renal trauma blunt
TRANSCRIPT
Wichien Sirithanaphol, MD
Management of Blunt Renal trauma
in Srinagarind Hospital: 10-year experience
• Urogenital system injuries are seen in 10% of traumatic patients and mostly in patients with multiple trauma and severe trauma of lower parts of abdomen or pelvis
• The prevalence of urogenital injuries has been reported between 10 and 30% in adults and less than 3% in children
MC Aninch JW. Genitourinary trauma. World Urol 1999.17: 95-96.
Introduction
• Renal injury is the most common injury in urogenital system
• The prevalence of Renal Injury in Abdomonal Traumatic Patients has reported 8 – 10%1 and 13.6 % in Siriraj Hospital2
1Peterson NE. complications of renal trauma. Urol Clin North Am 1989; 16: 221-36.
2 เกษียร ภงัคานนท,์ สิงหพนัธ์ ทองสวสัด์ิ ใน: เกษียร ภงัคานนท,์ บรรณาธิการ.บาดเจ็บท่ีทอ้ง. กรุงเทพมหานคร: โครงการต าราศิริราช, 2522: 1-13.
Introduction
• Blunt trauma is the cause of more than 90% of Renal Injuries1
– Accidents, falling and being hit are the most frequent of blunt injury
• Bullet and stab wounds are the most common cause for penetrating injuries2
1Dreitlein AA, Snner S, Basler J. Genitourinary trauma.Emery med clin North Am 2001 19(3): 599-90.
2Palmer LS, Rosenbaum RR, Gershbaum MD. Penetrating ureteral trauma at an urban trauma center.
Urology 1999 54(1): 34-36.
Introduction
• Grading of renal injuries is performed using the American Association for the Surgery of Trauma organ injury severity scale
Moore EE, Shackford SR, Pachter HL, et al: Organ injury scaling: spleen, liver, and kidney. J Trauma 29: 1664–1666, 1989.
Introduction
• Nonoperative management of renal injuries has gained much support in past decades
• A trial of Nonoperative management has been advocated for most adult blunt renal injuries1, many renal stab wounds2, and selective renal gunshot wounds3
1Danuser H, Wille S, Zoscher G, et al: How to treat blunt kidney ruptures: primary open surgery or
conservative treatment with deferred surgery when necessary? Eur Urol 39: 9–14, 2001.
2Bernath AS, Schutte H, Fernandez RR, et al: Stab wounds of the kidney: conservative management in
flank penetration. J Urol 129: 468–470, 19833
Serafetinides E, Mitropoulos D, Constantinedes C, et al: Management of renal gunshot injuries (RGI). J Urol 171: 20, 2004.
Introduction
Patient & Method
• Retrospective review : case review
• Srinagarind hospital, university hospital in Khon-Kaen
• Period of study : 1 Jan 1999 - 31 Dec 2008
• Retrieve data from ICD10 code– Renal trauma
– Renal injury
Research methodology
Inclusion & Exclusion criteria
Inclusion criteria
• Blunt renal Trauma
• Referred patients with Renal Injury related complication
Exclusion criteria
• Penetrating injury
• Iatrogenic Renal injury
• Referred patients with Non-Renal Injury related complication
Group of Study
• Non Operative Management (NOM) group
(+Interventional Treatment)
- Successful NOM
- Failed NOM
• Operative Management group
- Renal exploration
• The absolute indications for renal exploration– Life-threatening hemorrhage from a renal source
– Pulsatile perirenal hematoma (suggestive of a grade V vascular injury)
– Active extravasation of intravenous contrast
Management
• The patients who were considered non-operative treatment– Absolute bed rest until gross hematuria resolves
– Regular & frequent vital sign measurement
– Serial abdominal examination
– Serial Hct checked
• Surgical procedures were performed in operative group, depended on intra-operative finding
Management
• This study have proved by The Khon Kaen University Ethics Committee for Human Research
• No : HE 521112
Ethical Consideration
Results
Renal trauma (80 pt)
Renal trauma (77 pt)
Missing data (3 pt = 3.89%)
Exclude (8 pt = 10.4 %)
Penetrating injury 5 pt Iatrogenic injury 3 pt (kidney biopsy)
Blunt renal trauma (69 pt)
Blunt renal trauma (69 pt)
Abdominal trauma (1,693 pt)
