Management of late-stage parapneumonic empyema

doi:10.1053/jpsu.2002.30828

Journal of Pediatric Surgery

Volume 37, Issue 3, March 2002, Pages 371-374

https://doi.org/10.1053/jpsu.2002.30828 Get rights and content

Abstract

Purpose: Despite the reported value of early video-assisted thoracoscopic surgery (VATS) for empyema, many children are still referred to the surgeon late in the disease process. The authors wished to determine the optimal management strategy for this group of children. Methods: Medical records of all children (n = 70) from 1990 to 2000 with late-presenting empyema (stage II or III) were reviewed. Patients were grouped as (G1) successful management with chest tube (CT), (G2) surgery after initial CT, (G3) thoracentesis followed by surgery, and (G4) surgery alone. Results: There were no significant differences with respect to age, gender, pleural cultures or fluid analysis. Fifty-one (73%) patients required surgical intervention. Treatment using CT (G1, G2) or thoracentesis (G3) was associated with prolonged length of stay (LOS) when compared with surgery alone (G4; 12 v 8 days). For G2, G3, and G4, rapid clinical improvement and early discharge (6 days) was seen after surgery. For all surgery groups (G2, G3, G4), video-assisted thoracoscopic surgery (n = 19) was associated with a longer postoperative fever (4 v 2 days; P [lt ] .05), but a shorter total LOS (12 v 15 days; P [lt ] .05) when compared with open decortication (n = 32). Conclusions: Over 70% of children with late presenting empyema required surgery, including more than half of the children who received initial chest tube drainage. Delay in surgery was associated with more procedures, more radiographs, and an increased LOS. Despite later intervention, patients undergoing surgery as an initial approach had the shortest length of stay. Early surgical intervention is indicated for most children referred with established empyema.

