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Di Mitri M, Thomas E, Capano E, Bisanti C, D'Antonio S, Libri M, Gargano T, Lima M. The role of the early video-assisted thoracoscopic surgery in children with pleural empyema. Pediatr Surg Int 2024; 40:134. [PMID: 38761186 PMCID: PMC11102380 DOI: 10.1007/s00383-024-05715-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/01/2024] [Indexed: 05/20/2024]
Abstract
PURPOSE Pleural empyema (PE) is a collection of purulent material in the pleural space. PE's management in children is a challenge and an inappropriate diagnostic-therapeutic work up can lead to serious short and long-term complications. The aim of this study is to define the correct timing to approach a pediatric PE by video-assisted thoracoscopic surgery (VATS). METHODS A retrospective observational study was conducted including pediatric patients who underwent video-assisted thoracoscopy for pleural empyema between May 2005 and September 2022. RESULTS 62 patients were subjected to VATS for PE (32 in Group Early VATS, 30 in Group Late VATS). It emerged that the elapsed period between the onset of symptoms and surgery correlates in a statistically significant way with the post-operative stay in intensive care (z score 4.3 and p value < 0.0001) and the analysis between early VATS, late VATS and postoperative hospitalization showed a statistically significant reduction of the post-operative hospitalization in the early VATS groups (p value < 0.02). CONCLUSIONS VATS resulted to be safe and effective for the treatment of PE in children, and an early minimally invasive thoracoscopic intervention (early VATS) correlates with better outcomes, specifically in terms of intensive care hospitalization and overall hospitalization.
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Affiliation(s)
- Marco Di Mitri
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126, Bologna, Italy
| | - Eduje Thomas
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126, Bologna, Italy
| | - Eleonora Capano
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126, Bologna, Italy
| | - Cristian Bisanti
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126, Bologna, Italy.
| | - Simone D'Antonio
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126, Bologna, Italy
| | - Michele Libri
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126, Bologna, Italy
| | - Tommaso Gargano
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126, Bologna, Italy
| | - Mario Lima
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126, Bologna, Italy
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Liu X, Yang Y, Ma X, Wang X, Ma B, Li S. The Effect of CT-Guided Artificial Pneumothorax plus Thoracoscopy and Central Venous Catheterization on the Drainage Effect of Pediatric Empyema and Pulmonary Function. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:8230212. [PMID: 36110977 PMCID: PMC9448614 DOI: 10.1155/2022/8230212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/30/2022] [Accepted: 07/26/2022] [Indexed: 11/30/2022]
Abstract
The aim of the study is to investigate the effect of CT-guided artificial pneumothorax combined with a thoracoscopic and central venous catheter on empyema drainage effect and pulmonary function in children. A total of 82 pediatric patients with empyema admitted to our hospital from January 2020 to December 2021 were retrospectively analyzed. The control group was treated with artificial pneumothorax combined with thoracoscopy. The study group was treated with a CT-guided and central venous catheter. The operation time, intraoperative bleeding, surgical field exposure, WBC, C-reactive protein, and pulmonary function were compared between the two groups. The size of effusion and sonographic staging were compared between the two groups. All children underwent spirometry and a maximal incremental cardiopulmonary exercise test. The operation indicators (operation time, intraoperative blood loss, etc.) and adverse reactions were compared between the two groups. The differences in the operation time, intraoperative blood loss, postoperative hospital stay, postoperative drainage volume, and surgical field exposure between the two groups had a statistical significance (P < 0.05); the differences in the body temperature, total peripheral white blood cell count, C-reactive protein, size of effusion, and sonographic staging between the two groups had no statistical significance (P > 0.05); before operation, the differences in the expression levels of FVC (%), FEV1 (%), FEV1/FVC, and MVV (%) and indicators of cardiopulmonary function including VE/VO2, breathing reserve(%), VD/VT(%), and VO2/work between the two groups had no statistical significance, but at 6 months after operation, FVC (%), FEV1 (%), FEV1/FVC, and MVV (%) in the study group were significantly higher than those in the control group (P < 0.05) and VE/VO2 and VD/VT(%) in the study group were obviously lower than those in the control group (P < 0.05); the incidence rate of chest pain, pulmonary edema, and skin infection in the study group was lower than that in the control group (P < 0.05). CT-guided artificial pneumothorax combined with thoracoscopic and central venous catheter drainage of empyema in children is more thorough, with less bleeding, less trauma, rapid recovery of pulmonary function, and is worthy of clinical promotion.
