Management of late-stage parapneumonic empyema

Purpose: Despite the reported value of early video-assisted thoracoscopic surgery (VATS) for empyema, many children are still referred to the surgeon late in the disease process. The authors wished to determine the optimal management strategy for this group of children. Methods: Medical records of all children (n = 70) from 1990 to 2000 with late-presenting empyema (stage II or III) were reviewed. Patients were grouped as (G1) successful management with chest tube (CT), (G2) surgery after initial CT, (G3) thoracentesis followed by surgery, and (G4) surgery alone. Results: There were no significant differences with respect to age, gender, pleural cultures or fluid analysis. Fifty-one (73%) patients required surgical intervention. Treatment using CT (G1, G2) or thoracentesis (G3) was associated with prolonged length of stay (LOS) when compared with surgery alone (G4; 12 v 8 days). For G2, G3, and G4, rapid clinical improvement and early discharge (6 days) was seen after surgery. For all surgery groups (G2, G3, G4), video-assisted thoracoscopic surgery (n = 19) was associated with a longer postoperative fever (4 v 2 days; P [lt ] .05), but a shorter total LOS (12 v 15 days; P [lt ] .05) when compared with open decortication (n = 32). Conclusions: Over 70% of children with late presenting empyema required surgery, including more than half of the children who received initial chest tube drainage. Delay in surgery was associated with more procedures, more radiographs, and an increased LOS. Despite later intervention, patients undergoing surgery as an initial approach had the shortest length of stay. Early surgical intervention is indicated for most children referred with established empyema.     

Management of postoperative pain in infants and children

The management of postoperative pain in infants and children is a multidisciplinary challenge. It is achieved successfully with careful assessment and the use of multimodal analgesia.     

Management of severe hydroureteronephrosis in infants and young children.

Loop cutaneous ureterostomy and cutaneous pyelostomy are safe and effective means of temporary diversion with few complications. Reconstructive operation is delayed until the upper urinary tract has shown maximum improvement in form and function and the patient's tolerance for elective operation has improved. Results of reconstruction may be less than optimal and serious complications may arise. However the staged approach has been shown to be safe and effective. Experience with 29 patients has led to a reassessment of the approach to patients with posterior urethral values and a stronger inclination to primary valve resection, thus avoiding many of the reconstructive procedures ultimately associated with temporary diversion. Patients with posterior urethral valves who have hydronephrotic upper urinary tracts, normal or near normal serum chemistry studies and are free of infection may receive initial valve ablation. All patients with massive hydroureteronephrosis require long-term followup to ensure preservation of renal function regardless of the approach used.     

Role of decortication in management of parapneumonic empyema thoracis in children

Background

Parapneumonic empyema thoracis is a rare complication of bacterial pneumonia in children that emencely increases the morbidity. Classically parepneumonic effusions are divided into three stages. Stage I or exudative stage, Stage II or fibrinopurulent stage and stage III or organised effusion stage. The present study was designed to highlight the role of open decortication by thoracotomy in cases of para-pneumonic empyema of stage II and stage III disease in children.

Methods

A prospective observational study was done on 31 children of less than 15 years of age, who presented with stage II and stage III parapneumonic empyema thoracis. They underwent decortication surgery through postero-lateral thoracotomy.

Results

Out of the 31 children included in this study, there were 21 boys (67.74 %) and 10 girls (32.26 %). The average duration of symptoms was 17.84 days. The mean duration of post-operative chest drain was 2.55 days. Staphylococcus aureus was the most frequently encountered organism isolated in culture of fibrino-purulent material from the pleural cavity in 12 cases (38.7 %). Mean duration of total hospital stay was 8.3 days.

Conclusion

Decortication by thoracotomy is a safe and effective approach for stage II & III parapneumonic empyema thoracis in children leading to early recovery and less hospital stay.     

