants.

AIM OF STUDY: Injury severity stratification has important clinical outcome significance and can influence nutritional management. Although surgery alone has been shown not to increase measured energy expenditure (MEE) substantially, large increases in MEE can result from severe underlying acute illness, which frequently necessitates surgery (like sepsis or intense inflammation). The authors hypothesized that the magnitude and duration of the MEE response to surgery associated with a severe preoperative acute injury would exceed that of surgery in which no substantial preoperative stress was present, thus representing an index of overall injury severity in surgical infants. METHODS: MEE (kcal/kg/d) was determined on postoperative days (POD) 2, 5, and 8 in 12 infants (average age, 47 days) after two separate injury insults (at least 8 days apart). In each patient, one operation resulted in a peak serum C-reactive protein (CRP) concentration of less than 6.5 mg/dL (low stress), and the second operation, preoperatively associated with sepsis or a major inflammatory insult, resulted in a peak CRP of more than 6.5 mg/dL (high stress). Data were paired so that each child served as his or her own control. The initial basal protein-calorie delivery was similar in both groups. MAIN RESULTS: The mean peak CRP values were 14.1 +/- 10.7 mg/dL (high stress) and 4.1 +/- 2.3 mg/dL (low stress) and returned to normal levels earlier (before POD 8) after injury insult in the low-stress group. Analysis of energy expenditure on POD 2 demonstrated significantly elevated mean MEE values in the high-stress group (58.0 +/- 12.2 kcal/kg/d v 39.4 +/- 9.5 kcal/kg/d in the low-stress group; P = .0001). In contrast, analysis of POD 8 energy expenditure showed significantly lower mean MEE values in the high-stress group (50.7 +/- 12.0 kcal/kg/d) v (66.4 +/- 15.1 kcal/kg/d in the low-stress group; P = .0118) group. CONCLUSION: The early (POD 2) hypermetabolic response to injury as determined by MEE effectively differentiated the two stress groups. This finding suggests that acute underlying illness is an important determinant of postoperative MEE. Furthermore, in the low-stress group, serial CRP levels returned to normal earlier, associated with significantly greater late (POD 8) MEE values. Because MEE is directly proportional to growth rate in healthy infants, and growth is retarded during acute metabolic stress, these findings suggest that increased energy is utilized for growth recovery following the earlier resolution of the acute injury response in the low-stress group. These data indicate that serial postoperative MEE can be used to stratify injury severity and may be an effective parameter to monitor the return of normal growth metabolism in surgical infants.

Early postoperative alterations in infant energy use increase the risk of overfeeding.

AIM OF STUDY: Energy needs in infants are decreased after surgery because of growth inhibition (resulting from catabolic stress metabolism), decreased insensible losses, and inactivity. Using standardized formulas that account for growth, activity, and insensible losses during this stress period can lead to overfeeding in excess of 200% of the actual measured requirement. Overfeeding during this acute injury period can result in increased CO2 production from lipogenesis. This study determined the effects of a reduced rate of mixed caloric repletion on infant energy use during the early postoperative period. METHODS: C-reactive protein (CRP), oxygen consumption (VO2), carbon dioxide production (VCO2), measured energy expenditure (MEE), and total urinary nitrogen (TUN) were measured serially in seven infants (average age, 78 days) during the first 72 hours after abdominal or thoracic surgery. Nonprotein respiratory quotient (RQnp), and values for oxidation of carbohydrate (Ce) and fat (Fe) were calculated. Injury severity was stratified based on serum CRP concentrations of > or = 6.0 mg/dL (high stress) or < 6.0 mg/dL (low stress). Recovery from acute stress was analyzed by comparing studies in which CRP had decreased to < or = 2.0 mg/dL (resolving stress group) with those in which CRP values were greater than 2.0 mg/dL (acute stress group). RESULTS: Average total caloric intake (64.56 +/- 18.51 kcal/kg/d; approximately 50% of predicted energy requirement) exceeded average MEE (42.90 +/- 9.98 kcal/kg/d) by approximately 50%. Average TUN was 0.18 +/- 0.07 g/kg/d (high stress 0.2 +/- 0.05 versus low stress 0.16 +/- 0.09 g/kg/d). Average RQnp was 1.05 +/- 0.13 and average Ce was 37.28 +/- 16.86 kcal/kg/d. The average calculated Fe was 0.0 +/- 12.27 kcal/kg/d, reflecting approximately equal amounts of fat oxidized compared with fat generated from excess glucose (lipogenesis). When individual studies were analyzed at a CRP cutpoint of 2.0 mg/dL, overfeeding (RQ > 1.0) was significantly less likely in the resolving (2/6 studies, 33.4%) versus acute stress (9/13 studies, 69.2%, Z test P < .001) group. Five of seven (5/7) patients (9/19 individual studies) had negative Fe values (average -9.89 +/- 10.02) reflecting net lipogenesis. The RQnp for these nine studies was 1.14 +/- 0.11 versus 0.97 +/- 0.09 for the remaining 10, and this difference was significant (P < .01). A significant correlation existed between carbohydrate intake and VCO2 (Pearson r = .6951, P < .01). In addition, there was a good correlation between carbohydrate intake and VCO2 (Pearson r = .6591, P < .01). The coefficient of variation for MEE was 8.0% (low stress) versus 30.2% (high stress). CONCLUSION: Lipogenesis with increased CO2 production is substantial, even at reduced caloric delivery rates that exceeded MEE by only 50%, during the early postoperative acute metabolic stress period in infants. These data suggest that caloric requirements during stress are likely equal to or only minimally in excess of actual MEE. Intersubject variability, especially in more severely stressed infants, underscores the importance of serial measurements of energy expenditure to enable precise caloric delivery and avoid overfeeding. In the absence of calorimetric measurement, the data suggest that PBMR (predicted basal metabolic rate) should be used to estimate caloric delivery until CRP values are < or = 2.0 mg/dL.

