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Forster J, Paul P, Liese J. Current Management of Pediatric Parapneumonic Pleural Effusions and Pleural Empyema. Pediatr Infect Dis J 2023; 42:e407-e410. [PMID: 37566896 DOI: 10.1097/inf.0000000000004061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/13/2023]
Affiliation(s)
- Johannes Forster
- From the Institute for Hygiene and Microbiology, Julius-Maximilians-Universität Würzburg, Würzburg, Germany
| | - Pia Paul
- Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
| | - Johannes Liese
- Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
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Thimmesch M, Mulder A, Lebrun F, Piérart F, Genin C, Loeckx I, Demaret P. Management of parapneumonic pleural effusion in children: Is there a role for corticosteroids when conventional nonsurgical management fails? A single-center 15-year experience. Pediatr Pulmonol 2022; 57:245-252. [PMID: 34559458 DOI: 10.1002/ppul.25699] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 09/15/2021] [Accepted: 09/21/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Description of the use of corticosteroids for the management of parapneumonic pleural effusion in children. METHODS Retrospective single-center observational study of all children hospitalized with a diagnosis of parapneumonic pleural effusion during a 15-year period. RESULTS We documented 97 cases of parapneumonic effusion during the study period, with a median age (interquartile range [IQR]) of 43 (33-61) months. Most of the children benefited from an evacuation of the pleural effusion (89/97, 91.8%): 21 patients (21.6%) were treated with needle thoracocentesis only, while a chest tube was inserted in 68 children (70.1%). Thirty-two patients (33%) were treated with intrapleural fibrinolysis. Fifty-five children (56.7%) received corticosteroids for persistent fever. The median time (IQR) between hospital admission and initiation of corticosteroids was 5.5 (4-7) days. When corticosteroids were initiated, children had been febrile for 9 (IQR: 8-11) days. The fever ceased in a median (IQR) of 0 (0-1) day after corticosteroids initiation. Only one patient required a video-assisted thoracoscopy that was necessary for morphological reasons (morbid obesity). No children treated with corticosteroids required surgery. All children were discharged from hospital. The median (IQR) hospital length of stay was 11 (8-14) days, with no difference between children with and those without corticosteroids. CONCLUSION Our findings indicate that corticosteroids may be a part of the therapeutic armamentarium for children with parapneumonic effusion when conventional nonsurgical management fails.
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Affiliation(s)
- Matthieu Thimmesch
- Division of Pediatric Pulmonology, Department of Pediatrics, CHC MontLégia, Liège, Belgium
| | - André Mulder
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHC MontLégia, Liège, Belgium
| | - Frédéric Lebrun
- Division of Pediatric Pulmonology, Department of Pediatrics, CHC MontLégia, Liège, Belgium.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHC MontLégia, Liège, Belgium
| | - Frédéric Piérart
- Division of Pediatric Pulmonology, Department of Pediatrics, CHC MontLégia, Liège, Belgium
| | - Caroline Genin
- Division of Pediatric Infectiology, Department of Pediatrics, CHC MontLégia, Liège, Belgium
| | - Isabelle Loeckx
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHC MontLégia, Liège, Belgium
| | - Pierre Demaret
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHC MontLégia, Liège, Belgium
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Turan Ciftci T, Akinci D, Unal E, Tanır G, Artas H, Akhan O. Percutaneous management of complicated parapneumonic effusion and empyema after surgical tube thoracostomy failure in children: a retrospective study. ACTA ACUST UNITED AC 2021; 27:401-407. [PMID: 34003128 DOI: 10.5152/dir.2021.20331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to evaluate the results of percutaneous management of complicated parapneumonic effusions (PPE) and empyema after surgical tube thoracostomy failure in children. METHODS A total of 84 children treated percutaneously after surgical tube thoracostomy failure between 2004 and 2019 were included to this retrospective