Empiema pleural en 343 casos con tratamiento quirúrgico: características, resultados inmediatos y factores asociados a morbilidad y mortalidad / Pleural empyema: retrospective review of 343 patients

Background: Pleural empyema still has a dismal prognosis. Aim: To describe features and prognostic factors of patients with pleural empyema subjected to surgical procedures. Material and Methods: Retrospective review of 343 patients with pleural empyema (mean age 52 years, 71 percent males), that were subjected to any type of surgical procedure. Criteria for diagnosis of empyema were a positive culture, a fluid pH of less than 7.2 or a compatible macroscopic appearance of the fluid. Results: Empyema was secondary to pneumonia in 243 patients (71 percent, secondary to surgical procedures in 41 patients (12 percent), secondary to trauma in 19 patients (5.5 percent), secondary to a lung abscess in 10 patients (3 percent), tuberculous in 10 patients (3 percent), neoplastic in two cases (0.6 percent), secondary to pneumothorax in 2 cases (0.6 percent) and of unknown origin in 13 patients (4 percent). A microorganism was isolated from pleural fluid in 89 patients (26 percent). The surgical procedures performed were 251 decortications by thoracotomy (73 percent), 70 pleurotomies (20 percent), 11 video assisted surgeries (3 percent), seven decortications with lung resections and four fenestrations. Complications were recorded in 104 patients (30 percent), 29 patients were re-operated (8.5 percent) and 31 died (10 percent), all due to sepsis. Conclusions: The main cause of pleural empyema is pneumonia. In most patients, microorganisms are not isolated from pleural fluid, thoracotomy with decortication is the most frequent surgical procedure. There is a high rate of complications and mortality.

Objetivos: Describir características, resultados inmediatos y evaluar factores asociados a morbi-mortalidad de Empiema Pleural (EP) con tratamiento quirúrgico. Método: Revisión retrospectiva. Período: enero 2000 - agosto 2006. Se describen características, resultados inmediatos y factores asociados a morbi-mortalidad. Se utilizó programa SPSS 15.0. Se consideró significativo p < 0,05. Resultados: 343 pacientes, 243 (70,8 por ciento) hombres (relación 2,4:1), edad promedio 51,7 años. Etiología: 242 (70,6 por ciento) paraneumónico, 41 (12,0 por ciento) postquirúrgico, 19 (5,5 por ciento) postraumático, 10 (2,9 por ciento) absceso pulmonar, 10 (2,9 por ciento) tuberculoso, 6 (1,7 por ciento) neoplásico, 2 (0,6 por ciento) neumotórax y 13 (3,8 por ciento) desconocido. Se aisló germen en líquido pleural en 89 (25,9 por ciento). Se realizaron: 251 (73,2 por ciento) decorticaciones por toracotomía, 70 (20,4 por ciento) pleurotomías, 11 (3,2 por ciento) cirugías video-asistidas, 7 (2,1 por ciento) decorticaciones con resección pulmonar y 4 (1,2 por ciento) fenestraciones. Presentaron complicaciones 104 (30,3 por ciento) pacientes. Se reoperaron 29 (8,5 por ciento). Fallecieron 31 (9,6 por ciento), todos por sepsis. Se encontraron variables asociadas a morbi-mortalidad. Conclusiones: El EP tiene como causa más frecuente el empiema paraneumónico seguido de los postoperatorios, en la mayoría no se identifican gérmenes en líquido pleural. La toracotomía con decorticación es el procedimiento quirúrgico más frecuente. El EP tiene una considerable morbi-mortalidad. Se identifican variables asociadas a morbilidad y mortalidad.

Empiema y efusión pleural en niños / Empyema and pleural efussion in children

Introducción: El empiema pleural (EP) es una complicación grave de la neumonía adquirida en la comunidad (NAC). Objetivos: Describir las características de los pacientes hospitalizados por EP en el Servicio de Pediatría del Hospital de la Universidad Católica durante el período 2000-2005. Se identificaron 86 hospitalizaciones por NAC con efusión pleural, practicándose en 59 (70 por ciento), al menos una toracocentesis. Se consideró EP a la presencia de pus, tinción de Gram con bacterias, cultivo positivo o pH < 7,10 en el líquido pleural, siendo las efusiones para-neumónicas los controles. Resultados: Se analizaron 24 EP y 25 controles [promedio 2,9 años (rango: 8 meses - 14,3 años)], 78 por ciento de edad inferior a 5 años con diferencia entre los grupos EP y controles [1,6 vs 3,3 años, respectivamente (p = 0,01)]. El promedio global (días) de síntomas previo al ingreso en los EP fue 7 (rango: 2-21), siendo los más frecuentes fiebre (100 por ciento) y tos (96 por ciento). Se identificó algún microorganismo en 15/24 EP, Streptococcus pneumoniae fue el más frecuente (n: 9). En 48 niños, el manejo inicial fue conservador, requiriéndose cuatro rescates quirúrgicos luego del cuarto día. El promedio (días) de hospitalización fue significativamente superior en el grupo EP vs controles [15 (rango: 5-38) vs 9 (rango: 3-16) (p < 0,01)]. Requirieron drenaje pleural 83 por ciento del grupo EP y 36 por ciento de los controles (p = 0,002). No hubo diferencia en el número de días de empleo de oxígeno [6 vs 4,5 (p = 0,36)] o drenaje pleural [3 vs 2,5 (p = 0,29)]. No se registraron fallecidos. Conclusión: El EP en niños fue una condición respiratoria aguda que se asoció a estadías hospitalarias prolongadas, especialmente en los de menor edad, no requiriéndose, en la mayoría, una intervención quirúrgica de rescate.

