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Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion
Published on: November 10, 2023
Management of children with empyema: Pleural drainage is not always necessary
Edward Carter1, John Waldhausen, Weiya Zhang
1Department of Pediatrics, University of Washington, Seattle, Washington, USA. edward.carter@seattlechildrens.org
Insights
Pediatric empyema can be effectively managed with intravenous antibiotics alone in stable patients, avoiding drainage procedures. Intensive care unit admission and large effusions predict the need for pleural drainage.
Area of Science:
- Pediatric Pulmonology
- Thoracic Surgery
- Infectious Diseases
Background:
- Management of pediatric empyema lacks clear guidelines for pleural drainage.
- Current strategies show significant variation in clinical practice.
- Need for criteria to guide intervention in pediatric empyema cases.
Purpose of the Study:
- To review the efficacy of a treatment strategy for pediatric empyema starting with intravenous (IV) antibiotics alone.
- To determine the need for pleural drainage only if no clinical improvement occurs within 48 hours.
- To identify predictors for requiring pleural drainage in pediatric empyema patients.
Main Methods:
- Retrospective review of 182 children (1-18 years) hospitalized with empyema (December 1996 - December 2008).
- Primary outcomes: proportion of patients needing pleural drainage and hospital length of stay (LOS).
- Analysis of patient data to identify factors associated with drainage procedures.
Main Results:
- 52% of patients received antibiotics alone; 45% underwent drainage procedures.
- Mean LOS was significantly shorter for the antibiotics alone group (7.0 days) versus the drainage group (11 days).
- Predictors for pleural drainage included intensive care unit admission and large effusion size (>1/2 thorax).
Conclusions:
- Intravenous antibiotics alone can be a successful treatment for select pediatric empyema cases, leading to shorter hospital stays.
- Children requiring intensive care or presenting with large effusions and mediastinal shift are more likely to need pleural drainage.
- This strategy offers a viable alternative for managing pediatric empyema, reserving drainage for specific indications.
Background:
There is considerable variation in the management of pediatric empyema, and there are no clear criteria for when to perform pleural drainage. Our study aims were: (1) to retrospectively review our experience with an empyema treatment strategy that started with intravenously administered (IV) antibiotics alone in medically stable patients with procession to pleural drainage only if there was no clinical improvement after 48 hr, and (2) to identify predictors for undergoing pleural drainage.
Methods:
We performed a retrospective review of 182 previously healthy children, 1-18 years old, hospitalized with empyema from December 1996 through December 2008. The primary outcome measures were the proportion of patients requiring pleural drainage procedures and hospital length of stay (LOS).
Results:
Ninety-five children (52%) received antibiotics alone, and 87 (45%) underwent drainage procedures (21 chest tube alone, 57 VATS/thoracotomy, and 8 chest tube followed by VATS/thoracotomy); only 4 received fibrinolytics. Mean (standard deviation) LOS was significantly shorter in the antibiotics alone group, 7.0 (3.5) versus 11 (4.0) days. The strongest predictors of undergoing pleural drainage were admission to the intensive care unit and large effusion size (>(1/2) thorax filled).
Conclusions:
Some children with empyema can be treated with IV antibiotics alone and have reasonably short LOS. At our institution, those that required intensive care or had large effusions with mediastinal shift were more likely to require pleural drainage.
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