Çocuklardaki Dalak Travmalarında Standardize Bir Yaklaşım

Amaç: Bu çalışmanın amacı, künt dalak travması olan ve standart bir sıvı protokolü ile izlenen pediyatrik hastaların sonuçlarını değerlendirmektir. Hastalar ve yöntem: Bir üniversite hastanesinde 2012-2015 yılları arasında künt dalak travması nedeniyle tedavi edilen çocuklar çalışmaya dahil edildi. Yaş, cins, yaralanma mekanizması, dalak yaralanma skalası, eşlik eden diğer yaralanmalar, hemoglobin düzeyleri, trombositopeni ve trombositoz, verilen kan ve kan ürünleri, hastanede kalma süresi ve sonuçlar değerlendirildi. Stabil çocuklarda sıvı gereksinimleri Holliday-Segar denklemine göre hesaplandı. İdame sıvı, idrar çıkışı 1 ml/kg/sa olacak şekilde ayarlandı. Bulgular: Yaşları 3-18 yaş arasında toplam 28 çocuk çalışmaya dahil edildi. Yaralanma derecesi (G) 3 hastada G1, 12'sinde G2, 10'unda G3, ikisinde G4 ve bir hastada G5 idi. Sıvı protokolüne ait yan etki gözlenmedi. İdrar çıkışının monitorizasyonu yararlı bulundu. G5 hastaya hemen splenektomi yapıldı. Hastane yatış süresi içinde 4 hastada trombositoz ortaya çıktı, bunlardan ikisi, dalak klirensinin azaldığı düşünülen G4 yaralanması olan hastalardı. Bir G3 hastada taburculuk sonrasında kanama tekrarladı. Seride mortalite olmadı. Sonuç: Yaklaşım protokolümüz başarıyla uygulandı ve sadece G5 hastada dalak kaybı oldu. Sıvı gereksinimlerinin idrar çıkışına göre ayarlanması, sıvı yüklenmesini ve kanamanın tekrar başlamasını önledi. Ağır dalak yaralanmalarından sonra trombositoz ortaya çıkabilir ve dikkatle izlenmeyi gerektirir.

A Standardized Approach for Spleen Trauma in the Children

Aim: The aim of this study is to evaluate the results of pediatric blunt spleentrauma patients who were treated with a standard fluid protocol.Patients and Method: Children who were treated in a university hospital forblunt spleen trauma between 2012 and 2015 were included. Age, gender,mechanism of the injury, spleen injury scale, concomitant injuries, hemoglobinlevels, thrombocytopenia and thrombocytosis, administration of blood andblood products, and hospital stay duration and results were evaluated. Thefluid requirements of the stable children were calculated according toHolliday-Segar equation. The fluid intake of the children was adjusted so thatthe urine output was 1 ml/kg/h.Results: Totally 28 children who were at the age of 3-18 years were evaluated.Injury grade (G) was G1 in 3 patients, G2 in 12 patients, G3 in 10 patients, G4in 2 patients, and G5 in 1 patient. There were no side effects related to thefluid protocol and the monitoring of the urinary output was helpful. Grade 5patient needed an immediate splenectomy. Thrombocytosis was developed infour patients during the hospitalization and it suggested an impaired clearanceof spleen in Grade 4 patients. Re-bleeding developed in one G3 patient afterdischarge. No mortality was observed.Conclusion: Our management protocol was successfully applied and spleenloss was observed only in a case of grade 5 injury. Adjusting the fluid volumeaccording to the urinary output prevented volume overload and re-bleeding.Thrombocytosis may occur after severe splenic trauma and it should becarefully followed up.

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Stylianos S, APSA Trauma Committee. Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. J Pediatr Surg, 2000; 2: 164-9.
Bairdain S, Litman HJ, Troy M, McMahon M, Almodovar H, Zurakowski D, et al. Twenty-years of splenic preservation at a level 1 pediatric trauma center. J Pediatr Surg 2015; 50: 864-8.
Nytrup KB, Stensballe J, Bøttger M, Johansson PI, Ostrowski SR. Transfusion therapy in paediatric patients: a review of the literature. Scandinavian J Trauma, Resuscitation and Emergency Medicine 2015; 23: 21.
Tosounidis TH, Giannoudis PV. Paediatric trauma resusciation: an update. Eur J Trauma Emerg Surg 2016; 42: 297-301.
Lee LK, Fleisher GR. Trauma management: Approach to the unstable child. http://www.uptodate.com/contents/trauma-management-approach-to-theunstable-child, 2015 (accessed 31.03.2016)
Acker SN, Petrun B, Patrick DA, Roosevelt GE, Bensard DD. Lack of utility of repeat monitoring of hemoglobin and hematocrit following blunt solid organ injury in children. J Trauma Acute Care Surg 2015; 79: 991-4.
Dodgion CM, Gosain A, Rogers A, St. Peter SD, Nichol PF, Ostlie DJ. National trends in pediatric blunt spleen and liver injury management and potential benefits of an abbreviated bed rest protocol. J Ped Surg. 2014; 49: 1004-8.
Pommerening MJ, Rahbar E, Minei K, Holcomb JB, Wade CE, Schreiber MA, et al. Splenectomy is associated with hypercoagulable thromboelastopathy values and increased risk of thromboembolism. Surgery 2015; 158: 618-26.
Scheuerman O, Bar-Sever Z, Voffer V, Gilad O, Marcus N, Garty BZ. Functional hyposplenism is an important and underdiagnosed immunodeficiency condition in children. Acta Paediatrica 2014; 103: 399-403.
Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Organ injury scaling: spleen and liver (1994 revision). J Trauma 1994; 38: 323-4.
Reyers MS. Pediatric fluid and electrolyte therapy. J Pediatr Pharmacol Ther 2009; 14: 204–11.
Wisner DH, Kupperman N, Cooper A, Menaker J, Ehrlich P, Kooistra J, et al. Management of children with solid organ injuries after blunt torso trauma. J Trauma Acute Care Surg 2015; 79: 206-14.
otrica DM, Eubanks JW, Tuggle DW, Maxson RT, Letton RW, Garcia NM, et al. Nonoperative management of blunt liver and spleen injury in children: Evaluation of the ATOMAC guideline using GRADE. J Trauma Acute Care Surg 2015; 79: 683-93.
Zuckerbraun BS, Peitzman AB, Billar TR. Shock. In: Bruncardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, et al (editors). Schwartz's Principals of Surgery, 9th Edition, U.S.A., The Mc Graw-Hill; 2010, p. 89-112.
Acker S, Ross JT, Partrick DA, DeWitt P, Bensard DD. Injured children are resistant to the adverse effects of early high volume crystalloid resuscitation. J Pediatr Surg, 2014; 49: 1852-5.
Weinrich M, Dahmen RP, Black KJL, Lange SA, Bindewald H. Postoperative long-term results in high grade traumatic ruptures of the spleen in children. Zentralbl Chir. 2014; 139: 632-7.
Chie TL, Chesney TR, Isa D, Mnatzakanian G, Colak E, Belmont C, et al. Thrombocytosis in splenic trauma: in-hospital course and accociation with venous thromboembolism. Injury 2017; 48: 142-7.