ILMIAH RS TUGU Journal Reading - Updated APSA Guidelines for the Management of Blunt Liver and Spleen Injuries.pptx

ournal Reading - Updated APSA Guidelines for the Management of Blunt Liver and Spleen Injuries

1. PROGRAM STUDY OF SURGERY SUB-DEPARTMENT OF PEDIATRIC SURGERY FA CULTY OF MEDICINE DIPONEGORO UNIVERSITY / DR. KARIADI CENTRAL GENERAL HOSPITAL SEMARANG 202 4 Updated APSA Guidelines for the Management of Blunt Liver and Spleen Injuries. J Pediatr Surg. 2023 Aug ; 58 (8) : 1411 -1418. Dwi Feris Martua Sidabutar

2. Updated APSA Guidelines for the Management of Blunt Liver and Spleen Injuries. J Pediatr Surg. 2023 Aug ; 58 (8) : 1411 -1418.

3. INTRODUCTION Non-operative management of blunt liver and spleen injuries was championed initially in children with the first management guideline published in 2000 by the American Pediatric Surgical Association (APSA)

4. INTRODUCTION Multiple articles have expanded on the original guidelines and additional therapy has been investigated to improve care for these patients . Based on a literature review and current consensus, the management guidelines for the treatment of blunt liver and spleen injuries are presented .

5. ADMISSION W hich children with isolated spleen or liver injury should be admitted to the hospital, and who should go to the ICU ? ICU Admission is indicated irrespective of CT grade if initial volume resuscitation does not normalize vital signs (hemodynamics) or response was only transient Patients with normal vital signs regardless of grade of injury should be admitted to the hospital ward for observation though recent data may support discharge from the emergency department for low grade injuries

6. ADMISSION W hat level of activity or bed rest should be allowed after admission to the hospital ? Patients admitted to the intensive care unit should remain on bed rest until vital signs are normal. No inpatient activity restrictions are necessary for patients admitted to the ward

7. ADMISSION W hat are the recommendations for diet ? Patients requiring ICU monitoring should remain “nothing by mouth” (NPO) until vital signs are normal and hemoglobin stable. All other patients should have a regular diet ordered upon admission

8. PROCEDURES When should children with blunt liver and/or spleen injuries receive transfusions ? Children with BLSI should receive pRBC transfusion when they have clinical signs of shock after one initial isotonic fluid bolus of 20 mL/kg. Transfusion in the acute phase is also recommended when the hemoglobin is less than 7 g/ dL , or when clinical signs of ongoing or recent bleeding are present .

9. PROCEDURES When do children with blunt liver and/or spleen injury need angioembolization ? Prophylactic angioembolization should not be done in asymptomatic patients with a contrast blush on initial CT. Therapeutic angioembolization should be used for hemorrhage control in children with liver or spleen injuries with signs of ongoing bleeding despite blood product transfusion , particularly in patients who would not otherwise benefit from an operative exploration and are hemodynamically stable enough to travel to the interventional suite.

10. PROCEDURES When do children with blunt liver and/or spleen injury need operative exploration ? Operative exploration with control of bleeding should occur in BLSI patients with unstable vital signs despite RBC transfusion and is preferred to angioembolization in the setting of other intraabdominal injuries that may be contributing to patient instability

11. SET FREE When can children with blunt liver and/or spleen injury be discharged safely home? Given the recent literature, it is reasonable to consider hospital discharge based on overall clinical condition rather than the specific grade of blunt liver or spleen injury. We recommend hospital discharge when children have met the following conditions: tolerating an age appropriate diet, minimal abdominal pain, and have normal vital signs without evidence of ongoing bleeding .

12. AFTERCARE When do children with blunt liver and/or spleen injury need repeat imaging ? Routine imaging in asymptomatic patients with low-grade injuries is not indicated. Imaging may be considered in patients with high-grade injuries and persistent symptoms.

13. AFTERCARE When can children with blunt liver and/or spleen injury return to normal activities? Activities should be restricted grade of injury plus two weeks though shorter restrictions may be safe. There is not adequate data to support decreasing activity restrictions following injury .

14. CONCLUSION

15. CRITICAL APPRAISAL 1. Purpose of the guideline is specified. YES 2. Rationale and importance of the guideline are explained. YES 3. The participants in the guideline development process and their areas of expertise are specified. YES 4. Targeted health problem or technology is clearly defined. YES 5. Targeted patient population is specified. YES 6. Intended audience or users of the guideline are specified. YES 7. The principal preventive, diagnostic, or therapeutic options available to clinicians and patients are specified. YES 8. The health outcomes are specified. YES 9. The method by which the guideline underwent external review is specified. YES 10. An expiration date or date of scheduled review is specified. NO

16. CRITICAL APPRAISAL 11. Method of identifying scientific evidence is specified. YES 12. The time period from which evidence is reviewed is specified. YES 13. The evidence used is identified by citation and referenced. YES 14. Method of data extractions is specified. YES 15. Method for grading or classifying the scientific evidence is specified. YES 16. Formal methods of combining evidence or expert opinion are used and described. YES 17. Benefits and harms of specific health practices are specified. NO 18. Benefits and harms are quantified. NO 19. The effect on healthcare costs from specific health practices is specified. NO 20. Costs are quantified. NO

17. CRITICAL APPRAISAL 21. The role of value judgments used by the guideline developers in making recommendations is discussed. YES 22. The role of patient preferences is discussed. NO 23. Recommendations are specific and apply to the stated goals of the guideline. YES 24. Recommendations are graded according to the strength of the evidence. NO 25. Flexibility in the recommendations is specified. NO