title: Can we safely decrease intensive care unit admissions for children with high grade isolated solid organ injuries? Using the shock index, pediatric age-adjusted and hematocrit to modify APSA admission guidelines.
abstract: BACKGROUND
  In 2000, the American Pediatric Surgical Association (APSA) disseminated consensus practice guidelines for the management of blunt liver and splenic injury which included intensive care unit (ICU) admission for children with grade IV injuries. We sought to determine if we could better predict which children with isolated solid organ injuries (SOI) underwent an ICU-level intervention, thus necessitating ICU admission.
  
  
  METHODS
  Children with isolated liver, spleen, or kidney injuries admitted to the ICU from November 2003 to August 2015 were identified in our trauma registry, and data were extracted from the medical record. ICU-level interventions were defined as transfusion, vasopressor use, intubation, and operative/procedural intervention. Shock index and pediatric age-adjusted (SIPA) was calculated for all patients. The sensitivity and negative predictive values (NPV) were determined.
  
  
  RESULTS
  133 children met inclusion criteria. 19 (14.3%) required ICU-level intervention, and 114 (85.1%) did not. 95% (n=18) of the intervention group had either an elevated SIPA or a hematocrit <30% on admission compared to 22% (n=25) of patients in the no intervention group. Sensitivity was 95%, and NPV was 99%.
  
  
  CONCLUSIONS
  Limiting ICU admission in children with isolated SOI to those with an elevated SIPA or hematocrit <30% would reduce the ICU admission rate by two-thirds while maintaining patient safety.
  
  
  METHODS
  Diagnostic study.
  
  
  METHODS
  III.
authors.affiliation: Boston Children's Hospital, Department of Surgery, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115, United States. Electronic address: mary.kathleen.arbuthnot@gmail.com.
authors.forename: Mary
authors.initials: M
authors.lastname: Arbuthnot
authors.affiliation: Boston Children's Hospital, Department of Surgery, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115, United States.
authors.forename: Lindsey Bendure
authors.initials: LB
authors.lastname: Armstrong
authors.affiliation: Boston Children's Hospital, Department of Surgery, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115, United States.
authors.forename: David P
authors.initials: DP
authors.lastname: Mooney
mesh_terms: D000293:Adolescent; D000367:Age Factors; D002648:Child; D002675:Child, Preschool; D000066491:Clinical Decision-Making / Q000379:methods; D003661:Decision Support Techniques; D005260:Female; D006400:Hematocrit; D006801:Humans; D007223:Infant; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D007668:Kidney / Q000293:injuries*; D008099:Liver / Q000293:injuries*; D008297:Male; D010343:Patient Admission / Q000592:standards* / Q000706:statistics & numerical data; D061214:Patient Safety; D017410:Practice Guidelines as Topic; D012042:Registries; D012189:Retrospective Studies; D012769:Shock / Q000175:diagnosis / Q000209:etiology; D013154:Spleen / Q000293:injuries*; D015599:Trauma Severity Indices; D014949:Wounds, Nonpenetrating / Q000150:complications / Q000175:diagnosis / Q000628:therapy*
keywords: Hematocrit; ICU; Pediatric; SIPA; Solid organ injury; Trauma