Parapneumonic empyema in children: a scoping review of the literature.

Community-acquired pneumonia can lead to a serious complication called empyema, which refers to pus within the pleural space. While it poses a significant threat to morbidity, particularly in children, it is fortunately not associated with high mortality rates. However, determining the best course of management for children, including decisions regarding antibiotic selection, administration methods, and treatment duration, remains a topic of ongoing debate. This scoping review aims to map the existing literature on empyema in children, including types of studies, microbiology, therapies (both antimicrobial and surgical) and patient outcomes. We systematically searched PubMed and SCOPUS using the terms "pediatric" (encompassing children aged 0 to 18 years) and "pleural empyema" to identify all relevant studies published since 2000. This search adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA ScR) checklist.A total of 127 studies was included. Overall, 15 attempted to compare medical treatments (alone or in combination with pleural drainage or fibrinolysis) with more invasive surgical approaches, and six studies compared diverse surgical interventions. However, the diversity of study designs makes it difficult to derive firm conclusions on the optimal approach to pediatric empyema. The heterogeneity in inclusion criteria, pharmacological/surgical approaches and settings limit the ability to draw definitive conclusions. Overall, 78 out of 10,896 children (0.7%) included in the review died, with mortality being higher in Asia and Africa. Our scoping review highlights important gaps regarding several aspects of empyema in children, including specific serotypes of the most common bacteria involved in the etiology, the optimal pharmacological and surgical approach, and the potential benefits of newer antibiotics with optimal lung penetration. New trials, designed on a multi-country level a higher number of patients and more rigorous inclusion criteria and designs, should be urgently funded.

Management of pediatric pleural empyema: a national survey of pediatric surgeons in Brazil.

OBJECTIVE: To identify how pediatric surgeons manage children with pneumonia and parapneumonic pleural effusion in Brazil. METHODS: An online cross-sectional survey with 27 questions was applied to pediatric surgeons in Brazil through the Brazilian Association of Pediatric Surgery. The questionnaire had questions about type of treatment, exams, hospital structure, and epidemiological data. RESULTS: A total of 131 respondents completed the questionnaire. The mean age of respondents was 44 ± 11 years, and more than half (51%) had been practicing pediatric surgery for more than 10 years. The majority of respondents (33.6%) reported performing chest drainage and fibrinolysis when facing a case of fibrinopurulent parapneumonic pleural effusion. A preference for video-assisted thoracic surgery instead of chest drainage plus fibrinolysis was noted only in the Northeast region. CONCLUSIONS: Chest drainage plus fibrinolysis was the treatment adopted by most of the respondents in this Brazilian sample. There was a preference for large drains; in contrast, smaller drains were preferred by those who perform chest drainage plus fibrinolysis. Respondents would rather change treatment when facing treatment failure or in critically ill children.

Benefit of intrapleural fibrinolytic therapy in the treatment of complicated parapneumonic effusion and empyema.

Our study aimed to assess the benefit of intrapleural fibrinolysis before resorting to surgery to treat complicated parapneumonic effusion and empyema. We conducted a retrospective and descriptive study, including all patients hospitalized in the intensive care unit (ICU) of the Abderhaman Mami hospital, Tunisia for empyema treated with instillation of intrapleural fibrinolytic therapy between the 1st January 2000 and 31st December 2016. In all patients, empyema was diagnosed on clinical features, imaging findings (chest X-ray, thoracic echography and/or computed tomography (CT), and microbiological data. The fibrinolytic agent used was streptokinase. The efficiency of intrapleural fibrinolytic therapy was judged on clinical and paraclinical results. Among 103 cases of complicated parapneumonic effusion and empyema, 34 patients were included. The mean age was 34 years [15-81] with a male predominance (sex ratio at 2.77). Median APACH II score was 9. Fifty (50%) of the patients (n=17) had no past medical history; addictive behavior was described in 17 patients (50%). All patients were admitted for acute respiratory failure and one patient for septic shock. Pleural effusion was bilateral in 7 patients. Bacteria isolated were Streptococcus pneumonia (6 cases), Staphylococcus aureus (3 cases, including one which methicillin-resistant), Staphylococcus epidermidis (1 case), anaerobes (5 cases), and Klebsiella pneumoniae (1 case). First-line antimicrobial drug therapy was amoxicillin-clavulanate in 20 patients. A chest drain was placed in all cases in the first 38 hours of ICU admission. The median number of fibrinolysis sessions was 4 [2-9] and the median term of drainage was 7 days [3-16]. No side effects were observed. Video-assisted thoracoscopic surgery was proposed in 5 patients. The median length of hospitalization stay was 15 days [6-31]. One patient died due to multi-organ failure.

