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J Pediatr Surg. 2019 May 6. pii: S0022-3468(19)30322-7. doi: 10.1016/j.jpedsurg.2019.04.021. [Epub ahead of print]

Safe phlebotomy reduction in stable pediatric liver and spleen injuries.

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Division of Pediatric Surgery, Zucker School of Medicine at Hofstra/Northwell, Cohen, Children's Medical Center, New Hyde Park, NY 11040, USA. Electronic address:
Department of Surgery, Maimonides Medical Center, Brooklyn, NY 11219.
Division of Pediatric Surgery, Loma Linda University Children's Hospital, Loma Linda, CA 92354, USA.
Department of Surgery, Marshfield Clinic and Marshfield Children's Hospital, Marshfield, WI, 54449.
Division of Pediatric Surgery, Zucker School of Medicine at Hofstra/Northwell, Cohen, Children's Medical Center, New Hyde Park, NY 11040, USA.



Pediatric blunt solid organ injury management based on hemodynamic monitoring rather than grade may safely reduce resource expenditure and improve outcomes. Previously we have reported a retrospectively validated management algorithm for pediatric liver and spleen injuries which monitors hemodynamics without use of routine phlebotomy. We hypothesize that stable blunt pediatric isolated splenic/liver injuries can be managed safely using a protocol reliant on vital signs and not repeat hemoglobin levels.


A prospective multi-institutional study was performed at three pediatric trauma centers. All pediatric patients from 07/2016-12/2017 diagnosed with liver or splenic injuries were identified. If appropriate for the protocol, only a baseline hemoglobin was obtained unless hemodynamic instability as defined in an age-appropriate fashion was determined by treating physician discretion. Descriptive statistics were conducted.


One hundred four patients were identified of which 38 were excluded from the protocol. There was a significant difference in abnormal shock index, pediatric age-adjusted (SIPA) values, hematocrit, and percentage of patients with hemoglobin less than 10 between the excluded and included patients. Of the 66 patients managed on the protocol, four patients had to be removed, two each on day one and day two. Of those four patients, only one required intervention. There were no mortalities.


A phlebotomy limiting protocol may be a safe option for stable pediatric splenic and liver injuries cared for in a pediatric trauma center with the resources for rapid intervention should the need arise. The differences in groups highlight the importance of utilizing this protocol in the correct patient population. Reduced phlebotomy offers the potential for reduced resource expenditure without any evidence of increased morbidity or mortality.


Level IV.


Liver injury; Pediatric trauma; Phlebotomy; Solid organ injury; Splenic injury

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