Dr. Daniel Giambini - Sociedad Argentina de Pediatría
Contents
1. Opciones quirurgicas terap uticas Toracocentesis seriadas Tubos de drenaje comunes Colocacion de pequefios tubos pig tail Video Toracoscopia VATS Toracotomia Decorticaci n Fibrinoliticos Video toracoscopia 1 e E E maturi ml hi ii a LE e I selle f Ioi T A sl y Liquido pleural Aspecto es citrino Bacteriologia f sico Sensibilidad Especificidad quimico Glucosa 75 95 Cultivo del liquido pleural Hemocultivo G I 23 G Il 18 G II 6 Streptococcus pneumoniae Haemophilus influenzae tipo b Micoplasma pneumoniae Streptococcus grupo B Staphilcoccus aureus MR Chlamydia trachomatis Streptococcus pneumoniae resistente Otros Liguido Pleural Derivados 30 11 Vo 21 11 3 0 Total n 905 2001 2012 GI 14 47 G Il 92 48 G III 32 37 Vo Registro de datos Protocolos pre impresos que incluian Datos del paciente nombre edad sexo Fecha de ingreso y egreso Dias de evolucion Sintomatologia Ex menes complementarios olm genes Rx Ecografia TAG oLaboratorio Hemograma Cultivos o Tratamiento ATB Oxigenoterapia Toracocentesis Material obtenido caracteristicas citoquimico y cultivo volumen drenaje calibre STK dosis d as d bito Cl nica General Retiro drenaje Alta estudios al alta Toi Tassa SEA HB E Tr 72 BIT I fi Mil ita om 1 i Ld i F i I tr2. matar HH HH Tratamiento Medico del Empiema 6 Congreso Argentino de Neumonologia Pedi trica h Htal Gral de Ninos Dr Pedro de Elizalde 22 Noviembre 2012 Comision de Empiema 1914 Mortalidad 70 Fiover Ki Comparativa rosmlis of management of emprema in World Wars In A Tropical patients with chronic ompprema in Zone of Interior hoepitale in Moi m T L Thanks to PENICILLIN He Will Come Home Empyema in children a twenty five year study B Lionakis S Gray J Skandalakis J Pediatr 53 6 719 25 1958 Parece probable que este estudio abarque el periodo de la extincion practica del empiema como una enfermedad importante De 210 nihos ingresados con derrame pleural demostraron que el 68 de los derrames son paraneumonicos y el 32 empiema en USA Hardie VV Bokulic R Garcia VF et al Pneumococcal pleural empyemas in children Clin Infect Dis Jun 1996 22 6 1057 63 Empiema se informo en aproximadamente 0 6 2 de los nifios con neumonia bacteriana Chonmaitree T Powell KR Parapneumonic pleural effusion and empyema in children Review of a 19 year experience 1962 1980 Clin Pediatr Phila Jun 1983 22 6 414 9 Mocelin HT Fischer GB Epidemiology presentation and treatment of pleural effusion Paediatr Respir Rev Dec 2002 3 4 292 EI 2 4 tuvieron neumonia comp
3. LA IT Empiema Inclusion Protocolo STK Debe cumplir con los siguientes requisitos Enfermedad febril con la consolidaci n neum nica en el inicio Liquido en el espacio pleural en la radiografia de torax y ecografia Liquido pleural turbio con celulas de pus y 0 loculacion en la ecografia Drenaje tradicional Drenaje pleural pig tail Chest 1998 114 1116 1121 Arch Dis Ghild 2002 87 331 332 Thorax 2002 57 343 347 Ped Pulm 2005 39 127 134 Neumonia Complicada con Empiema Segundo Periodo Septiembre 2005 Agosto 2012 7 Afios VU N C Fistula VT VATS STK 2012 91 6 85 2011 81 7 74 2010 101 9 92 642 2009 85 5 80 594 2008 96 5 91 2007 90 7 83 2006 98 9 89 2005 89 14 49 2004 76 6 27 2003 62 15 15 2002 36 2 12 Total 905 697 De un total de n 642 utilizamos STK en 594 92 52 n 48 con fistula Se incluyeron 1 35 dias 1 38 dias 1 43 d as Se excluyeron pacientes drenados con mas de 45 dias de evolucion y aquellos con fistula alv olo pleural SIK Dosis 10000 Ul Kg d hasta un m ximo de 250000 Ul Presentacion 250000 Ul 750000 Ul 1500000 Ul Costo 2300 3000 Htal Particular Preparacion Dilucion 15 cc 100000 Ul mi Conservacion Jeringas prellenadas de 100000 Ul c u En freezer 6 meses STK Estabilidad de las diluciones conservadas a 25 C Pigliapoco V Bartoletti S Giambini D Balbarysky J Aba Vol 74 2010 Mod