Therapy of parapneumonic empyema in children: a protocol for a scoping review of the literature.

Background: Empyema (the presence of pus in the pleural space) is a severe complication of community-acquired pneumonia and significant cause of morbidity, but, fortunately, not mortality in children. Between 0.6 and 2% of pneumonias are complicated by empyema and the three main pathogens involved are Streptococcus pneumoniae, Staphylococcus aureus and group A Streptococcus 1,2,3,4. Optimal management in children, especially the choice of antibiotics, method of administration and duration of therapy, pleural dranage or surgery, are still a matter of debate and currently, lack of strong specific recommendations. This paper displays the study protocol for a scoping review that aims to summarize the available literature on the microbiological epidemiology, the medical and surgical treatment options, and the outcomes of pleural empyema in pediatric population. Methods: Comprehensive research combining the terms pediatric (children aged 0 to 18 years) and pleural empyema will be performed on PubMed and SCOPUS to identify all eligible studies. At first, two reviewers will screen the abstract and then their full text to determine the articles that meet the inclusion criteria. This work will be carried out independently, everyone on a different Excel spreadsheet and each researcher will be blinded to the decision of the other researcher. When the process is completed, in case of discordance, any disagreement will be identified and resolved through discussion or with help of a third author. Dissemination: The findings of this review will be published in a peer-reviewed journal.

Complicated pneumonia with empyema caused by streptococcus anginosus in a child / Complicated pneumonia with empyema caused by streptococcus anginosus in a child

ABSTRACT Objective: To highlight the pathogenicity of Streptococcus anginosus, which is rare in pediatric patients, but can cause severe infections that are known to have a better outcome when treated early with interventional procedures and prolonged antibiotic therapy. Case description: The patient is a 6-year-old boy with global developmental delay, examined in the emergency room due to fever and respiratory distress. The physical examination and diagnostic workout revealed complicated pneumonia with empyema of the left hemithorax; he started antibiotic therapy and underwent thoracic drainage. Pleural fluid cultures grew Streptococcus anginosus. On day 11, the child had a clinical deterioration with recurrence of fever, hypoxia, and respiratory distress. At this point, considering the causative agent, he was submitted to video-assisted thoracoscopic decortication, with good progress thereafter. Comments: Streptococcus anginosus is a commensal bacterium of the human oral cavity capable of causing severe systemic infections. Although reports of complicated thoracic infections with this agent are rare in the pediatric population, they have been increasing in adults. Streptococcus anginosus has a high capacity to form abscess and empyema, requiring different therapeutic approaches when compared to complicated pneumonia caused by other agents.

RESUMO Objetivo: Alertar para a patogenicidade do Streptococcus anginosus que, apesar de raro em pediatria, pode causar infeções graves que necessitam de tratamento invasivo e antibioterapia de longo curso para obter um melhor prognóstico. Descrição do caso: Criança de seis anos, com atraso do desenvolvimento psicomotor, avaliado no serviço de urgência por febre e dificuldade respiratória. O exame físico, juntamente com os exames complementares, revelou uma pneumonia complicada com empiema no hemitórax esquerdo, tendo iniciado antibioterapia e sido submetido à drenagem do líquido pleural. Foi identificado Streptococcus anginosus nesse líquido. No 11º dia de doença, a criança agravou o seu estado clínico, com recidiva da febre, hipoxemia e dificuldade respiratória. Considerando-se o microrganismo identificado, o paciente foi submetido à decorticação pulmonar por videotoracoscopia, com boa evolução clínica posterior. Comentários: Streptococcus anginosus é uma bactéria comensal da cavidade oral humana, que pode causar infecções sistêmicas graves. Apesar de serem raros os casos descritos em pediatria, têm sido cada vez mais descritas infecções torácicas complicadas em adultos. Esse microrganismo também tem a capacidade de formar abcessos e empiemas, que precisam de intervenções terapêuticas diferentes, quando comparados a pneumonias complicadas causadas por outros agentes.