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Affiliation(s)
- Xiaoping Liu
- Northwest University for Nationality School of Clinical Medicine, Lanzhou, China
- The Second People's Hospital of Gansu Province, Gansu, Lanzhou, China
- Affiliated Hospital of Northwest University for Nationalities, Lanzhou, China
| | - Yanxia Yang
- Northwest University for Nationality School of Clinical Medicine, Lanzhou, China
- The Second People's Hospital of Gansu Province, Gansu, Lanzhou, China
- Affiliated Hospital of Northwest University for Nationalities, Lanzhou, China
| | - Xueping Ma
- Northwest University for Nationality School of Clinical Medicine, Lanzhou, China
- Department of Respiratory and Critical Care Medicine, Second People's Hospital of Gansu Province, Gansu, Lanzhou, China
| | - Xin Wang
- Northwest University for Nationality School of Clinical Medicine, Lanzhou, China
- Department of Respiratory and Critical Care Medicine, Second People's Hospital of Gansu Province, Gansu, Lanzhou, China
| | - Bing Ma
- Northwest University for Nationality School of Clinical Medicine, Lanzhou, China
- Department of Respiratory and Critical Care Medicine, Second People's Hospital of Gansu Province, Gansu, Lanzhou, China
| | - Shuhua Li
- Northwest University for Nationality School of Clinical Medicine, Lanzhou, China
- The Second People's Hospital of Gansu Province, Gansu, Lanzhou, China
- Affiliated Hospital of Northwest University for Nationalities, Lanzhou, China
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Markham JL, Hackman S, Hall M, Burns A, Goldman JL. Inpatient outcomes for children receiving empiric methicillin-resistant Staphylococcus aureus coverage for complicated pneumonia. J Hosp Med 2022; 17:36-41. [PMID: 35504578 DOI: 10.1002/jhm.2736] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/22/2021] [Accepted: 12/09/2021] [Indexed: 11/07/2022]
Abstract
Rigorous evidence for antibiotic management of pediatric complicated pneumonia is lacking, likely contributing to variation in empiric antibiotic(s). Using the Pediatric Health Information System database, we sought to describe use and clinical outcomes of children hospitalized with complicated pneumonia who received empiric antibiotic regimens with and without methicillin-resistant Staphylococcus aureus (MRSA) coverage. We evaluated empiric antibiotic selection on Day 0-1, grouping based on use of an antibiotic with or without MRSA coverage. We used generalized linear mixed effects models to examine the association of MRSA coverage and outcomes. Across 46 children's hospitals, 71.5% of children (N = 1279) received an empiric antibiotic regimen with MRSA coverage. In adjusted analyses, length of stay, need for repeat pleural drainage procedures, 7-day emergency department revisits and 7-day readmissions were similar between groups. Future prospective studies examining the need for MRSA coverage may assist in refining national treatment guidelines for complicated pneumonia in children.
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Affiliation(s)
- Jessica L Markham
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Sophia Hackman
- Department of Graduate Medical Education, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Matt Hall
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Alaina Burns
- Department of Pharmacy, Children's Mercy Kansas City, University of Missouri-Kansas City School of Pharmacy, Kansas City, Missouri, USA
| | - Jennifer L Goldman
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
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Rix-Trott K, Byrnes CA, Gilchrist CA, Matsas R, Walls T, Voss L, Mahon C, Dickson NP, Reed P, Best EJ. Surveillance of pediatric parapneumonic effusion/empyema in New Zealand. Pediatr Pulmonol 2021; 56:2949-2957. [PMID: 34232567 DOI: 10.1002/ppul.25564] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 06/07/2021] [Accepted: 07/01/2021] [Indexed: 11/07/2022]
Abstract
AIM The incidence of childhood empyema has been increasing in some developed countries despite the introduction of pneumococcal vaccination. This study aimed to document the incidence, bacterial pathogens, and morbidity/mortality of parapneumonic effusion/empyema in New Zealand. METHODS A prospective study of 102 children <15 years of age requiring hospitalization with parapneumonic effusion/empyema between May 1, 2014 and May 31, 2016 notified via the New Zealand Paediatric Surveillance Unit. Parapneumonic effusion/empyema was defined as pneumonia and pleural effusion persisting ≥7 days, and/or any pneumonia, and pleural effusion necessitating drainage. Notifying pediatricians completed standardized questionnaires. RESULTS Annual pediatric parapneumonic effusion/empyema incidence was 5.6/100,000 (95% confidence interval [CI]: 4.7-6.9). Most children (80%) required surgical intervention and 31% required intensive care. A causative organism was identified in 71/102 (70%) cases. Although Staphylococcus aureus (25%) and Streptococcus pneumoniae (25%) infection rates were equal, prolonged hospitalization and intensive care admission were more common in children with S. aureus PPE/E. Māori and Pasifika children were over-represented at 2.2 and 3.5 times, their representation in the New Zealand pediatric population. Pneumococcal vaccination was incomplete, with only 61% fully immunized and 30% unimmunized. Haemophilus influenzae type b vaccine uptake was near complete at 89/94 (95%), with influenza immunization only 3/78 (4%). CONCLUSIONS New Zealand has a high incidence of pediatric complicated parapneumonic effusion/empyema with significant morbidity. S. aureus was a significant cause of severe empyema in New Zealand, particularly for Māori and Pasifika children. Improvements in vaccine coverage are needed along with strategies to reduce S. aureus disease morbidity.
