Author : Majed Asgher Mohammad, Firas Shakir Attar, Murtadha Almusafer,

Abstract : Background: The most common mechanism of renal injury is blunt trauma. Conservative management of such trauma is widely practiced all over the world. However, in our social-cultural environment, this approach leads sometimes to discussions with patients and families as it often is perceived as inactivity on the side of the surgeons. Therefore, we attempted to assess patients and patients families concerns and the acceptance of a conservative treatment approach in a group of patients with severe blunt renal trauma. Patients & method: From February 2000 to December 2018, 72 patients presented with blunt renal trauma. Mean age was 30 (range 10- 55) years. Sixty three (87.5%) were male. The study was approved by the ethical committee of Basrah College of Medicine under the approval number 0304092-2020. The initial management of all patients was adequate resuscitation in the emergency room. The patients and their families were given questionnaires at their discharge to assess their satisfaction and/ or worries about the conservative approach in managing renal trauma, and subsequently they were categorized into 3 groups according to their satisfaction: totally satisfied, partially satisfied, and not accepting the conservative approach of management. Results: Fifty five patients (76%) had blunt renal trauma following a road traffic accident, 17 (24%) had a fall from height. Sixty-six patients (92%) were hemodynamically stable while 6 patients (8%) were unstable and needed immediate surgical intervention. According to AAST grading (table 1), of those 22 had grade I injuries, 19 grades II, 15 grades III, and 10 IV, respectively. The stable patients were initially monitored with a conservative treatment approach by nil by mouth, administration of IV-fluids, broad- spectrum antibiotics (ceftriaxone), absolute bed rest, use of painkillers as paracetamol vials, and blood transfusions if required. Close observation of all patients was carried out by monitoring of vital signs and abdominal examination with two hourly chart for first 24 hour then 4 hourly chart thereafter, and daily measurement of hematocrit. However, 5 patients (8%) and their family members were so much worried about this approach that they insisted on surgical exploration despite having been made aware of the risk of nephrectomy but none of them ended with nephrectomy, 12 (18%) further patients and their family members underwent the same worries and discussions, but finally accepted the conservative approach after understanding its rationale. Two thirds of patients (n=49/ 74%) accepted the conservative approach from the start. Conclusion: Conservative treatment is the standard treatment for hemodynamically stable blunt renal traumata. However, for lay people such as patients and their family members it may be difficult to comprehend that the traumatized organ should not be explored and repaired. There is an expectation for surgical repair in one third of our patient population which has the potential to cause undue stress to the attending surgeon and may impair the impartiality of surgical decisions. Making the patients and relatives understand and be part of an informed decision making is crucial to act in the best interest of the patient.

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