Fístula biliopleural tras colecistecomía laparoscópica en un paciente nonagenario / Biliopleural fistula after laparoscopic cholecystectomy in a nonagenarian patient

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Uso de estreptoquinasa recombinante intrapleural en una mujer embarazada con empiema pleural / Use of intrapleural recombinant streptokinase in a pregnant woman with pleural empyema

Fundamento: la neumonía complica el 0,78-2,7 por 1 000 embarazos al estar en riesgo la madre y el feto. El empiema como complicación de una neumonía en una paciente embarazada agrega un alto índice de morbimortalidad para la madre y el feto si no se actúa de forma rápida. Objetivo: describir el caso de una mujer de 33 semanas de embarazo, la cual desarrolló un empiema pleural producto de una complicación de una neumonía adquirida en la comunidad tratada con fibrinólisis intrapleural. Caso clínico: paciente gestada de 33 semanas, asmática ingresada en el servicio de terapia intensiva del Hospital Universitario Manuel Ascunce Domenech con el diagnóstico de neumonía grave adquirida en la comunidad complicada con derrame paraneumónico el cual evolucionó hacia el empiema. El mismo fue tratado con tubo de toracostomía y terapia fibrinolítica, con buena evolución clínica y radiológica. Conclusiones: la estreptoquinasa recombinante se puede utilizar de manera segura y efectiva para el manejo del empiema pleural, como agente fibrinolítico intrapleural, durante el embarazo(AU)

Background: pneumonia complicates 0,78-2,7 per 1 000 pregnancies placing the mother and the fetus at risk. Empyema as a complication of pneumonia in a pregnant patient adds a high rate of morbidity and mortality to the mother and the fetus if one does not act quickly. Objective: to present the case of a pregnant woman of 33 weeks who developed a pleural empyema resulting from acquired pneumonia. Clinical case: 33-week gestated patient, asthmatic admitted to the intensive care unit of the University Hospital Manuel Ascunce Domenech with the diagnosis of severe pneumonia acquired in the community complicated with para-pneumonic effusion, which evolved into empyema. It was treated with a thoracotomy tube and fibrinolytic therapy, with good clinical and radiological evolution. Conclusions: Recombinant streptokinase can be used safely and effectively for the management of PE, as an intrapleural fibrinolytic agent, during pregnancy(AU)

Parapneumonic pleural effusion: reality and strategies in an Amazon university hospital / Derrame pleural parapneumônico: realidade e estratégias em um hospital universitário na Amazônia

ABSTRACT Objective: to define the profile and analyze the postoperative evolution of children with parapneumonic pleural effusion (PPE), and to evaluate strategies used in the presence of diagnostic and therapeutic limitations, emphasizing the open thoracic drainage (OTD) . Methods: we conducted a cross-sectional, prospective, analytical study in which we followed children admitted in an Amazon university hospital with surgically addressed PPE, from October 2010 to October 2011. Results: we studied 46 patients, most children under three years of age (74%), with no gender predominance. A significant portion of the sample (28%) had inappropriate body mass index. We found short stature in five patients (11%), which tended, in general, to a worst postoperative outcome when compared with children of normal height (p=0.039). The average duration of symptoms till admission was 16.9 days. Empyema was a common diagnosis in the first surgery (47.8%), and its bearers had longer duration of chest tube drainage (p=0.015). Most children (80.4%) were operated only once. The mean length of hospital stay was 25.9 days. Thoracic drainage (water-sealed) was the most common procedure (85%), with conversion to OTD in 24% of the sample, thoracotomy being rare (4%). There were no deaths. Conclusion: the studied individuals often had advanced disease and nutritional disorders, affecting outcome. OTD remains a valid option for specific situations, and further studies are needed for confirmation.