4. culture D Diagnostic analysis of pleural fluid N Pleural fluid must be sent for microbiological analysis including Gram stain and bacterial culture C N Aspirated pleural fluid should be sent for differential cell count D N Tuberculosis and malignancy must be excluded in the presence of pleural lymphocytosis C N If there is any indication the effusion is not secondary to infection consider an initial small volume diagnostic tap for cytological analysis avoiding general anaesthesia sedation whenever possible D N Biochemical analysis of pleural fluid is unnecessary in the management of uncomplicated parapneumonic effusions empyema D Diagnostic bronchoscopy N There is no indication for flexible bronchoscopy and it is not routinely recommended D Referral to tertiary centre N A respiratory paediatrician should be involved early in the care of all patients requiring chest tube drainage for a pleural infection D Conservative management antibiotics j simple drainage N Effusions which are enlarging and or compromising respiratory function should not be managed by antibiotics alone D N Give consideration to early active treatment as conservative treatment results in prolonged duration of illness and hospital stay D Repeated thoracocentesis N If a child has significant pleural infection a drain should be inserted at the outset and repeated taps are not recommended D Antibiotics N All cases should be treated wit
5. of bias I Well conducted meta analyses systematic reviews of RCTs or RCTs with a low risk of bias I Meta analyses systematic reviews of RC Ts or RGTS with a high risk of bias High quality systematic reviews of case control or cohort studies High quality case control or cohort studies with a very low risk of confounding bias or chance and a high probability that the relationship is Causal l Well conducted case control or cohort studies with a low risk of confounding bias or chance and a moderate probability that the relationship is causal II Gase control or cohort studies with a high risk of confounding bias or chance and a significant risk that the relationship is not causal III Non analytical studies e g case reports case series IV Expert opinion Balfour Lynn Abrahamson Cohen et al www thoraxjnl Cual es nuestra situacion actual 2 A que desafio nos enfrentamos cuando hablamos de empiema 2 Derrame loculado o tabicado Streptokinasa Polip ptido estreptococo b hemolitico grupo C Activador indirecto plasminogeno forma complejos 1 1 con plasminogeno m Chest 2004 125 566 571 Urokinasa Polip ptido humano tejido renal embrionario Activa directamente al plasminogeno m Thorax 2002 57 343 347 teaplasa t PA Factor tisular activaci n plasminogeno DNA recombinante m Acci n sobre plasmin geno unido a fibrina m Radiology 2003 228 370 378 Pediatrics 2003 111 92
6. urokinase but is routinely used in some centres and in the US Fibrinolytic therapy is usually not used following VATS or thoracotomy Recovery can be rapid following thoracotomy surgery may be an appropriate primary procedure in some children with a complex empyema i e when there are extensive loculations a thick pleural rind and severe lung entrapment in a sick child A lung abscess coexisting with an empyema does not usually require surgical drainage chest CT is appropriate imaging when an abscess is suspected Abstracted bullet points Clinical picture N All children with parapneumonic effusion or empyema should be admitted to hospital D N If a child remains pyrexial or