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The role of tissue plasminogen activator in the management of complex intra-abdominal abscesses in children
2012, Journal of Pediatric Surgery
Citation Excerpt :
Fibrinolytic therapy has been used extensively for the treatment of loculated empyema in both adults and children [13-15]. Although surgical management of complex empyema by thoracotomy or video-assisted thoracic surgery has been advocated by many authors [44,52], recent studies have shown that the use of fibrinolytic agents through a small chest tube is as effective as surgical intervention [14,45,53]. This study represents the largest series of patients undergoing fibrinolytic therapy reported to date and is the only one in children.
The objective of this study is to assess the safety of fibrinolytic therapy using tissue plasminogen activator (tPA) in children with complex intra-abdominal abscesses.
Intra-abdominal abscesses are common in children. Antibiotics and percutaneous drainage are the mainstays of treatment, but drainage may be less effective when the fluid is thick or septated. Fibrinolytic therapy using tPA is effective in a rat model of intra-abdominal abscesses, has recently been reported for the treatment of intra-abdominal abscesses in adults, and is commonly used in the treatment of empyema in children.
This is a retrospective review of all patients over a 10-year period who had intra-abdominal collections managed with tPA abscess drainage.
Sixty-four children had a total of 66 drains placed and 92 doses of tPA. Appendicitis was the cause of the abscesses in 52 of 64 children. Mean length of stay pre-tPA was 11.7 ± 7.63 days, mean time from drain insertion to tPA was 4.3 ± 3.78 days, and mean time from tPA to discharge was 8.6 ± 8.85 days. Thirty patients underwent an operation before tPA administration. No patients experienced bleeding complications, anastomotic or appendiceal stump leak, or wound dehiscence after the administration of tPA, and no patients had abnormalities in coagulation studies related to tPA administration. One child died of sepsis.
Tissue plasminogen activator is safe for the management of thick or septated intra-abdominal abscesses in children. A prospective controlled study will be needed to evaluate the efficacy of this technique.
Pediatric Chest I. Developmental and Physiologic Conditions for the Surgeon
2012, Surgical Clinics of North America
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It is believed that this strategy leads to a faster, more complete evacuation of the chest, a faster resolution of symptoms, and a decreased length of stay compared with other interventions. In addition, it may prevent multiple procedures in the case of failed initial therapy with thoracentesis or thoracostomy with or without fibrinolysis.57,71–79 Others believe that thoracostomy with fibrinolysis, using agents such as streptokinase, urokinase, or tissue plasminogen activator, is as effective as VATS drainage in most cases, and that it may be more cost-effective with less morbidity than VATS.52,57,79–81
Air and Liquid in the Pleural Space
2012, Kendig and Chernick's Disorders of the Respiratory Tract in Children
Video-Assisted Thoracoscopic Surgery
2010, Medical Management of the Thoracic Surgery Patient
Pediatric parapneumonic pleural effusions: Experience in a university central hospital
2009, Revista Portuguesa de Pneumologia
Introdução: Os derrames pleurais podem complicar as pneumonias na população pediátrica. Assumem especial importância pelas implicações na duração do internamento, geralmente prolongado, e pela morbilidade associada.
Objectivos: Caracterizar uma população de doentes com pneumonia complicada de derrame; determinar os possíveis factores de prognóstico a partir de dados clínicos, radiológicos e analíticos na admissão; e avaliar a influência das intervenções terapêuticas na evolução da doença.
Métodos: Revisão casuística dos doentes com idade inferior a 18 anos e derrame pleural parapneu mónico, internados de Julho de 1997 a Junho de 2004 (7 anos).
Resultados: Foram estudados 118 casos, 60% do sexo masculino, com idade média 7 anos. A incidência de derrame pleural aumentou ao longo do período do estudo. Verificou-se maior incidência de casos no Outono e no Inverno. Na admissão, 60% dos doentes apresentavam sinais de dificuldade respiratória e 39% dor torácica. Em 40% dos doentes foram detectados septos pleurais na admissão, o que se associou a maior duração de internamento e de antibioticoterapia e mais frequente necessidade de cirurgia. Em 72% dos doentes foi efectuada toracocentese (pH médio: 7,24). Em 17% foi possível isolar o agente: Streptococcus pneumoniae (cinco), Staphylococcus aureus (quatro) e Streptococcus pyogenes (quatro). Foram submetidos a drenagem pleural 52% e necessitaram de cirurgia 18%. A mediana da duração de internamento foi de 15 dias e a média de 16,4 dias (2 a 51).
Discussão: Associam-se a pior prognóstico a presença de: sinais de dificuldade respiratória; septos; empiema; baixo valor no líquido pleural de pH, glicose ou proteínas; desidrogenase láctica elevada no líquido pleural e proteína C-reactiva sanguínea aumentada. A drenagem pleural e/ou cirurgia mais precoces provavelmente diminuem o tempo de doença e de internamento.
Conclusão: Os derrames parapneumónicos complicados são tratados com êxito em centros de referência com experiência nos diferentes tipos de intervenção que poderão ser necessários.
Rev Port Pneumol 2009; XV (2): 241-259
Introduction: Pleural effusions can complicate pneumonias in children and adolescents and are usually associated with a long hospital stay and increased morbidity.
Aims: To characterise a population of patients with parapneumonic pleural effusion and to establish possible prognostic factors on admission based on clinical, imaging and analytical data. To correlate treatment options with the outcome.
Methods: Case review of patients under 18 years old with parapneumonic pleural effusion, admitted between July 1997 – June 2004 (7 years).
Results: 118 patients were included, 60% male, with mean age 7 years. The incidence of pleural effusion increased throughout the period of the study. The admissions occurred predominantly in autumn and winter. On admission 60% of patients had respiratory distress and 39% chest pain. In 40% loculations were found on admission and were associated with longer hospital stay, longer course of antibiotic therapy and more frequent need for surgery. Thoracentesis was performed in 72% of patients (mean pH pleural fluid 7.24). The aetiologic agent was identified in 17% of cases: Streptococcus pneumoniae (five), Staphylococcus aureus (four) and Streptococcus pyogenes (four). In our study, 52% of patients underwent pleural drainage and 18% surgery. Median length of hospital stay was 15 days with mean 16.4 days (2 – 51).
Discussion: Factors associated with worse prognosis were respiratory distress, loculations, empyema, low pH in pleural fluid, glucose or proteins in pleural fluid, high lactic dehydrogenase level in pleural fluid and high serum C-reactive protein. Pleural drainage and/or surgery can shorten hospital stay and improve outcome.
Conclusion: Complicated parapneumonic pleural effusions are managed successfully in centres with experience in the different types of procedure that might be necessary.
Rev Port Pneumol 2009; XV (2): 241-259
Surgical thoracoscopy in children
2007, Archives de Pediatrie
Cet article fait le point sur les principales indications diagnostiques et thérapeutiques de la chirurgie thoracoscopique pédiatrique. Les auteurs rappellent les particularités de cette chirurgie chez l’enfant en termes d’anatomie, d’anesthésie et d’analgésie postopératoires. Pour des équipes expérimentées, la majorité des lésions pleurales, médiastinales et pulmonaires peuvent être abordées par thoracoscopie.
This article is a state-of-the-art about the main diagnostic and therapeutic indications of paediatric surgical thoracoscopy. The authors stress the features of this surgery in children, in terms of anatomy, anaesthesia and postoperative analgesia. For experienced teams, almost any pleural, mediastinal or pulmonary lesion can be approached thoracoscopically

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