RESUMO Objetivo: definir o perfil e analisar a evolução pós-operatória de crianças com derrame pleural parapneumônico (DPP), bem como, avaliar estratégias utilizadas na vigência de limitações diagnóstico-terapêuticas, enfatizando a drenagem torácica aberta (DTA) . Métodos: estudo transversal, prospectivo, analítico, no qual foram acompanhadas as crianças admitidas em um hospital universitário da Amazônia com o diagnóstico de DPP abordado cirurgicamente, no período entre outubro de 2010 a outubro de 2011. Resultados: foram estudados 46 pacientes, a maioria menor de três anos de idade (74%), sem predominância de sexo. Significativa parcela da amostra (28%) possuía índice de massa corpórea inadequado. Baixa estatura foi encontrada em cinco pacientes (11%), que tenderam, em geral, à pior evolução pós-operatória, quando comparados com as crianças de estatura normal (p=0,039). A duração média dos sintomas à admissão foi 16,9 dias. O empiema foi diagnóstico comum na primeira intervenção cirúrgica (47,8%), e seus portadores apresentaram maior duração da drenagem torácica (p=0,015). A maioria das crianças (80,4%) foi operada apenas uma vez. A média de dias de internação hospitalar foi 25,9 dias. A drenagem torácica fechada em selo d'água foi a cirurgia mais realizada (85%), precisando ser convertida em DTA em 24% da amostra e toracotomias foram raras (4%). Não houve óbitos. Conclusão: os indivíduos estudados possuíam frequentemente doença avançada e distúrbios nutricionais, repercutindo na evolução clínica. A DTA permanece como uma opção válida para situações específicas, e novos estudos ainda são necessários para confirmação.

Empiema bilateral secundario a una perforación esofágica espontánea / Bilateral Empyema Due to Spontaneous Esophageal Perforation

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Derrame paraneumónico complicado: análisis de 2 cohortes consecutivas tratadas con distinto criterio / Complicated pleural infection: Analysis of 2 consecutive cohorts managed with a different policy

INTRODUCCIÓN: El tratamiento del derrame pleural paraneumónico complicado (DPC) es controvertido. Las principales guías recomiendan el drenaje, pero con el menor nivel de evidencia. Recientes trabajos han observado buenos resultados solo con antibióticos. Hemos comparado retrospectivamente nuestros resultados en 2 cohortes consecutivas de pacientes tratados con distinto criterio: en el grupo 1 (2005-2009, actitud intervencionista) el drenaje se decidía en función de las características del líquido pleural, de acuerdo con las principales guías; en el grupo 2 (2010-2013, actitud conservadora) el drenaje se decidía en función de la evolución clínica del paciente. MÉTODOS: Se revisaron las historias clínicas de los pacientes tratados por DPC entre 2005 y 2013. Las principales variables analizadas fueron la proporción de pacientes drenados y la duración de la estancia hospitalaria. RESULTADOS: Se analizó a 109 pacientes (64 grupo 1 y 45 grupo 2). Se colocó un tubo de drenaje en el 83% de los pacientes del grupo 1 y en el 47% de los del grupo 2 (p < 0,001). La duración media de la estancia hospitalaria fue de 11,4 días en el grupo 1 y 12,3 días en el grupo 2 (p = 0,45). No se observaron otras diferencias destacables. CONCLUSIÓN: Nuestros resultados coinciden con los de otros estudios recientes que han observado una buena evolución en niños tratados solo con antibióticos y cuestionan la necesidad del drenaje en muchos de los niños que presentan un DPC. Son necesarios ensayos clínicos para identificar las circunstancias en las que se puede obtener un beneficio del drenaje en el DPC

INTRODUCTION: The treatment of complicated pleural infection (CPI) is controversial. Clinical guidelines recommend drainage, but with the lowest grade of evidence. Recent reports have observed good outcomes with antibiotics alone. We retrospectively compared the outcomes in two consecutive cohorts treated with different policies: the first treated according to pleural fluid charactersitics (2005-2009, interventional-prone, group 1) and the second according to clinical assessment (2010-2013, conservative-prone, group 2). METHODS: The clinical records of all children treated for CPI in our hospital between 2005 and 2013 were thoroughly reviewed. Primary outcomes were the proportion of children drained and the length of hospital stay (LHS). RESULTS: One hundred and nine patients (64 group 1 and 45 group 2) were analyzed. A chest tube was placed in 83% of patients in group 1 and 47% in group 2 (P<0.001). The mean LHS was 11.4 days for patients in group 1 and 12.3 for patients in group 2 (P=0.45); no differences were observed in other outcomes. CONCLUSION: Our results add to few recent observations reporting good outcomes in many children treated with antibiotics alone and challenge the need to drain most children with CPI. Clinical trials are now needed to identify when a drainage procedure would be useful