study. Technical success was defined as appropriate placement of the drainage catheter. Clinical success was defined as complete resolution of infection both clinically and radiologically. Management protocol included imaging-guided pigtail catheter insertion, fibrinolytic therapy, serial ultrasonographic evaluation, catheter manipulations as necessary (revision, exchange, or upsizing), and appropriate antibiotherapy. All patients were followed up at least 6 months. RESULTS Technical success rate was 100%. Unilateral single, unilateral double, and bilateral catheter insertions were performed in 73, 9, and 2 patients, respectively. Inserted catheter sizes ranged from 8 F to 16 F. Streptokinase, urokinase, and tissue plasminogen activator were used as fibrinolytic agent in 29 (34%), 14 (17%), and 41 (49%) patients, respectively. In order to maintain effective drainage, 42 additional procedures (catheter exchange, revision, reposition, or additional catheter placement) were performed in 20 patients (24%). Clinical success was achieved in 83 of 84 patients (99%). Median catheter duration was 8 days (4-32 days). Median hospital stay during percutaneous management was 11.5 days (7-45 days). Factors affecting the median catheter duration were the presence of necrotizing pneumonia (p < 0.001) and bronchopleural fistulae (p < 0.001). CONCLUSION Percutaneous imaging-guided catheterization with fibrinolytic therapy should be the method of choice in pediatric complicated PPE and empyema patients with surgical tube thoracostomy failure. Percutaneous treatment is useful in avoiding more aggressive surgical options.
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Affiliation(s)
- Turkmen Turan Ciftci
- Department of Radiology, Hacettepe University School of Medicine. Ankara, Turkey
| | - Devrim Akinci
- Department of Radiology, Hacettepe University School of Medicine. Ankara, Turkey
| | - Emre Unal
- Department of Radiology, Hacettepe University School of Medicine. Ankara, Turkey
| | - Gonul Tanır
- Department of Pediatric Infectious Disease, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Hakan Artas
- Department of Radiology, Firat University School of Medicine, Elazig, Turkey
| | - Okan Akhan
- Department of Radiology, Hacettepe University School of Medicine. Ankara, Turkey
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Severe Pulmonary Infection in a 20-Month-Old Female. Case Rep Infect Dis 2020; 2020:7301617. [PMID: 32099701 PMCID: PMC7037976 DOI: 10.1155/2020/7301617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/21/2019] [Accepted: 01/18/2020] [Indexed: 11/30/2022] Open
Abstract
Community-Acquired Pneumonia (CAP) is a common reason for hospitalization of a pediatric patient. We report a 20-month-old female admitted for suspected CAP. History included a week-long cough, fever, dyspnea, single occurrence of seizure-like activity, and a sick contact. Initial chest X-ray (CXR) showed left lower lobe pneumonia and parapneumonic effusion with a complex left pleural effusion. Ultrasound findings prompted the need for contrast-enhanced computed tomography (CT) of the chest. Contrast-enhanced CT of the chest confirmed a large pleural effusion with major atelectasis and mediastinal shift. The patient was treated with empiric antibiotics, video-assisted thoracoscopic surgical (VATS) decortication of empyema, and chest tube placement. Due to intraoperative complications, the VATS decortication was aborted and patient was transferred to the pediatric intensive care unit (PICU). A thoracentesis with culture failed to isolate a bacterial organism. Dexamethasone was started after repeat CXR showed persistent infiltrate. Subsequent contrast-enhanced CT of the chest showed a large collection of air and persistent consolidation. The patient received repeat VATS decortication and reinsertion of a chest tube. Repeat pleural fluid cultures failed to isolate a bacterial organism. Infectious disease (ID) consult recommended linezolid 140 mg Q8H for 4 weeks. Seven days after second VATS, a respiratory pathogen panel was positive for rhinovirus/enterovirus. With resolution of leukocytosis and clinical improvement, the patient was discharged with the chest tube in place and pediatric surgery outpatient follow-up. After three months, sequalae from both the infection and interventions presented .
