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'Less may be best'-Pediatric parapneumonic effusion and empyema management: Lessons from a UK center
Anna-May Long1, Jonathan Smith-Williams2, Sarah Mayell3
1Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK.
Insights
Pediatric empyema management using a protocol-driven pathway and chemical fibrinolysis shows high success rates. Early imaging for necrotizing disease is key to preventing surgical intervention in children.
Area of Science:
- Pediatric Pulmonology
- Thoracic Surgery
- Infectious Diseases
Background:
- Children with empyema are managed via a protocol-driven clinical care pathway.
- Chemical fibrinolysis is the first-line treatment for significant pleural disease.
- This study benchmarks care standards and analyzes disease severity post-pneumococcal conjugate vaccine introduction.
Purpose of the Study:
- To examine clinical outcomes of pediatric empyema management.
- To benchmark standards of care for pediatric empyema.
- To analyze disease severity in relation to the pneumococcal conjugate vaccine.
Main Methods:
- Retrospective review of medical records from a UK pediatric center (Jan 2006-Dec 2012).
- Binary logistic regression used to analyze fibrinolytic therapy failure.
- Factors studied included age, comorbidity, prior antibiotic duration, and initial imaging findings.
Main Results:
- 239 children treated (median age 4 years); decreasing complicated pleural infections observed annually.
- 71% managed with chest drain and urokinase; 27% with antibiotics alone; only 2% required primary thoracotomy.
- Fibrinolysis failure occurred in 14.7%; suspicion of necrotizing disease on initial imaging predicted failure (P=0.002, OR 8.69).
Conclusions:
- Protocol-driven care pathways and multidisciplinary teams lead to good outcomes in pediatric pleural empyema.
- A 'less is best' approach minimizes the need for surgical intervention.
- Initial imaging is crucial for identifying patients at high risk of treatment failure.
Background:
Children with empyema are managed at our center using a protocol-driven clinical care pathway. Chemical fibrinolysis is deployed as first-line management for significant pleural disease. We therefore examined clinical outcome(s) to benchmark standards of care while analyzing disease severity with introduction of the pneumococcal conjugate vaccine.
Methods:
Medical case-records of children managed at a UK pediatric center were surveyed from Jan 2006 to Dec 2012. Binary logistic regression was utilized to study failure of fibrinolytic therapy. The effects of age, comorbidity, number of days of intravenous antibiotics prior to drainage and whether initial imaging showed evidence of necrotizing disease were also studied.
Results:
A total of 239 children were treated [age range 4months-19years; median 4years]. A decreasing number of patients presenting year-on-year since 2006 with complicated pleural infections was observed. The majority of children were successfully managed without surgery using antibiotics alone (27%) or a fine-bore chest-drain and urokinase (71%). Only 2% of cases required primary thoracotomy. 14.7% cases failed fibrinolysis and required a second intervention. The only factor predictive of failure and need for surgery was suspicion of necrotizing disease on initial imaging (P=0.002, OR 8.69).
Conclusion:
Pediatric patients with pleural empyema have good outcomes when clinical care is led by a multidisciplinary team and protocol driven care pathway. Using a 'less is best' approach few children require surgery.