Tratamiento quirúrgico del empiema pleural / Surgical treatment of pleural empyema

Empyema in children occurs mainly in association with an underlying pneumonia. The causative microorganisms have changed with the introduction of vaccines; Streptococcus pneumoniae remains the predominant organism. Symptoms and physical examination can not differentiate between pneumonia with or without pleural effusion, when this one is of small amount. So the chest radiograph is essential. Failure to respond to 48 hours of pneumonia treatment should suggest pleural empiema. If the chest radiograph shows parapneumonic pleural effusion, ultrasound should be performed to confirm the presence of fluid in the pleural space and evaluate the first loculations and wall septations. If liquid is clear and sufficient, pleurocentesis for cytochemical and microbiological analysis must be made. If pleural effusion reproduces or has septations, a pleuropulmonary debridement with videothoracoscopy must be done to cure the child in less time and with less consequences.

El empiema en pediatría se produce principalmente en asociación con una neumonía subyacente. Los organismos causantes han cambiado con la introducción de vacunas, siendo el Streptococcus pneumoniae el microorganismo predominante. Tanto los síntomas como el examen físico no permiten diferenciar entre una neumonía con o sin derrame pleural, cuando éste es de poca cuantía, por lo que la radiografía de tórax es fundamental. La falta de respuesta a 48 horas de terapia de la neumonía debe hacer sospechar empiema. Si la radiografía muestra derrame debe realizarse una ecografía torácica para confirmar la presencia de líquido en el espacio pleural y evaluar las primeras loculaciones y tabiques. Si el líquido está libre y en cantidad suficiente debe realizar una pleurocentesis para análisis citoquímico y microbiológico. Si el derrame se reproduce o está tabicado se debe realizar una debridamiento pleuropulmonar videotoracoscópico que mejora al niño en menor tiempo y con menos secuelas.

Neumonía complicada en pediatría, su manejo: un reto / Treatment of empyema thoracis and necrotizing pnueumonia in children

Complicated pneumonia with pleural effusion or empyema is a condition that its incidence has been increasing in recent years. Its early diagnosis and timely management reduce costs and shorten hospital stays for patients. The optimized diagnostic aids treatments. In recent years the intervention and fibrinolytic substances as VATS surgery have opened a positive outlook in handling controversies exist yet at the time of application. This article reviews these aspects.

La neumonía complicada con derrame pleural o empiema es una patología que ha ido incrementando su incidencia en los últimos años. Su diagnóstico temprano y su manejo oportuno disminuyen los costos y acortan las estancias hospitalarias de los pacientes. Las ayudas diagnósticas optimizan los tratamientos. En los últimos años la intervención con sustancias fibrinolíticas y las intervenciones quirúrgicas como la videotoracoscopia han abierto un panorama positivo en el manejo sin embargo, existen controversias en el momento de su aplicación. Este artículo hace una revisión de estos aspectos.

Uso de toracotomía mínima ampliada y lavado de cavidad pleural en el tratamiento del empiema / Using minimal thoracotomy enlarged cavity lavage in treating pleural empyema