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Chen NY, Bender JM, Bard JD, Trost MJ, Corden MH. Something Doesn't Smell Right: When a Patient With Empyema Isn't Responding to Guideline-Based Management. Hosp Pediatr 2016; 6:702-706. [PMID: 27742739 DOI: 10.1542/hpeds.2015-0274] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Nancy Y Chen
- Division of Hospital Medicine, Phoenix Children's Hospital, Phoenix, Arizona;
| | - Jeffrey M Bender
- Divisions of Infectious Diseases and.,Departments of Pediatrics, and
| | - Jennifer Dien Bard
- Laboratory and Pathology, Children's Hospital Los Angeles, Los Angeles, California; and.,Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Margaret J Trost
- Departments of Pediatrics, and.,Hospital Medicine, Departments of Pediatrics, and
| | - Mark H Corden
- Divisions of Infectious Diseases and.,Departments of Pediatrics, and.,Hospital Medicine, Departments of Pediatrics, and
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Barrett C, Ben-Shimol S, Greenberg D. Differences Between Radiologically Confirmed Pneumonia With and Without Pleural Fluid in Hospitalized Children Younger Than 5 Years in Southern Israel. Clin Pediatr (Phila) 2016; 55:897-903. [PMID: 26578358 DOI: 10.1177/0009922815616246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We compared demographic and clinical characteristics of pneumonia with and without pleural fluid (PF and Pn, respectively) in hospitalized children younger than 5 years in southern Israel, between 2002 and 2011. Overall, 108 PF and 5811 Pn episodes were recorded. Children with PF were older. Prematurity (6.6% vs 14.0%) and asthma (9.9% vs 23.5%) were less common in PF. Mean temperature and saturation were higher in PF while hemoglobin and sodium levels were lower in PF compared with Pn. Nasal washes were obtained in 30.6% and 39.9% of PF and Pn episodes, respectively, with respiratory syncytial virus identified more commonly in Pn (24.2% vs 42.3%). Streptococcus pneumoniae was identified in 5.2% and 0.9% of blood cultures in PF and Pn, respectively. In conclusion, PF differed from Pn in demographic and clinical characteristics, possibly due to differences in etiology. Although both diseases are considered bacterial, a high proportion of viral etiology was found in both, especially in Pn.
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Affiliation(s)
- Chiya Barrett
- Soroka University Medical Center, Ben-Gurion University, Beer-Sheva, Israel
| | - Shalom Ben-Shimol
- Soroka University Medical Center, Ben-Gurion University, Beer-Sheva, Israel
| | - David Greenberg
- Soroka University Medical Center, Ben-Gurion University, Beer-Sheva, Israel
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Cha LMJ, Choi S, Kim T, Yoon SW. Intrapleural urokinase therapy in a neonate with pleural empyema. Pediatr Int 2016; 58:616-9. [PMID: 27460398 DOI: 10.1111/ped.12906] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 10/05/2015] [Accepted: 11/30/2015] [Indexed: 11/30/2022]
Abstract
Pleural empyema is rare in neonates, and treatment with systemic antibiotics and tube drainage may fail because of the thick viscous fluid, bacterial products with fibrin deposition, and multiple loculations. Intrapleural fibrinolytic therapy with urokinase is an effective and non-invasive treatment option that avoids surgical intervention, although its use in neonates has not been studied extensively. In this report, we describe the case of a 13-day-old male neonate with Escherichia coli sepsis and pneumonia, which rapidly progressed to parapneumonic effusion and pleural empyema. After inadequate response to i.v. antibiotics and chest tube drainage, the patient was successfully treated with intrapleural urokinase.