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Affiliation(s)
- Katherine Rix-Trott
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand.,KidzFirst Children's Hospital, Counties Manukau District Health Board, Auckland, New Zealand
| | - Catherine A Byrnes
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand.,Department of Paediatrics: Child and Youth Health, School of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Catherine A Gilchrist
- Department of Paediatrics: Child and Youth Health, School of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Richard Matsas
- KidzFirst Children's Hospital, Counties Manukau District Health Board, Auckland, New Zealand
| | - Tony Walls
- Department of Paediatrics, University of Otago, Christchurch, New Zealand.,Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Lesley Voss
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
| | - Caroline Mahon
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - Nigel P Dickson
- New Zealand Paediatric Surveillance Unit, Department of Women's and Children's Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Peter Reed
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
| | - Emma J Best
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand.,Department of Paediatrics: Child and Youth Health, School of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Ljuhar D, Rayner J, Hyland E, King S. Management of thoracic empyema in children: a survey of the Australia and New Zealand Association of Paediatric Surgeons (ANZAPS). Pediatr Surg Int 2021; 37:897-902. [PMID: 33751198 DOI: 10.1007/s00383-021-04887-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To define the spectrum of management for thoracic empyema in children in Australia and New Zealand. METHODS Online survey of members of the Australian and New Zealand Association of Paediatric Surgeons (ANZAPS), limited to consultant/attending paediatric surgeons. RESULTS A total of 54/80 (67.5%) members, from 16 paediatric surgical centres, responded. The majority (33/54, 61%) preferred chest drain with fibrinolytics, whilst 21/54 (39%) preferred video-assisted thoracoscopic surgery (VATS) with drain insertion. Urokinase was the most commonly used fibrinolytic (64%). There were no significant differences in management preferences between practising surgeons in Australia and New Zealand (p = 0.54), nor between consultants who had been practising a shorter (< 5 years) or longer (> 20 years) amount of time (p = 0.21). The practices described by the surveyed ANZAPS members were in line with the Thoracic Society of Australia and New Zealand recommendations for the management of paediatric empyema. CONCLUSION Across Australia and New Zealand there exists significant variation surrounding the intra- and post-intervention management of thoracic empyema in children. The surveyed paediatric surgeons demonstrated a preference for fibrinolytics over the use of VATS. All management regimens were within published local guidelines.
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Affiliation(s)
- Damir Ljuhar
- Department of Paediatrics, Monash University, Melbourne, Australia.
| | - Jessica Rayner
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Australia
| | - Ela Hyland
- Department of Paediatric Surgery and Urology, Canberra Hospital, Canberra, Australia
| | - Sebastian King
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Australia.,Surgical Research, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
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Gross CJ, Porter JJ, Lipsett SC, Monuteaux MC, Hirsch AW, Neuman MI. Variation in Management and Outcomes of Children With Complicated Pneumonia. Hosp Pediatr 2021; 11:207-214. [PMID: 33579749 DOI: 10.1542/hpeds.2020-001800] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To assess the characteristics of children hospitalized with complicated pneumonia at US children's hospitals and compare these characteristics with those of children hospitalized with community-acquired pneumonia (CAP). METHODS We identified children hospitalized with complicated pneumonia (parapneumonic effusion, empyema, necrotizing pneumonia, or lung abscess) or CAP across 34 hospitals between 2011 and 2019. We evaluated differences in patient characteristics, antibiotic selection, and outcomes between children with complicated pneumonia and CAP. We, also, assessed seasonal variability in the frequency of these 2 conditions and evaluated the prevalence of complicated pneumonia over the 9-year study period. RESULTS Compared with children hospitalized with CAP (n = 75 702), children hospitalized with complicated pneumonia (n = 6402) were older (a median age of 6.1 vs 3.4 years; P < .001), with 59.4% and 35.2% of patients ≥5 years of age, respectively. Patients with complicated pneumonia had higher rates of antibiotic therapy targeted against methicillin-resistant Staphylococcus aureus (46.3% vs 12.2%; P < .001) and Pseudomonas (8.6% vs 6.7%; P < .001), whereas differences in rates of coverage against mycoplasma were not clinically significant. Children with complicated pneumonia had a longer median hospital length of stay and higher rates of ICU admissions, mechanical ventilation, 30-day readmissions, and costs. Seasonal variation existed in both complicated pneumonia and CAP, with 42.7% and 46.0% of hospitalizations occurring during influenza season. The proportion of pneumonia hospitalizations due to complicated pneumonia increased over the study period (odds ratio 1.04, 95% confidence interval: 1.02-1.06). CONCLUSIONS Complicated pneumonia more frequently occurs in older children and accounts for higher rates of resource use, compared to CAP.
