Non-operative management of renal trauma in very young children: experiences from a dedicated South African paediatric trauma unit

Abstract

Blunt abdominal trauma results in renal injury in 10% of paediatric cases. Over the last twenty years, the management of paediatric renal trauma has shifted towards a primarily non-operative approach that is now well-established for children up to 18 years old. This retrospective study reviews our experiences of non-operatively managing blunt renal trauma in a very young cohort of patients up to 11 years old. Between June 2006 and June 2010, 118 children presented to the Red Cross War Memorial Children's Hospital in Cape Town with blunt abdominal trauma. 16 patients shown to have sustained renal injury on abdominal computed tomography (CT) scanning were included in this study. Medical records were reviewed for the mechanism of injury, severity of renal injury, clinical presentation, associated injuries, management method and clinical outcomes. All renal injuries were graded (I-V) according to the American Association for the Surgery of Trauma Organ Injury Severity Scale. All renal trauma patients included in this study were aged between 1 and 11 years (mean of 6.5 years). 1 patient sustained grade V injuries; 2 grade IV, 6 grade III and 7 grade I injuries. The majority of injuries (9/16) were caused by motor vehicle crashes, whilst 5 children fell from height, 1 was struck by a falling tree and 1 hit by a moving train. 1 of 16 patients was haemodynamically unstable on presentation as a result of multiple splenic and hepatic lacerations. He was resuscitated and underwent immediate laparotomy. However, his renal injuries were not indications for surgical management. 15 haemodynamically stable patients were non-operatively managed for their renal injuries. Following lengths of admissions ranging from 4 to 132 days, all 16 patients were successfully discharged with no mortalities. No significant complications of renal trauma, such as new-onset hypertension, were detected during their first follow up outpatient appointments. Our findings successfully extend non-operative management of haemodynamically stable renal injuries to a very young cohort up to 11 years old. However, we still advocate immediate resuscitation and surgical intervention for any haemodynamically unstable child who had sustained any abdominal injury. We also argue for a limited role for abdominal CT imaging for diagnosing renal injury and routine follow up, instead recommending a greater emphasis on clinical observations for possible complications.