Patterns of power mower injuries in children compared with adults and the elderly.

Power mower trauma remains an alarmingly frequent cause of serious injury in young children. The patterns of mower-related injuries in children < 15 years old (n = 13) were compared with those of adults aged 15-64 (n = 16) and elderly victims > or = 65 years old (n = 6), who were similarly injured over the past 5 years. Children were more likely to be injured in accidents involving high-energy riding mowers. Of those children injured, 69% (9 of 13) were playing in the yard while 31% (4 of 13) were riding on the mower with a guardian when the injury occurred. Amputations in children were more frequent and more extensive than in the adults and included one forearm, two Symes, and three below-knee amputations. The need for transfusion was also significantly increased in children (62% vs. 6% adults, p < 0.005), who were also more likely to require prolonged hospitalization (11.8 days vs. 5 days in adults, p < 0.005). Aggressive efforts to increase public awareness regarding the cause and nature of power mower injuries are warranted to decrease the incidence of this debilitating but preventable trauma in young children.

Primary solid neoplasms of the greater omentum.

Primary solid tumors of the greater omentum are rare, with only 42 reported cases. Malignant hemangiopericytomas constitute only three of these cases. The 40-year-old patient described in this report had abdominal pain, a palpable abdominal mass, early satiety, and weight loss. At laparotomy a large omental hemangiopericytoma was excised, and no other evidence of disease was grossly evident. Eighteen months after initial laparotomy, the patient had widespread progression of the tumor and, despite chemotherapy, died 2 months later. A review of reported cases shows that abdominal discomfort (56%) and mass (35%) are the most common clinical characteristics of a primary omental tumor. Weight loss, ascites, and peritoneal implants usually indicate malignancy. Rare long-term follow-up prevents definitive conclusions regarding therapy and prognosis. At present, surgical excision alone appears to be the treatment of choice, with no demonstrable benefit from either chemotherapy or radiation.

Regulation of 25-hydroxyvitamin D3 metabolism in cultures of osteoblastic cells.

This study was designed to investigate the mechanisms involved in the regulation of the conversion of 25-hydroxyvitamin D3 (25-OHD3) to 1,25-dihydroxyvitamin D3 [1,25-(OH)2D3] and 24,25-dihydroxyvitamin D3 [24,25-(OH)2D3] in primary cultures of osteoblastlike cells from neonatal mouse calvariae. These cells, when incubated with tritiated 25-OHD3 ([3H]25-OHD3), spontaneously synthesized [3H]24,25-(OH)2D3 20-50 times more efficiently than [3H]1,25-(OH)2D3 at a rate of conversion that was substrate dependent and linear from 1 to 36 h. Gas chromatography-mass spectrometry verified the identity of the dihydroxylated metabolites. The calcium ionophore A23187 (5 microM) consistently stimulated the synthesis of 1,25-(OH)2D3 while suppressing the production of 24,25-(OH)2D3. This effect was sustained for 36 h and was dose dependent for concentrations from 0.05 to 10 microM. Furthermore, A23187 stimulated cAMP production and indomethacin (50 ng/ml) blocked the A23187-induced production of cAMP and 1,25-(OH)2D3 but had no effect on the suppression of 24,25-(OH)2D3 by A23187. This led to other experiments to find out whether the stimulative effect of A23187 on 1,25-(OH)2D3 synthesis is mediated by prostaglandins or cAMP, or both. PGE2 (10(-8)-10(-6) M) increased the production of 1,25-(OH)2D3 and of 24,25-(OH)2D3. Forskolin (0.01-10 microM) and dibutyryl cAMP (0.1-10 mM) increased the production of both metabolites but to a lesser degree than PGE2. These data suggest that osteoblastlike cells are stimulated by A23187 to increase the synthesis of 1,25-(OH)2D3 through mechanisms involving prostaglandins and cAMP. The synthesis of 24,25-(OH)2D3 is suppressed by A23187 through different mechanisms.