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Affiliation(s)
- Lily Myung-Jin Cha
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Sunha Choi
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Taehwan Kim
- Department of Diagnostic Radiology, National Health Insurance Medical Center, Ilsan Hospital, Goyang, South Korea
| | - Shin Won Yoon
- Department of Pediatrics, National Health Insurance Medical Center, Ilsan Hospital, Goyang, South Korea
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Krenke K, Urbankowska E, Urbankowski T, Lange J, Kulus M. Clinical characteristics of 323 children with parapneumonic pleural effusion and pleural empyema due to community acquired pneumonia. J Infect Chemother 2016; 22:292-7. [PMID: 26919911 DOI: 10.1016/j.jiac.2016.01.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 12/25/2015] [Accepted: 01/16/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND An increasing incidence of parapneumonic effusion and pleural empyema (PPE/PE) in children has been found in several studies published in the last decades. The aim of the study was to evaluate the incidence, etiology, clinical features, treatment strategies and outcomes of PPE/PE in children treated in a referral pulmonary center in central Poland. MATERIAL AND METHODS We performed a retrospective analysis of clinical, radiological and laboratory data of all children aged between 1 month and 18 years with PPE/PE due to community acquired pneumonia (CAP) between January 2002 and December 2013. RESULTS One thousand nine hundred and thirty three children with CAP were hospitalized between 2002 and 2013. Parapneumonic effusion or PE was diagnosed in 323 children (16.7%). The proportion of children with CAP related PPE/PE increased from 5.4% in 2002 to 18.8% in 2013. Streptococcus pneumoniae was the most common causative microorganism, responsible for 66.7% cases of known etiology. All children were treated with antibiotics and in 22.6%, and 74.3% of the patients therapeutic thoracentesis, pleural drainage with or without intrapleural fibrinolysis was performed, respectively. Approximately 3% of patients required surgical intervention. CONCLUSIONS A significant increase in the incidence of PPE/PE in children with CAP treated in our institution in the last twelve years was found. S. pneumoniae was the most common causative microorganism. Antibiotic therapy with chest drain insertion ± intrapleural fibrinolysis is an effective treatment of PPE/PE and surgical intervention is seldom necessary. With proper management, the overall prognosis in children with CAP related PPE/PE is good.
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Affiliation(s)
- Katarzyna Krenke
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Poland.
| | - Emilia Urbankowska
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Poland
| | - Tomasz Urbankowski
- Department of Internal Medicine, Pneumonology and Allergology, Medical University of Warsaw, Poland
| | - Joanna Lange
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Poland
| | - Marek Kulus
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Poland
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Scarci M, Abah U, Solli P, Page A, Waller D, van Schil P, Melfi F, Schmid RA, Athanassiadi K, Sousa Uva M, Cardillo G. EACTS expert consensus statement for surgical management of pleural empyema. Eur J Cardiothorac Surg 2015; 48:642-53. [PMID: 26254467 DOI: 10.1093/ejcts/ezv272] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 06/15/2015] [Indexed: 11/12/2022] Open
Affiliation(s)
- Marco Scarci
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridgeshire, UK
| | - Udo Abah
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridgeshire, UK
| | - Piergiorgio Solli
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridgeshire, UK
| | - Aravinda Page
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridgeshire, UK
| | - David Waller
- Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK
| | - Paul van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Franca Melfi
- Department of Cardiothoracic Surgery, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Ralph A Schmid
- Division of General Thoracic Surgery, Berne University Hospital, Berne, Switzerland
| | | | - Miguel Sousa Uva
- Unit of Cardiac Surgery, Hospital Cruz Vermelha, Lisbon, Portugal
| | - Giuseppe Cardillo
- Unit of Thoracic Surgery, Az. Osped. S. Camillo Forlanini, Carlo Forlanini Hospital, Rome, Italy
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Tomlinson JE, Byrne E, Pusterla N, Magdesian KG, Hilton HG, McGorum B, Davis E, Schoster A, Arroyo L, Dunkel B, Carslake H, Boston RC, Johnson AL. The Use of Recombinant Tissue Plasminogen Activator (rTPA) in The Treatment of Fibrinous Pleuropneumonia in Horses: 25 Cases (2007-2012). J Vet Intern Med 2015; 29:1403-9. [PMID: 26256909 PMCID: PMC4858032 DOI: 10.1111/jvim.13594] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 05/06/2015] [Accepted: 07/08/2015] [Indexed: 11/29/2022] Open
Abstract
