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Renal Trauma

Renal Trauma. George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, MO. Renal Trauma. Trauma is most common cause of death in children Injuries to the kidneys account for 60% of genitourinary injuries 90% blunt trauma Usually do not require operation

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Renal Trauma

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  1. Renal Trauma George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, MO

  2. Renal Trauma • Trauma is most common cause of death in children • Injuries to the kidneys account for 60% of genitourinary injuries • 90% blunt trauma • Usually do not require operation • 10-20% penetrating trauma • More often require operation • Deceleration/flexion injuries • Produce renal arterial or venous injuries

  3. Renal Trauma • Due to their size and location, kidneys are susceptible to injury from blunt trauma • Children are more susceptible than adults to major renal injury • Less perirenal fat • Weaker abdominal musculature • Less well-ossified thoracic cage • Kidneys with congenital abnormalities are at increased risk of injury • Pediatric evaluation and treatment guidelines not clearly defined for children

  4. Renal Trauma • Standard Imaging Modality – (U.S.) • CT scan often performed in trauma w/u • CT scan recommended in patients with hematuria • Ultrasound may be used to screen hemodynamically unstable patients • FAST 95% specificity, but 33-89% sensitivity

  5. Renal Trauma • Management goal: renal salvage • Indications for immediate exploration • Hemodynamic instability • Penetrating injury – unstable patient • Associated non-renal injuries • Nephrectomy required in less than 10% of cases • Isolated penetrating renal injury in stable patient can be managed conservatively • Aggressive radiologic, laboratory and clinical efforts important in managing patients w/o operation

  6. American Association for the Surgery of Trauma Injury Scale

  7. Renal Trauma • Stable grade I-III injuries • Managed non-operatively • Severe grade IV-V • Require careful selection based on • hemodynamic stability • mechanism • associated non-renal injuries • Stable patients may need monitoring in ICU setting

  8. Renal Trauma • Management • Inconclusive data • Antibiotics • Likely only needed when stent placed • Bedrest • Variable practice: bedrest for 5-7 days, or until hematuria clears, or once physically able • No consensus

  9. Renal Trauma • Management • Ureteral stent indications • 80% of grade IV and V collecting system injuries heal without intervention • If collecting system extravasation does not resolve within two weeks, stenting is then considered • Symptomatic urinomas may require stenting • Lack of contrast in ipsilateral ureter may indicate significant injury, necessitating stent

  10. Renal Trauma • Complications • Hypertension • Estimated incidence: 0 - 7.5% • Follow-up imaging • Little data to support its use

  11. J PediatrSurg 45:1311-1314, 2010

  12. Children’s Mercy1995 - 2007 • All patients with blunt renal trauma • Mean age 11 yrs • MVC - 44% • Falls - 30% • Sports - 22% • Grade I - 26% Grade II - 23% Grade III - 35% Grade IV - 13% Grade V - 3% J PediatrSurg 45:1311-1314, 2010

  13. Children’s Mercy • Isolated renal injury - (44%) • Bed rest - 3.8 ± 1.9 d (mean) • Hospital - 3.8 ± 3.1 d (mean) • Blood tx – 15 pts • Mean vol – 700 c • Op – 6 pts – None for renal injury • No tx in isolated renal injury • No tx Grade IV or V injury • Renal salvage – 99.1% • One nephrectomy in pt w/ESRD • HTN – 3 pts – 1 resolved • Urinoma – 1 pt – resolved w/drainage J PediatrSurg 45:1311-1314, 2010

  14. Renal Trauma • CMH is currently participating in multi-institutional, prospective, randomized trial with long-term follow-up • Patients allowed out of bed when physically able • Daily UA while in hospital • Once discharged, weekly UA until hematuria is cleared • Discharged when patients meet general discharge criteria • 3 year follow-up for hypertension

  15. References • Fraser, JD, Aguayo P, Ostlie DJ, et al: Review of the evidence on the management of blunt renal trauma in pediatric patients. Pediatr Surg Int (2009) 25:125-132. • Holcomb GW III, Murphy JP. Ashcraft’s Pediatric Surgery. 5th ed. Philadelphia, PA: Saunders An Imprint of Elsevier, 2010. • Nerli RB, Metgud T, Patil S, et al: Severe renal injuries in children following blunt abdominal trauma: selective management and outcome. Pediatr Surg Int (2011) 27:1213-1216 • Suson KD, Gupta AD, Wang MH. Bloody urine after minor trauma in a child: isolated renal injury versus congenital anomaly? J Pediatr. (2011) 159:870.

  16. QUESTIONS www.cmhclinicaltrials.com

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