Introduction: Pleural empyema (PE) is a serious complication of community-acquired pneumonia (CAP). Objectives: To describe the clinical profile of hospitalized patients with PE in the pediatric ward of the Catholic University Hospital between 2000-2005. Patients y methods: Retrospectively, all pediatric admission due to CAP and pleural effusion (86 children) were identified. In 59 (70 percent) children > 1 thoracocentesis were performed. We considered PE as the presence in the pleural effusion of pus, and/or a positive gram strain and/ or positive culture, and/or a pH < 7.10. Children with effusions not meeting any criteria were used as controls. Results: Twenty four PE and 25 controls were identified, with a global mean age of 2.9 years (range: 8 months to 14.3 years); 78 percent were < 5 years, with a significant difference between PE and controls [1.6 vs 3.3 years (p = 0.01)]. The mean duration of symptoms in PE patients before admission was 7 days (range: 2-21), and the most frequent symptoms were fever (100 percent) and cough (96 percent). In 15/24 cases a microorganism was identified being Streptococcus pneumoniae (n = 9) the most common. In 48 patients management was conservative and in 4 surgical procedures were required. The mean duration of hospitalization was significantly higher in the PE group vs controls group: 15 (range: 5-38) vs 9 days (range 3-16) (p < 0.01). A chest tube was inserted in 83 percent of children with EP compared with 36 percent in the control group (p = 0.002). There were no difference in number of days of oxygen use [6 vs 4.5 (p = 0.36)] or number of chest tubes per child [3 vs 2.5 (p = 0.29)]. No deaths were reported. Conclusion: PE in children represented an acute respiratory event associated with more prolonged hospitalization especially at younger ages; the majority of cases did not require surgical intervention.

Empiema pleural no tuberculoso: resultados en el Hospital Abel Santamaría Cuadrado (2000 a 2004) / Empiema non tuberculous pleural: results in the Hospital Abel Squared Santamaría (2000 at 2004)

El empiema pleural es una enfermedad infecciosa de incidencia moderada en nuestro medio, de diagnóstico fácil y de tratamiento exitoso cuando se logra descubrir a tiempo. Sin embargo, su persistencia determina la aparición de secuelas con impacto importante en la morbilidad y mortalidad del paciente. Realizamos un estudio retrospectivo, transversal y descriptivo en el que se hace una evaluación del tratamiento de los pacientes con empiema pleural no tuberculoso tratados en el Servicio de Cirugía General del Hospital Abel Santamaría Cuadrado entre enero de 2000 y diciembre de 2004. En una muestra de 34 pacientes fueron estudiadas las variables: edad, sexo, causa, gérmenes, tratamiento adoptado. Se observó que el grupo de edad más afectado fue el de 41 a 60 años (17 pacientes; 50 por ciento) y sobre todo, los pacientes del sexo masculino (82,4 por ciento), con una relación de 3,8:1. En el 61,8 por ciento de los pacientes se encontraron enfermedades pulmonares asociadas y los gérmenes patógenos más frecuentes fueron el Staphylococcus aureus (29,4 por ciento) y el Streptococcus pneumoniae(20,6 por ciento). El mayor porcentaje de los casos fue resuelto mediante cirugía torácica videoasistida (32,4 por ciento). La mayoría de los pacientes llegó a los servicios quirúrgicos en las fases avanzadas de la afección y se apreció un incremento de los cultivos mixtos de gérmenes patógenos. El tratamiento más agresivo de las colecciones purulentas fue el de mejor resultado(AU)

The empiema pleural is an infectious illness of incidence moderated in our means, of easy diagnosis and of successful treatment when it is possible to discover on time. However, their persistence determines the appearance of sequels with important impact in the morbilidad and the patient's mortality. We carry out a retrospective, traverse and descriptive study in which one makes an evaluation of the treatment of the patients with empiema pleural non tuberculous treaties in the Service of General Surgery of the Hospital Abel Squared Santamaría between January of 2000 and December of 2004. In a sample of 34 patients the variables were studied: age, sex, causes, germs, adopted treatment. It was observed that the affected age group went the one from 41 to 60 years (17 patients; 50 percent) and mainly, the patients of the masculine sex (82,4 percent), with a relationship of 3,8:1. By 61,8 percent of the patients they were associate lung illnesses and the germs more frequent patógenos were the Staphylococcus aureus (29,4 percent) and the Streptococcus pneumoniae(20,6 percent). The biggest percentage in the cases was resolved by means of surgery thoracic videoasistida (32,4 percent). most of the patients arrived to the surgical services in the advanced phases of the affection and an increment of the mixed cultivations of germs patógenos was appreciated. The most aggressive treatment in the collections purulentas was that of better result(AU)

Evaluation of 68 cases of chest injuries.