Background Information about treatment protocols, adverse effects and outcomes with intrapleural recombinant tissue plasminogen activator (rTPA) use in horses with fibrinous pleuropneumonia is limited. Hypothesis/Objectives Describe factors that contribute to clinical response and survival of horses treated with rTPA intrapleurally. Animals Horses with bacterial pneumonia and fibrinous pleural effusion diagnosed by ultrasonography, that were treated with rTPA intrapleurally. Methods Retrospective multicenter case series from 2007–2012. Signalment, history, clinical and laboratory evaluation, treatment, and outcome obtained from medical records. Regression analysis used to identify associations between treatments and outcomes. Results Thirty three hemithoraces were treated in 25 horses, with 55 separate treatments. Recombinant tissue plasminogen activator (375–20,000 μg/hemithorax) was administered 1–4 times. Sonographically visible reduction in fibrin mat thickness, loculations, fluid depth, or some combination of these was seen in 32/49 (65%) treatments. Response to at least 1 treatment was seen in 17/20 (85%) horses with sonographic follow‐up evaluation after every treatment. Earlier onset of rTPA treatment associated with increased survival odds. No association was found between cumulative rTPA dose or number of rTPA doses and survival, development of complications, duration of hospitalization or total charges. Clinical evidence of hypocoagulability or bleeding was not observed. Eighteen horses (72%) survived to discharge. Conclusions and clinical importance Treatment with rTPA appeared safe and resulted in variable changes in fibrin quantity and organization within the pleural space. Recombinant tissue plasminogen activator could be a useful adjunct to standard treatment of fibrinous pleuropneumonia, but optimal case selection and dosing regimen remain to be elucidated.
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Affiliation(s)
- J E Tomlinson
- Department of Clinical Studies, New Bolton Center, University of Pennsylvania School of Veterinary Medicine, Kennett Square, PA
| | - E Byrne
- Alamo Pintado Equine Medical Center, Los Olivos, CA
| | - N Pusterla
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, CA
| | - K Gary Magdesian
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, CA
| | - H G Hilton
- Departments of Structural Biology and Microbiology & Immunology, Stanford University School of Medicine, Stanford, CA
| | - B McGorum
- Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Easter Bush, Midlothian, UK
| | - E Davis
- Department of Clinical Sciences, College of Veterinary Medicine, Kansas State University, Manhattan, KS
| | - A Schoster
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Canada
| | - L Arroyo
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Canada
| | - B Dunkel
- Department of Clinical Science and Services, The Royal Veterinary College, North Mymms, Herts, UK
| | - H Carslake
- Philip Leverhulme Equine Hospital, University of Liverpool, Wirral, UK
| | - R C Boston
- Department of Clinical Studies, New Bolton Center, University of Pennsylvania School of Veterinary Medicine, Kennett Square, PA
| | - A L Johnson
- Department of Clinical Studies, New Bolton Center, University of Pennsylvania School of Veterinary Medicine, Kennett Square, PA
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Timely thoracoscopic decortication promotes the recovery of paediatric parapneumonic empyema. Pediatr Surg Int 2015; 31:665-70. [PMID: 26036322 DOI: 10.1007/s00383-015-3723-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Parapneumonic empyema is one of the most commonly encountered yet difficult to manage paediatric thoracic conditions. Conservative treatment with chest tube drainage and fibrinolytic agents had been proposed but operative decortication remains the gold standard for refractory cases. Thoracoscopic decortication has been advocated in recent years due to its superiority in terms of post-operative pain, cosmesis and other long-term results. However, few studies investigated the effect of timing on peri-operative outcomes. This study aims to explore the benefits of early decortication. METHODS Retrospective study of all patients who underwent thoracoscopic decortication between 1999 and 2013 at a tertiary referral centre was performed. Data were extracted from respective medical records. Patients' demographics, peri-operative outcomes, length of hospitalization and post-operative complications were analysed. RESULTS A total of 28 patients were identified, 12 males and 16 females. Average age of patients was 4.5 years (range 12 months-14 years). Right-sided empyema was involved in 14 of the patients. Patients who underwent operation within 2 weeks from symptom onset (n = 16) showed significant shorter post-operative hospital stay (mean 9.5 vs 20.4 days, p = 0.003) and total hospitalization duration (mean 19.3 vs 38.8 days, p < 0.001). Correlation study demonstrated a strong relation between delay in operation and prolonged hospitalization (r = 0.63, p = 0.001). The peri-operative and post-operative outcomes were similar. No major post-operative complication was encountered except one patient who required a second decortication for residual empyema. CONCLUSION Thoracoscopic decortication is a safe and feasible procedure for parapneumonic empyema. Timely surgery is recommended as it promotes early recovery and shorter hospitalization.
