Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis

A pediatric trauma society collaborative

Bindi J. Naik-Mathuria, Eric H. Rosenfeld, Ankush Gosain, Randall Burd, Richard A. Falcone, Rajan Thakkar, Barbara Gaines, David Mooney, Mauricio Escobar, Mubeen Jafri, Anthony Stallion, Denise B. Klinkner, Robert Russell, Brendan Campbell, Rita V. Burke, Jeffrey Upperman, David Juang, Shawn St Peter, Stephon J. Fenton, Marianne Beaudin & 17 others Hale Wills, Adam Vogel, Stephanie Polites, Adam Pattyn, Christine Leeper, Laura V. Veras, Ilan Maizlin, Shefali Thaker, Alexis Smith, Megan Waddell, Joseph Drews, James Gilmore, Lindsey Armstrong, Alexis Sandler, Suzanne Moody, Brandon Behrens, Laurence Carmant

Research output: Contribution to journalArticle

7 Citations (Scopus)

Abstract

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).

Original languageEnglish (US)
Pages (from-to)589-596
Number of pages8
JournalJournal of Trauma and Acute Care Surgery
Volume83
Issue number4
DOIs
StatePublished - Oct 1 2017

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Critical Pathways
Pediatrics
Wounds and Injuries
Trauma Centers
Enzymes
Diet
Multiple Trauma
Parenteral Nutrition
Needles
Drainage
Hospitalization
Tomography
Observation
Demography
Guidelines

All Science Journal Classification (ASJC) codes

  • Surgery
  • Critical Care and Intensive Care Medicine

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Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis : A pediatric trauma society collaborative. / Naik-Mathuria, Bindi J.; Rosenfeld, Eric H.; Gosain, Ankush; Burd, Randall; Falcone, Richard A.; Thakkar, Rajan; Gaines, Barbara; Mooney, David; Escobar, Mauricio; Jafri, Mubeen; Stallion, Anthony; Klinkner, Denise B.; Russell, Robert; Campbell, Brendan; Burke, Rita V.; Upperman, Jeffrey; Juang, David; St Peter, Shawn; Fenton, Stephon J.; Beaudin, Marianne; Wills, Hale; Vogel, Adam; Polites, Stephanie; Pattyn, Adam; Leeper, Christine; Veras, Laura V.; Maizlin, Ilan; Thaker, Shefali; Smith, Alexis; Waddell, Megan; Drews, Joseph; Gilmore, James; Armstrong, Lindsey; Sandler, Alexis; Moody, Suzanne; Behrens, Brandon; Carmant, Laurence.

In: Journal of Trauma and Acute Care Surgery, Vol. 83, No. 4, 01.10.2017, p. 589-596.

Research output: Contribution to journalArticle

Naik-Mathuria, BJ, Rosenfeld, EH, Gosain, A, Burd, R, Falcone, RA, Thakkar, R, Gaines, B, Mooney, D, Escobar, M, Jafri, M, Stallion, A, Klinkner, DB, Russell, R, Campbell, B, Burke, RV, Upperman, J, Juang, D, St Peter, S, Fenton, SJ, Beaudin, M, Wills, H, Vogel, A, Polites, S, Pattyn, A, Leeper, C, Veras, LV, Maizlin, I, Thaker, S, Smith, A, Waddell, M, Drews, J, Gilmore, J, Armstrong, L, Sandler, A, Moody, S, Behrens, B & Carmant, L 2017, 'Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis: A pediatric trauma society collaborative', Journal of Trauma and Acute Care Surgery, vol. 83, no. 4, pp. 589-596. https://doi.org/10.1097/TA.0000000000001576
Naik-Mathuria, Bindi J. ; Rosenfeld, Eric H. ; Gosain, Ankush ; Burd, Randall ; Falcone, Richard A. ; Thakkar, Rajan ; Gaines, Barbara ; Mooney, David ; Escobar, Mauricio ; Jafri, Mubeen ; Stallion, Anthony ; Klinkner, Denise B. ; Russell, Robert ; Campbell, Brendan ; Burke, Rita V. ; Upperman, Jeffrey ; Juang, David ; St Peter, Shawn ; Fenton, Stephon J. ; Beaudin, Marianne ; Wills, Hale ; Vogel, Adam ; Polites, Stephanie ; Pattyn, Adam ; Leeper, Christine ; Veras, Laura V. ; Maizlin, Ilan ; Thaker, Shefali ; Smith, Alexis ; Waddell, Megan ; Drews, Joseph ; Gilmore, James ; Armstrong, Lindsey ; Sandler, Alexis ; Moody, Suzanne ; Behrens, Brandon ; Carmant, Laurence. / Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis : A pediatric trauma society collaborative. In: Journal of Trauma and Acute Care Surgery. 2017 ; Vol. 83, No. 4. pp. 589-596.
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title = "Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis: A pediatric trauma society collaborative",
abstract = "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).",
author = "Naik-Mathuria, {Bindi J.} and Rosenfeld, {Eric H.} and Ankush Gosain and Randall Burd and Falcone, {Richard A.} and Rajan Thakkar and Barbara Gaines and David Mooney and Mauricio Escobar and Mubeen Jafri and Anthony Stallion and Klinkner, {Denise B.} and Robert Russell and Brendan Campbell and Burke, {Rita V.} and Jeffrey Upperman and David Juang and {St Peter}, Shawn and Fenton, {Stephon J.} and Marianne Beaudin and Hale Wills and Adam Vogel and Stephanie Polites and Adam Pattyn and Christine Leeper and Veras, {Laura V.} and Ilan Maizlin and Shefali Thaker and Alexis Smith and Megan Waddell and Joseph Drews and James Gilmore and Lindsey Armstrong and Alexis Sandler and Suzanne Moody and Brandon Behrens and Laurence Carmant",
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TY - JOUR

T1 - Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis

T2 - A pediatric trauma society collaborative

AU - Naik-Mathuria, Bindi J.

AU - Rosenfeld, Eric H.

AU - Gosain, Ankush

AU - Burd, Randall

AU - Falcone, Richard A.

AU - Thakkar, Rajan

AU - Gaines, Barbara

AU - Mooney, David

AU - Escobar, Mauricio

AU - Jafri, Mubeen

AU - Stallion, Anthony

AU - Klinkner, Denise B.

AU - Russell, Robert

AU - Campbell, Brendan

AU - Burke, Rita V.

AU - Upperman, Jeffrey

AU - Juang, David

AU - St Peter, Shawn

AU - Fenton, Stephon J.

AU - Beaudin, Marianne

AU - Wills, Hale

AU - Vogel, Adam

AU - Polites, Stephanie

AU - Pattyn, Adam

AU - Leeper, Christine

AU - Veras, Laura V.

AU - Maizlin, Ilan

AU - Thaker, Shefali

AU - Smith, Alexis

AU - Waddell, Megan

AU - Drews, Joseph

AU - Gilmore, James

AU - Armstrong, Lindsey

AU - Sandler, Alexis

AU - Moody, Suzanne

AU - Behrens, Brandon

AU - Carmant, Laurence

PY - 2017/10/1

Y1 - 2017/10/1

N2 - 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).

AB - 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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DO - 10.1097/TA.0000000000001576

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