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Are some children with empyema at risk for treatment failure with fibrinolytics? A multicenter cohort study
Michael H Livingston1, Eyal Cohen2, Lucy Giglia3
1McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada; Clinician Investigator Program, McMaster University, Hamilton, Ontario, Canada.
Insights
Predicting treatment failure in pediatric empyema is difficult. Key risk factors for treatment failure with intrapleural fibrinolytics include positive blood cultures, intensive care unit admission, and lack of complex septations on ultrasound.
Area of Science:
- Pediatric Pulmonology
- Thoracic Surgery
- Pediatric Critical Care
Background:
- Current guidelines recommend chest tube insertion and intrapleural fibrinolytics for pediatric empyema.
- Treatment failure occurs in some children, necessitating identification of associated risk factors.
Purpose of the Study:
- To identify risk factors associated with treatment failure in children with empyema treated with intrapleural fibrinolytics.
- To determine predictors of poor outcomes in pediatric empyema management.
Main Methods:
- Retrospective study of 314 children with empyema treated with fibrinolytics across three children's hospitals.
- Treatment failure defined as repeat pleural drainage or length of stay > 2 weeks.
- Multivariable logistic regression analysis to identify independent risk factors.
Main Results:
- 34% of children experienced treatment failure; 13% required repeat drainage.
- Positive blood culture (OR=2.7), immediate ICU admission (OR=2.6), and absence of complex septations on ultrasound (OR=2.1) were associated with increased risk of failure.
- Routine blood work and inflammatory markers showed no significant prognostic value.
Conclusions:
- Predicting treatment failure in pediatric empyema remains challenging.
- Positive blood culture, intensive care unit admission, and absence of complex septations on ultrasound are significant risk factors.
- Standard laboratory markers have limited utility in predicting treatment failure.
Background:
Guidelines recommend that children with empyema be treated initially with chest tube insertion and intrapleural fibrinolytics. Some patients have poor outcomes with this approach, and it is unclear which factors are associated with treatment failure.
Methods:
Possible risk factors were identified through a review of the literature. Treatment failure was defined as need for repeat pleural drainage and/or total length of stay greater than 2weeks.
Results:
We retrospectively identified 314 children with empyema treated with fibrinolytics at The Hospital for Sick Children (2000-2013, n=195), Children's Hospital, London Health Sciences Centre (2009-2013, n=39), and McMaster Children's Hospital (2007-2014, n=80). Median length of stay was 11days (range 5-69days). Thirteen percent of children required repeat drainage procedures, and 34% experienced treatment failure. There were no deaths. White blood cell count, erythrocyte sedimentation rate, C-reactive protein, albumin, urea to creatinine ratio, and signs of necrosis on initial chest x-ray were not associated with treatment failure. Multivariable logistic regression demonstrated increased risk with positive blood culture (odds ratio=2.7), immediate admission to intensive care (odds ratio=2.6), and absence of complex septations on baseline ultrasound (odds ratio=2.1). Male gender and platelet count were associated with treatment failure in the univariate analysis but not in the multivariable model.
Conclusions:
Predicting which children with empyema are at risk for treatment failure with fibrinolytics remains challenging. Risk factors include positive blood culture, immediate admission to intensive care, and absence of complex septations on ultrasound. Routine blood work and inflammatory markers have little prognostic value.
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