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12
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Marhuenda C, Barceló C, Fuentes I, Guillén G, Cano I, López M, Hernández F, Pérez-Yarza EG, Matute JA, García-Casillas MA, Alvarez V, Moreno-Galdó A. Urokinase versus VATS for treatment of empyema: a randomized multicenter clinical trial. Pediatrics 2014; 134:e1301-7. [PMID: 25349313 DOI: 10.1542/peds.2013-3935] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Parapneumonic empyema (PPE) is a frequent complication of acute bacterial pneumonia in children. There is limited evidence regarding the optimal treatment of this condition. The aim of this study was to compare the efficacy of drainage plus urokinase versus video-assisted thoracoscopic surgery in the treatment of PPE in childhood. METHODS This prospective, randomized, multicenter clinical trial enrolled patients aged <15 years and hospitalized with septated PPE. Study patients were randomized to receive urokinase or thoracoscopy. The main outcome variable was the length of hospital stay after treatment. The secondary outcomes were total length of hospital stay, number of days with the chest drain, number of days with fever, and treatment failures. The trial was approved by the ethics committees of all the participating hospitals. RESULTS A total of 103 patients were randomized to treatment and analyzed; 53 were treated with thoracoscopy and 50 with urokinase. There were no differences in demographic characteristics or in the main baseline characteristics between the 2 groups. No statistically significant differences were found between thoracoscopy and urokinase in the median postoperative stay (10 vs 9 days), median hospital stay (14 vs 13 days), or days febrile after treatment (4 vs 6 days). A second intervention was required in 15% of children in the thoracoscopy group versus 10% in the urokinase group (P = .47). CONCLUSIONS Drainage plus urokinase instillation is as effective as video-assisted thoracoscopic surgery as first-line treatment of septated PPE in children.