El empiema se define como la acumulación patológica de líquido en el espacio pleural y es el resultado de un desequilibrio entre la formación y la reabsorción de líquido a este nivel, causado por neumonías. Evaluar el uso de la toracotomía mínima ampliada y lavado de la cavidad pleural en el tratamiento del empiema, en los pacientes que asistieron al Hospital Universitario de Caracas entre enero de 2007 y Noviembre de 2008. 20 pacientes (12 varones, 8 hembras), con edades comprendidas entre 2 y 9 años fueron tratados por presentar Neumonía complicada con Empiema. La Toracotomía mínima convencional fue realizada en 11 pacientes (5 varones, 6 hembras) y la Toracotomía mínima ampliada y lavado de cavidad pleural fue realizada en 9 pacientes (7 varones, 2 hembras). El tiempo promedio de hospitalización fue de 23,3 días en el grupo control y 23,9 días en el grupo muestra. El tiempo promedio del postoperatorio en el grupo control fue de 7,1 días y 5,9 días en el grupo de casos. Las complicaciones fueron tres en el grupo control, dos requirieron Toracotomía más decorticación, y segmentectomía del lóbulo medio adicional en uno; el grupo muestra no ameritó la realización de procedimiento quirúrgico adicional. El uso de la toracotomía mínima ampliada mas lavado de la cavidad pleural en los pacientes con empiema en etapa temprana; es una opción accesible y útil en aquellos centros en los que no se cuenta con toracoscopio para la realización de la misma, y por ende no requiere realizar decorticaciones o segmentectomias

Empyema is defined as abnormal accumulation of fluid in the pleural space and is the result of an imbalance between formation and resorption of fluid at this level, caused by pneumonia. Our goal is to evaluate the use of extended minimal thoracotomy and pleural lavage in the treatment of empyema in patients attending the Hospital Universitario de Caracas. In total 20 patients (12 males and 8 females), aged between 2 and 9 years were treated for pneumonia complicated with empyema. The conventional minimum Thoracotomy was performed in 11 patients (5 males and 6 females) and the expanded minimum Thoracotomy and pleural cavity lavage was performed in 9 patients (7 males and 2 females). The average length of hospital stay was 23.2 days in the control group and 23. 8 days in the sample group shows no difference from a statistical standpoint. The average time post-procedure hospitalization in the control group was 7 days and 5.8 days in group shows no significant differences. Complications were 3 in the control group, requiring more Thoracotomy and decortication in two cases and middle lobe segmentectomy in another, while in the sample group does not warrant the performance of additional surgical procedure, statistically significant differences exist. We conclude that the use of minimal thoracotomy extended more of the pleural lavage in patients with early-stage empyema, is a useful and accessible option, since it may avoid making decortications or segmentectomy.

Empiema pleural causado por tricomonas: caso clínico / Pleural empyema caused by trichomonas: case report

Pleural empyema formation is one of the potential complications of lower respiratory tract infections and it is characterized by bacterial organisms seen on gram stain or the aspiration of pus on thoracentesis. Very rarely empyema can be caused by trichomonas species, of which Trichomonas Tenax appears to be the most common cause. In this article we report the case of a 51-year-old man who developed a pleural empyema caused by trichomonas, and review the available literature of this rare infection of unknown incidence and uncertain pathogenetic significance. Our patient was treated with metronidazole, however complete cure was not achieved and pulmonary decortication was necessary for the successful outcome. As far as we know, this is the first case of pleural empyema caused by trichomonas reported in Chile.

La formación de un empiema pleural es una de las potenciales complicaciones de las infecciones de la vía aérea inferior, y se caracteriza por la observación de bacterias en la tinción de Gram, o la aspiración de pus en la toracocentesis. Muy infrecuentemente el empiema puede ser causado por alguna de las especies de tricomonas, de las cuales Trichomonas Tenax parece ser la causa más común. En este artículo, reportamos el caso de un hombre de 51 años que desarrolló un empiema pleural causado por tricomonas, y revisamos la literatura disponible de esta rara infección, de incidencia desconocida, y significancia patogénica incierta. Nuestro paciente fue tratado con metronidazol, observándose sólo una respuesta parcial, necesitándose decorticación pulmonar para una recuperación completa. Hasta donde sabemos, este es el primer caso de empiema pleural causado por tricomonas reportado en Chile.

Toracoscopia en niños con empiema pleural en fase II. ¿Lavado y desbridamiento de tabiques de fibrina o decorticación? / Thorascoscopy in children with pleural empyema in 2nd stage, breaking and washing fibrinous loculations or decortication?