Diagnosis of parapneumonic pleural effusion by polymerase chain reaction in children

Purpose

Most pleural effusions are associated with bacterial pneumonia, and the identification of the pathogen will assist the therapeutic decision. A specific method that is not affected by previous antibiotic therapy is sought to detect the main causative agents of pneumonia in infants and children (Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus). The aim of the present study was to compare the polymerase chain reaction (PCR) technique with standard culture methods in identifying bacterial infections in infants' and children's pleural effusion.

Methods

Samples obtained from pediatric patients (n = 37) with a diagnosis of pneumonia associated to pleural effusion, submitted to thoracentesis, were analyzed by PCR with specific primers.

Results

The PCR technique identified the presence of bacterial infection in a larger proportion (95.2%) than the standard culture method (33.3%) on complicated pleural effusion samples. The microorganism detection on uncomplicated pleural effusion samples was positive only by the PCR method (31.3%). The frequencies of microorganisms identified on complicated pleural effusion were 57.1% of all patients for methicillin-resistant Staphylococcus; 52.4%, S pneumoniae; 28.6%, S aureus; and 23.8%, H influenzae. The previous use of antibiotics interferes with standard culture method, but it did not interfere with the PCR results.

Conclusions

The molecular diagnosis by PCR method could improve the etiologic diagnosis and might help to guide the treatment of parapneumonic effusion in children.     

Evolution of practice in the management of parapneumonic effusion and empyema in children

Aim

To assess the evolution in management of children with parapneumonic effusion and empyema in a tertiary referral centre.

Subdural-atrial and subdural-peritoneal shunting in infants with chronic subdural fluid collections

BACKGROUND: In symptomatic infants with chronic subdural fluid collections a variety of treatment strategies, such as observation, repeated subdural tapping, external or internal subdural drainage, and craniotomy have been advocated. Until now, the ideal management for this etiologically heterogenous group of children seems controversial. METHODS: The authors present their treatment with subdural-peritoneal and subdural-atrial shunts and the follow-up in 8 infants (mean age, 7 months) with bifrontal subdural hygromas and hematomas caused by different etiologic conditions. RESULTS: Initially, all children were symptomatic, and repeated subdural taps showed no clinical and neuroradiologic benefit. Shunting resulted in disappearance of all clinical signs in all infants, with complete removal of the chronic subdural fluid collections in 6 cases and remarkable improvement in 2 cases. In all infants the shunt system was removed after disappearance of signs and decrease of fluid collections. As the only complication the shunt system had to be removed in 1 case on the fourth postoperative day because of infection without any further disadvantages. In none of the cases was a recurrence of the fluid collections seen during the follow-up. CONCLUSION: These results suggest that in infants with symptomatic chronic subdural fluid collections who fail to respond to repeated tapping, the early placement of an unilateral subdural-peritoneal shunt with a low pressure valve represents a safe, benign, and effective treatment option.     

Management of postoperative mediastinitis in infants and children by muscle flap rotation

Between July 1, 1976, and June 30, 1986, at the Henrietta Egleston Hospital for Children, 2,242 infants and children underwent palliation or repair of a congenital heart defect. Twenty-one (0.94%) of these patients developed mediastinitis following a median sternotomy. Nineteen of these twenty-one patients had required cardiopulmonary bypass. All patients had positive mediastinal cultures. The first 8 patients were managed traditionally by debridement and irrigation. Three of these patients suffered serious metabolic complications related to the povidone-iodine irrigant, which resulted in 1 death. Another patient died from persistent sepsis following debridement. Subsequently, 13 patients were managed by early debridement and rotation of the pectoralis major or rectus abdominis muscle flaps, or both. Following muscle flap rotation and early wound closure, 2 patients had subsequent incisional complications. One patient had incisional dehiscence and 1 had a superficial skin separation. Two deaths in this group, 28 and 51 days, respectively, following muscle flap rotation, resulted from nonincisional problems in patients with healed median sternotomies. The group having muscle flap rotation required a significantly shorter duration of postoperative ventilatory support (3.2 versus 24 days, p less than 0.05) and a significantly shorter confinement in the intensive care unit (6.2 versus 33 days, p less than 0.01). Also, the physiological and physical trauma of continued wound care in the awake child was minimized in the group with muscle flap rotation.