During the period of January, 2003 to December 2004 a descriptive cross-sectional study was done to evaluate the variations in clinical pictures of chest injury, rural and urban distribution, weapons used commonly and finally the result of existing treatment facilities in a general surgical unit of a tertiary level hospital. Total number of patient was 68. All patients of chest injury with or without extra-thoracic other injuries admitted in this period was included non-randomly. Diagnosis was based on history, clinical examination and relevant investigation like radiography and ultrasonography. Penetrating injury predominates over blunt injury in this study. Associated extra thoracic injury was present in a good number of cases. Most of the weapons were made locally and were used in household purposes. Homicidal injury predominates over accidental and incidence is more in rural than in urban areas. Most of the cases were treated by general supportive measures with or without intercostal tube thoracostomy. The outcome of treatment was satisfactory. Only one patient developed empyema thoracis and two patients died.

Outcome of parapneumonic empyema.

OBJECTIVE: Empyema thoracis is known to have variable age group affection, causative agents and controversy regarding primary mode of management. To look into current demography, bacteriology and treatment outcome. METHODS: Prospective study made on admitted cases of parapneumonic empyema from July 2001 to June 2003. All cases were treated with chest tube drainage, parenteral antibiotics or thoracotomy in multiloculated or non-improving cases. RESULTS: 0.8% (C.I. 0.6-1.0) of total pediatric admission had empyema, who were more likely to be females (P< 0.05), under-weight (P< 0.05) compared to children admitted for other reasons. Staphylococcus aureus is still the commonest isolate (13.2%). All cases received antibiotics prior to hospitalisation. Majority of cases (90.5%) could be successfully managed with antibiotics and chest tube drainage alone. 9.4% cases needed thoracotomy. 5.8% cases needed salvage thoracotomy following non-improvement with chest tube drainage. Fever remission time and duration of hospital stay were comparable in both groups. Thoracotomy cases required antibiotics for shorter period (P=0.04). Two cases died due to reasons other than mode of management. Radiological and lung function recovery was excellent in most of the cases. CONCLUSION: Chest tube drainage is a safe, efficacious primary method of empyema management.

Retrospective study of empyema cases in National Pediatric Hospital, Cambodia.

Majority of empyema cases admitted into the National Pediatric Hospital (NPH), Cambodia were of bacterial origin (EB: 95%), the rest were caused by tuberculosis bacilli (ETB: 5%). The morbidity of overall empyema, empyema of bacterial origin and empyema of TB origin between boys and girls was the same, even though boys were more likely to be exposed than girls. The mean age of patients with ETB was significantly greater than those of EB, 84.7 +/- 46 months versus 52.5 +/- 37 months. Since NPH is located in Phnom Penh, most of our cases were from Kandal, Phnom Penh, and provinces nearby. On average all of the patients stayed in the hospital for 23.26 +/- 14.9 days (rank 1-91 days), and the mean duration of hospitalization of the ETB patients was significantly longer than that of EB patients, 32 +/- 19 days versus 22 +/- 14 days respectirely. The yearly incidence of empyema cases in 1990-1993 had the trend of slightly increased frequency during March to May. The overall EB case fatality rate was 3%, contributed to by delayed referral of cases.

Protective and risk factors for acute respiratory infections in hospitalized urban Malaysian children: a case control study.

We performed a case control study to examine protective and risk factors for acute respiratory infections (ARI) in hospitalized children in Kuala Lumpur. Consecutive children between the ages of one month and five years hospitalized for pneumonia (n = 143), acute bronchiolitis (n = 92), acute laryngotracheobronchitis (n = 32) and empyema (n = 4) were included as cases and were compared with 322 children hospitalized during the same 24 hour period for non-respiratory causes. Potential risk and protective factors were initially analysed by univariate analysis. Logistic regression analysis confirmed that several home environmental factors were significantly associated with ARI. The presence of a coughing sibling (OR = 3.76, 95%CI 2.09, 6.77), a household with more than five members (OR = 1.52, 95%CI 1.03, 2.19) and sleeping with three other persons (OR = 1.45, 95%CI 1.00, 2.08) were independent risk factors. Significant host factors were history of allergy (OR = 2.50, 95%CI 1.74, 3.61) and ethnicity (Malay race) (OR = 2.07 95%CI, 1.27, 3.37). Breast feeding for at least one month was confirmed as an independent protective factor (OR = 0.58, 95%CI 0.38, 0.86). However, the study was not able to demonstrate that domestic air pollution had an adverse effect. This study provides further evidence that home environmental factors, particularly those associated with crowding, may predispose to ARI and that breast feeding is an important protective factor.