Introducción: Ante el aumento de incidencia de derrames pleurales paraneumónicos complicados en niños, ha aumentado considerablemente el número de toracoscopias realizadas, ya sea para el lavado y el desbridamiento de los tabiques de fibrina para liberar el líquido acumulado, o completando la intervención con decorticación completa de la fibrina aún no organizada adherida a la pared pulmonar. Material y métodos: Estudiamos una muestra de 31 niños tratados toracoscópicamente por un derrame pleural complicado en fase II. Estudiamos diversas variables: edad, tiempo de clínica y de tratamiento antibiótico preoperatorios, composición del líquido pleural, germen, opción quirúrgica, tiempo operatorio, días con drenaje pleural mayor de 20 mL/día o fiebre y complicaciones. Resultados: De 31 toracoscopias, el 52% son descorticaciones pulmonares y el 48% desbridamientos y lavados. Mediante el test de la t de Student comprobamos que el tiempo de drenaje pleural en los pacientes con desbridamiento simple es estadísticamente superior, al igual que los días de fiebre (sin diferencias significativas), y se requieren más fibrinolíticos y reintervención. No observamos una mayor incidencia de fuga aérea en la decorticación, aunque sí de íleo paralítico posquirúrgico. Conclusiones: La decorticación pulmonar en los derrames pleurales complicados en fase II conlleva un menor tiempo de drenaje torácico y clínica febril. En manos entrenadas no aumenta el tiempo operatorio ni el número de complicaciones graves (AU)

Introduction: Before the increase of incidence of complicated pleural parapneumonic effusion in children, has increased the number of Video Assisted Thoracoscopy (VATS) considerably. Whether it is for the washing or breaking of the nasal bone fibrin to liberate the accumulated liquid, or complete the intervention with complete decortication of a non-organized fibrin wall attached to the lung. Material and methods: We study a sample of 31 children whounder went VATS for complicated pleural effusion in 2nd stage. We study: age, clinical time and pre-surgical symptoms and antibiotics, composition of the pleural liquid, infectious agent, surgical option, operative time, days with fever and pleural drainage more than 20 cc/day or fever and complications. Results: From 31 VATS, 52 % were pulmonary decortications and 48 % debridement and wash. Using the t-student we get statistically significative difference in time of pleural drainage, longer in patients with simple debridement, as in days with fever, not being this difference significant. There is more need of fibrinolysis and reintervention in this group. We do not see more incidence of air leak in the decortication group, but there is more post surgery paralytic ileus. Conclusions: Lung decortication in pleural complicated effusions2nd stage entails less time with thoracic drainage and fever. In trained hands it does not increase neither the operative time nor the number of serious complications (AU)

Eficacia y seguridad de la instilación precoz de estreptoquinasa intrapleural en el tratamiento del empiema paraneumónico complicado en niños / Efficacy and safety of early intrapleural instillation of streptokinase in the treatment of complicated parapneumonic empyema in children

En enero de 2005, en el Hospital Pediátrico del Centro Hospitalario Pereira Rossell se implementó un protocolo de instilación de estreptoquinasa (STK) intrapleural como alternativa al tratamiento quirúrgico del empiema complicado. La STK intrapleural administrada en los primeros ocho d¡as de colocado el drenaje disminuy la duracion del drenaje de tórax, la necesidad de toracotom¡a y la estad¡a hospitalaria. Objetivo.: describir los resultados de la instilación intrapleural precoz de STK en niños hospitalizados con empiema paraneumónico complicado, y compararlos con los resultados obtenidos tras la instilación en los primeros ocho d¡as de colocado el drenaje de tórax. Material y método: se incluyeron los niños con empiema paraneumónico complicado hospitalizados entre el 1º de abril de 2005 y el 30 de set. de 2007. Se dividieron en dos cohortes. Histórica: niños hospitalizados entre el 1º de abril de 2005 y el 1º de agosto de 2006, en los que el diagnóstico de empiema complicado se hizo según criterios cl¡nicos y ecográficos, que recibieron STK intrapleural en los primeros ocho d¡as luego de colocado el drenaje de tórax. Prospectiva: niños hospitalizados entre el 1º de marzo y el 30 de setiembre de 2007 diagnosticados y tratados según el nuevo protocolo. Se comparó la evolución mediante las siguientes variables: duración del drenaje de tórax, complicaciones, necesidad de toracotom¡a, estad¡a hospitalaria y muerte. Resultados: ambos grupos fueron comparables. La duración de la estad¡a hospitalaria y deldrenaje de tórax fueron menores en los niños tratados con STK intrapleural en forma precoz (p<0,05). Requirieron toracotom¡a dos niños, uno en cada cohorte. El número y tipo de complicaciones fue similar en ambos grupos. Ninguno de los pacientes incluidos en el estudio falleció. Conclusiones: la instilación intrapleural precoz de STK constituye una alternativa terapéutica para el tratamiento de niños con empiema paraneumónico complicado.