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Affiliation(s)
- Caroline J Gross
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts; and.,Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| | - John J Porter
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Division of Emergency Medicine and
| | - Susan C Lipsett
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts; and.,Division of Emergency Medicine and
| | - Michael C Monuteaux
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts; and.,Division of Emergency Medicine and
| | - Alexander W Hirsch
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts; and.,Division of Emergency Medicine and
| | - Mark I Neuman
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; .,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts; and.,Division of Emergency Medicine and
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Abstract
BACKGROUND The duration of antibiotic treatment after resolution of empyema in children is variable. We evaluated the efficacy and safety of a protocol-driven antibiotic regimen aimed to decrease antibiotic duration following treatment with fibrinolysis. METHODS Our institutional protocol consisted of 7 further days of antibiotics upon removal of the thoracostomy tube, with the patient being afebrile, off supplemental oxygen, and having negative cultures. A prospective observational study was then performed between September 2014 and March 2019. Empyema recurrence and antibiotic-related complications were recorded. Results were compared with previously published data from the preprotocol era. RESULTS A total of 37 patients were included. Mean total duration of antibiotics decreased from 26 ± 6.5 days in the preprotocol group to 22 ± 9.7 days in the postprotocol group (P = 0.004). This resulted in a significant decrease in hospital stay from the preprotocol cohort to the postprotocol cohort, respectively (9.3 ± 4.8 d versus 6.8 ± 3.1 d, P = 0.003). Sixty-two percentage of the patients were intended to treat according to the protocol, with a 50% adherence rate. Patients in which the protocol was followed had an average of 2.8 fewer days of antibiotics after discharge (P = 0.004), although overall duration was not statistically different. Significantly fewer antibiotic-related complications were noted after protocol initiation. There was no difference in empyema recurrence or readmissions. CONCLUSIONS Institution of a protocol-driven approach to antibiotic duration following resolution of pleural space disease may reduce antibiotic duration and complications without reducing efficacy.
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Characteristics of Streptococcus pyogenes Versus Streptococcus pneumoniae Pleural Empyema and Pneumonia With Pleural Effusion in Children. Pediatr Infect Dis J 2020; 39:799-802. [PMID: 32804461 DOI: 10.1097/inf.0000000000002699] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Streptococcus pneumoniae is the most common cause of complicated pneumonia in children, but its incidence is decreasing since the introduction of the antipneumococcal conjugated vaccines. Streptococcus pyogenes is an uncommon cause of community-acquired pleuropneumonia/empyema in children, but its relative incidence is rising. METHODS The medical records of all children 0-18 years of age from 2004 to 2019, with discharge diagnoses of pleuropneumonia or empyema, and a positive blood and/or pleural effusion culture for group A streptococcus (GAS) (S. pyogenes), or S. pneumonia (SP) were reviewed. A comparison of clinical and laboratory characteristics for the 2 etiologies was performed. RESULTS Ninety cases of community-acquired pleuropneumonia/empyema caused by these organisms were included: 20 GAS and 70 SP. Compared with children with SP, those with GAS were more likely to have larger pleural effusion requiring drainage and longer hospitalization, and less likely to have a positive blood culture. The relative portion of GAS empyema increased over the study period. CONCLUSIONS Compared with patients with SP empyema, GAS appears to cause more morbidity and a longer hospital stay. This organism is more frequently recovered from pleural fluid without bacteremia, and thus necessitates pleural fluid tap for accurate diagnosis.
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