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Affiliation(s)
| | | | | | | | - Indalecio Cano
- Department of Pediatric Surgery, Hospital 12 de Octubre, Madrid, Spain
| | - María López
- Department of Pediatric Surgery, Hospital 12 de Octubre, Madrid, Spain
| | | | - Eduardo G Pérez-Yarza
- Department of Pediatrics, University of the Basque Country, UPV/EHU, San Sebastian, Spain; Division of Pediatric Respiratory Medicine, Hospital Universitario Donostia-Instituto Biodonostia, San Sebastián, España; Biomedical Research Centre Network for Respiratory Diseases (CIBERES), San Sebastián, Spain
| | - José A Matute
- Department of Pediatric Surgery, Hospital Gregorio Marañón, Madrid, Spain; and
| | | | - Víctor Alvarez
- Department of Pediatric Surgery, Hospital Central de Asturias, Oviedo, Spain
| | - Antonio Moreno-Galdó
- Pediatric Pulmonology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona. Barcelona, Spain
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13
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Clinical outcome of parapneumonic empyema in children treated according to a standardized medical treatment. Eur J Pediatr 2014; 173:1339-45. [PMID: 24838799 DOI: 10.1007/s00431-014-2319-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 04/04/2014] [Accepted: 04/07/2014] [Indexed: 10/25/2022]
Abstract
UNLABELLED Treatment of parapneumonic empyema (PE) consists of intravenous antibiotics and, in case of large effusions and persisting fever, pleural chest drain (±intrapleural fibrinolytics) or video-assisted surgical intervention. We standardized the treatment for PE in our tertiary care center choosing a first-step nonsurgical approach. The aim was to evaluate the need for surgery and to collect data on disease course, outcome, and microbiology. For all children treated for PE between 2006 and 2013, data were prospectively collected concerning treatment, length of stay, duration of fever, complications, and causative agent. Of 132 children treated for PE, 20 % needed surgical intervention. Analyzed per year, the need for surgery decreased from almost 40 % in 2007 to 0 % in 2010 again increasing to 40 % although this did not reach statistical significance (p = 0.115). Median duration of "in-hospital fever" was 5 days (IQR, 3-8). The duration of fever correlated with pleural LDH (r = 0.324; p = 0.002) and pleural glucose (r = -0.248; p = 0.021) and was inversely correlated with pleural pH (r = -0.249; p = 0.046). Based on pleural PCR data, 85 % of PE were caused by Streptococcus pneumoniae (40 % serotype 1). CONCLUSION After introduction of a standardized primary medical approach (chest drain ± fibrinolysis) for PE in our institution, the need for surgical rescue interventions overall remained at 20 %, which is higher than in some other reports. Difference in microbiology or disease severity could not be proven.
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14
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Nutritional status of children hospitalized for parapneumonic effusion. PLoS One 2014; 9:e94242. [PMID: 24705414 PMCID: PMC3976397 DOI: 10.1371/journal.pone.0094242] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 03/14/2014] [Indexed: 11/23/2022] Open
Abstract
Background & Aims Among children hospitalized for pneumonia, those with parapneumonic effusion (PPE) are at particular risk for nutritional deterioration. This study aimed to 1) investigate the evolution of the nutritional status during hospitalization and at outpatient follow-up; 2) determine clinical risk factors for weight loss during hospitalization; 3) describe the nutritional interventions for these children. Methods Retrospective chart review (January ‘07 - September ‘12) of 56 children with pneumonia, complicated by PPE in two Belgian hospitals for data on body weight and height at admission (t0) and discharge (t1), and two weeks (t2) and one month (t3) after discharge. Length of hospitalization (LoS), length of stay in paediatric intensive care (LoSPICU) and maximal in-hospital weight loss (tmax) were calculated and nutritional interventions were recorded. Results The median (range) age was 3.5 (1.0–14.8) years. Weight or height was lacking in five (8.9%) children at t0 and in 28 (50%) at t1; 21.4% was weighed only once during hospitalization. At tmax, respectively 17/44 and 5/44 children lost ≥5% and ≥10% of their weight. Median (range) LoS and LoSPICU were 18.0 (10–41) and 4.0 (0–23) days. One-fourth received a nutritional intervention. Weight for height at admission (WFH(t0)) significantly predicted maximal weight loss (β (95% CI) = −0.34 (−2.0–−0.1); p = 0.03). At t2 and t3, 13/32 and 5/22 of the children with available follow-up data did not reach WFH(t0), whilst in 4/35 and 5/26 body weight remained ≥5% under the weight(t0). Conclusions One-third of children with pneumonia complicated by PPE and monitored for weight and height, lost ≥5% of their body weight during hospitalization. One-fourth did not reach initial WFH one month after discharge. Those with a higher WFH at admission were at higher risk of weight loss. More attention for monitoring of weight loss and the nutritional policy during and after hospitalization is warranted.
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