In January 2005, a protocol was implemented at the Pereira Rossell Hopital Centre, for the administration of intrapleural streptokinase (STK) as an alternative to surgical treatment of complicated empyema. Intrapleural STK, when administered in the first eight days subsequent to the placing of the drainage diminished the duration of thoracic drainage, the need for thoracotomy and a prolonged stay in hospital. Objective: to describe results of early intrapleural instillation of streptokinase in children hospitalized with complicated parapneumonic empyema, and to compare them to the results obtained after instillation during the first eight days subsequent to the placement of thoracic drainage. Method: children with complicated parapneumonic empyema that were hospitalized from April 1, 2005 through September 30, 2007 were included in the study. They were divided into two cohorts. Historical: children hospitalized from April 1, 2005 and August 1, 2006, when diagnosis of complicated empyema was made according to clinical and ecographic criteria, who received intrapleural STK during the first eight days subsequent to the placement of thoracic drainage. Prospective: children hospitalized from March 1, 2007 and September 30, 2007, diagnosed and treated according to the new protocol. Evolution was compared through the following variables: duration of thoracic drainage, complications, need for thoracotomy, duration of hospital stay and death. Results: both groups were comparable. Duration of hospital stay and thoracic drainage were lower in children treated with early intrapleural STK (p<0,05). Two children required thoracotomy, one in each cohort group. The number and type of complications was similar in both groups. None of the patients included in the study died. Conclusions: early intrapleural instillation of STK constitutes a therapeutic alternative in the treatment of children with complicated parapneumonic empyema.

Em janeiro de 2005, no Hospital Pediátrico do Centro Hospitalar Pereira Rossell foi implementado um protocolo de instilação de estreptoquinase (STK) intrapleural como alternativa ao tratamento cirúrgico do empiema complicado. A STK intrapleural administrada nos primeiros oito dias após a colocação do dreno reduziu a duração da drenagem de tórax, a necessidade de toracotomia e a permanência no hospital. Objetivo: descrever os resultados da instilação intrapleural precoce de STK em crianças hospitalizadas com empiema parapneumônico complicado, e fazer uma comparação com os resultados obtidos após a instilação nos primeiros oito dias após o começo da drenagem de tórax. Material e método: foram inclu¡das crianças com empiema parapneumônico complicado internadas no per¡odo 1º de abril de 2005 - 30 de setembro de 2007. Foram divididas em duas coortes. Histórico: crianças internadas no per¡odo 1º de abril de 2005 - 1º de agosto de 2006, com diagnóstico de empiema complicado feito por critérios clínicos e ecográficos, que receberam STK intrapleural nos primeiros oito dias após a colocação da drenagem de tórax. Prospectiva: crianças internadas no per¡odo 1º de março - 30 de setembro de 2007 diagnosticadas e tratadas de acordo como o novo protocolo. A comparação da evolução foi feita empregando as seguintes variáveis: duração da drenagem de tórax, complicações, necessidade de toracotomia, permanência no hospital e morte. Resultados: os resultados de ambos grupos eram comparáveis. A duração da internação e da drenagem de tórax foi menor nas crianças tratadas com STK intrapleural precoce (p<0,05). Em duas crianças foi necessário realizar toracotomia, uma em cada coorte. O número e tipo de complicações foi similar em ambos grupos. Nenhum paciente faleceu. Conclusões: a instilação intrapleural precoce de STK‚ uma alternativa terapêutica para o tratamento de crianças com empiema parapneumônico complicado.