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"Child`s Health" 4 (47) 2013

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Сonservative approach efficacy in closed injuries of parenchymal abdominal cavity organs in children

Authors: I.P. Zhurilo, S.V. Mishakov, V.N. Grona, P.A. Lepikhov, S.V. Moskalenko, N.L. Kushch Pediatric Surgery Clinic (Head of the clinic. – M.D., prof. I.P. Zhurilo), M. Gorkiy Donetsk National Medical University (Rector – corresponding member of Academy of Medical Science of Ukraine, prof. Y.V. Dumansky).

Categories: Pediatrics/Neonatology

Sections: Specialist manual

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Summary

This article summarizes the experience of the conservative approach application in closed injuries of parenchymal organs of the abdominal cavity in children. In our clinic 53 patients underwent treatment with closed injuries of the spleen and liver for the period 2004-2011. The age of patients ranged from 2.5 to 17 years. Spleen injuries were revealed in 38 patients (71.7%), liver damage was observed in 12 patients (22.6%), concomitant injury of the liver and spleen occurred in 3 cases (5.7%). Conservative approach was used in 50 patients (94.3%), it was successful in 47 cases (94.0%). Sonographic examination allows to identify and determine accurately the origin of the organ injury, and USM provides the ability to prognose intraabdominal bleeding risk and assess the evolution of the initially identified damages in dynamics.


Keywords

spleen, liver, closed injury, conservative approach, children.

This article summarizes the experience of the conservative approach application in closed injuries of parenchymal organs of the abdominal cavity in children. In our clinic 53 patients underwent treatment with closed injuries of the spleen and liver for the period 2004-2011. The age of patients ranged from 2.5 to 17 years. Spleen injuries were revealed in 38 patients (71.7%), liver damage was observed in 12 patients (22.6%), concomitant injury of the liver and spleen occurred in 3 cases (5.7%). Conservative approach was used in 50 patients (94.3%), it was successful in 47 cases (94.0%). In addition to assessing general clinical manifestations and laboratory parameters in children with closed injuries of the spleen and liver, ultrasound monitoring (USM) was used. The damaged organ, the volume and quality characteristics of free abdominal fluid, as well as the evolution of the previously identified changes were estimated.

Two periods are considered to be the most problematic in terms of making adequate solutions. It is necessary to be certain that the bleeding is arrested. The second critical period is revealed by hemorrhagic peritonitis manifested symptoms and typical for 3-4 days after the injury.

During the above mentioned period in our clinic experience of conservative treatment of patients with closed injuries of the spleen and liver was accumulated. As it was mentioned above, we avoided surgical intervention in patients with this disease in 94% of cases. Conservative approach of the identified spleen and liver ruptures was applied in children if there was no hemorrhagic shock signs (impairment of consciousness, hemodynamic instability, moderate / severe anemia) and symptoms of abdominal cavity hollow organs damage. Subsequently, the hemodynamic parameters and "red blood" indexes in the dynamics were checked and USM was carried out.

According to sonographic criteria there are the followings types of injuries: intraorgan / subcapsular (bruise, intraorgan rupture, subcapsular hematoma) and injury with damaged capsule (rupture, crushing). Free fluid in the abdominal cavity has got sonographic characteristics of reactive effusion in intraorgan injuries, and it has got sonographic characteristics of blood in injury with damaged capsule.

In the analyzed patients’ group the integrity of the capsule was observed in 31 patients (62.0%), capsule injury with free blood in the abdominal cavity was observed in 20 (40.0%) children. We created the classification of closed injuries of the liver and spleen, taking into account the intensity of the intraabdominal bleeding or threat of its occurrence. According to this classification there are the following groups:

a) intraorgan damage of the spleen and liver with intraabdominal bleeding risk;

b) penetrating damage of parenchymal organs of the abdominal cavity with hemoperitoneum.

Analyzing the obtained sonographic data, comparing them with the circulating blood volume (CBV) and post-injury period we offered calculation version of bleeding intensity index (BII). The latter represented the percentage ratio of the free blood volume to CBV per time unit (%CBV/ hour). We established the maximum speed of blood loss (MSBL) rate, which was 5% CBV per hour. If BII ≤ 5% conservative approach was considered to be efficient. If the index exceeded the level of 5% CBV per hour, the patient had to be under USM every hour and BII had to be recalculated to make final decision about approach.

To simplify the procedure to determine BII we created the nomogram that allowed to define its value without additional calculations and to prognose bleeding outcome.

The main goal of treatment was arrest of bleeding. Conservative therapy consisted of strict bed regimen, rest, cold on the damaged area, infusion therapy, the introduction of hemostatic agents and fibrinolysis inhibitors, as well as antibacterial broad-spectrum drugs administration. The volume of fluid therapy should not exceed the estimated amount of blood loss. The basic drugs were 5-10% glucose solutions, saline solutions. Correction of symptomatic treatment was based on clinical situation; the question of replacement therapy application was also solved.

All the patients were discharged in a satisfactory state, there were no lethal outcomes.

Ultrasound showed echographic signs of the posttraumatic pseudocyst of the spleen / liver in 18 cases (37.5%). 10 of them underwent follow-up that revealed no abnormalities.

Thus, conservative approach in closed injuries of the spleen / liver in patients with stable hemodynamics was justified and deserved widespread application into clinical practice. Sonographic examination allows to identify and determine accurately the origin of the organ injury, and USM provides the ability to prognose intraabdominal bleeding risk and assess the evolution of the initially identified damages in dynamics. Taking into account the risk of the two-phase (delayed) ruptures, patients who didn’t have any echographic signs of organ capsule injury were referred to the group " unstable prognostically ", as they had the risk of the intra-abdominal bleeding. In the application of a conservative method in children with traumatic rupture of the spleen and liver "3-4 days" symptom was observed (hemoperitoneum, blood components adsorption), which manifested false positive symptoms of progressive intra-abdominal bleeding and provoked a specialist to perform unwarranted laparotomy.



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