4.07 % of Abdominal trauma
Characteristic
MaleFemale
Mean age
Underlying disease
Blunt injury 69 pt
56 pt (82%)
13 pt (18%)
29.8 yr (1-68 yr)
No 55 pt (80%)
Mechanism of injury
Blunt Renal injury 69 pt
Management
NOM Group 55 pt (80%)
Operative Group 14 pt (20%)
Renal Exploration 7 pt (10%)
Other intraabdominal injury 7 pt (10%)
Blunt Renal injury 69 pt
NOM Group 55 pt (80%)
Renal Exploration 7 pt (10%)
Mean SBP
Mean Hct (at ER)
113 (0-179mmHg) 78 (0-139 mmHg)
35% (15-48%) 30% (20-44%)
NOM Group 55 pt (80%)
Patients with shock on arrival
5/55 pt
6/7 pt
Injury severity score (ISS)
78%
22%
14%
86%
Revised Trauma Score (RTS)
Trauma Score - Injury Severity Score (TRISS)
Grading of injuryBlunt Renal injury
69 pt
33%
23%
21%14%
9%
Non operative group 55 pt
Operative group 7 pt
Associated injury
Head injury 23
Hemo/pneumothorax 22
Rib fracture 18
ExtremitylowerUpper
128
Facial bone 6
Spine 5
Extra-abdominal injury Pt
Spleen 13
Liver 8
Small bowel 2
Colon 1
Pancreas 1
IVC 1
Intra-abdominal injury pt
Mean hospital stay
Mean ICU stay
Mean PRC used
Non operative group(55 pt)
Operative group(7 pt)
11.8 days (1-54) 19 days (1-74)
0.5 days (0-9 ) 5.14 days (0-23)
1.6 units (0-16) 5.14 units (0-9 )
Management outcome
Management outcome
Non-operative Group (55 Pt)
Successful NOM
48/55 pt (87.2%)
Failed NOM
4/55 pt (7.3%)
Peritonitis : 1 pt
- Avulsion of upper pole of kidney
Complication : 3 pt
- Pseudoaneurysm : 1 pt
- Infected urinoma : 1 pt
- Delayed bleeding : 1 pt
Death
3/55 pt (5.5%)
Severe head injury : 2 pt
Massive hemothorax : 1 pt
Management outcome
Operative Group (7 Pt)
Death
1/7 pt (14%)
Severe head injury
Procedure
EL c nephrectomy 6 pt
EL c ureteropyeloplasty 1 pt
Non specific complication
Non operative group(55 pt)
Operative group(7 pt)
Pneumonia 1UTI 7
Pneumonia 6
Wound infection 2
ARF 2
ARDS 1
Specific complication
Non operative group(55 pt)
Perinephric abscess 2
Infected urinoma 1
Delayed bleeding 1
Pseudoaneurysm 1
Operative group(7 pt)
Compartmental syndrome
1
Specific complication treatment
Non operative group(55 pt)
Perinephric abscess 2
Infected urinoma 1
Delayed bleeding 1
Pseudoaneurysm 1
ATB
Percutaneous drainage EL c nephrectomy
Embolization EL c left lower pole nephrectomy
EL c nephrectomy
failed
failed
ATB
Specific complication treatment
Operative group(7 pt)
Compartmental syndrome
1EL c temporaryabdominal closure
• According to the obtained results from this study, Renal Injury develops in a little portion of abdominal traumatic patients – 4.07%
– This is quite less than findings of other studies
• However, these injuries may lead to mortality, urogenital dysfunction, neglecting them could cause serious sequelae
Discussion
• 20 – 30 years are the most common age group, may be because of traumatic pattern which mostly affect the youth
• Regarding gender, Male were enrolled 4.5 times more than female in this study
• Blunt trauma is the cause of more than 90% of Renal Injuries
Which are almost similar to other studies
Discussion
• NOM Groups– NOM is the treatment of choice in stable patients
– Most of blunt renal injury can be managed conservatively
• Grade 5 is only 1 pt
• Failed NOM– 3 pt : Death due to serious associated injury
– 2 pt : due to late sequale (Infected urinoma, Delayed bleeding)
– 1 pt : due to immediated sequale (Developed peritonitis)
Discussion
• Mortality in operative group is higher than NOM group– 5% vs. 36%
– Severe Renal Injury
– Severe associated injury
• Conservative Management have also been applied to penetrating renal injuries, who were hemodynamically stable and without peritoneal signs– In this study can't be manage due to contraindication
Discussion
• Most of blunt renal injury can be managed conservatively
• Penetrating renal injuries can be managed nonoperatively in selected patients
• Multimodality of Treatment– Procedure should be suited for individual
Conclusion
Thank You