unwell 48 hours after admission for pneumonia parapneumonic effusion empyema must be excluded D Diagnostic imaging N Posteroanterior or anteroposterior radiographs should be taken there is no role for a routine lateral radiograph D N Ultrasound must be used to confirm the presence of a pleural fluid collection D N Ultrasound should be used to guide thoracocentesis or drain placement C N Chest CT scans should not be performed routinely D Diagnostic microbiology N Blood cultures should be performed in all patients with parapneumonic effusion D N When available sputum should be sent for bacterial
7. 130 000 100 000 80 000 J 60 000 E 40 000 E 20 000 El de los ingresos fueron de Pcia de Bs As E Mortalidad 20 B Mortalidad 10 mu LE ma LE 7 s na HA E Fr aa as i mi r s Pr n HH H mi ai LL mi mr 7 1 m n k me le LI 2 m mi lum P E mi mi EE AV gt Q0 T gt s ici SA 4 PS Do x Sr SS i EH FE E E Shq gt i PET PES PS KG on wer a X E gt SG d i AA e
8. UE CHACABUCO se ropios 38 4 mn eee lt slilla5 6a10 gt 10 84 451 312 92 n 905 d E ua y 1 1 F E PJ 2 B 5 6 7 8 9 10 11 12 13 14 15 Sintomas mi 100 90 a 80 70 60 50 40 30 20 10 0 e Te gt V O y z S e NS SH S N gt O Q S SY OV Radiografia de torax 100 de los casos de Frente Limitaciones No es posible diferenciar el liquido de engrosamiento pleural No es util para estadificar la enfermedad Ecografia Tomografia Ecografia pleural Se realiz en todos los ni os Es la mejor t cnica para diferenciar l quido pleural y consolidaci n Estima tama o complejidad y grado del derrame Demuestra presencia de septos de fibrina y Guia colocaci n de drenaje tor cico TAG No la hemos utilizado de rutina Indicaciones Evolucion desfavorable Hemitorax opaco Evaluar cirugia Empiema bloqueado Diferenciar compromiso pleural parenquimatoso tumoral i Hi An Mmm ar 1 e fm Shk ie jn TT S I AA E Clasificamos en Grupo 1 Gl pacientes con SPP que consultaron con 7 d as de evolucion Grupo 2 G II pacientes con SPP que consultaron o fueron derivados de otros centros entre los 8 y 14 dias de evolucion Grupo 3 G III pacientes con SPP con gt 15 d as de evoluci n Ed LA 10 a s 2 I li f 32 u
9. and Marjorie J Arca Columbus Ohio Journal of Pediatric Surgery Vol 39 No 11 November 2004 pp 1638 1642 Estudio con 52 pac Treatment of encapsulated pleural effusions in children a prospective trial Kobr J Pizingerova K Sasek L Fremuth J Siala K Racek J Pediatr Int 2010 Jun 52 3 453 8 Nov 16 Prospective study 76 consecutive children average age 5 0 4 14 years Neumonia Combplicada con Empiema Per odo 11 a os 2001 2012 905 pac Primer Periodo Septiembre 2001 Agosto 2005 MET Empiemas VT VATS STK 2005 89 14 49 2004 6 6 21 2003 62 19 19 2002 36 2 12 Total 103 casos PG v Cl nicos La Cirujanos STK Anestesistas Distribucion por sexos Masculino Femenino 62 Vo 38 Yo E Localizaci n Derecho Izquierdo ud 59 95 41 9o n 905 Procedencia en TAA pe SA A r je 2 q zi i s a n zu n y Di TI ma PROVINCIA ea e e ae a i m J i RENTAL sE c xd EN AA p gt qe tre Fara rn z ll Pop mas A Drit URUGUAY nn Pcia Bs As 46 52 2 n 905 70 60 50 40 30 20 10 0 c gt VILLA REAL gt MES Derivado A 62 Vo VILLA LUGANO 7 os 74 Ls VILLA RIACHUELO 5 n 905 ey SE ne Tt NE TA U t 33 ALMAGRO f BOEDO PARQ
10. ante Atb 29 4 dias n 40 HOSPITAL ELIZALE 4000 Dual FRANCOS GLUSTAN TX 4723 U0SY MOTA gr A 2012 Jun Bam 11 14 19 0 vin sh h1 4000 Dual A HOSPITAL ELIZA E TORAX 9072 KAREN CALC 015 E TORAX Wee 4000 Dual A HOSPITAL ELIZALDE Ex TORAX 6344 ABDALA THIAGO 0044 M TORAX 6344 ACC 2012 Jul 05 Acq Im 10 52 41 000 100 0 kV 50 0 m 2 0 mme Tilt 0 0 1205 AA L 35 i DFOR 21 0 x 21 0cm OE o A HOSPITAL ELIZALDE COLOMER WILLIAM x TOR COLOMER WILLIAM 016Y M TORAX 8069 DT ACC Dee AX 4000 Dual Ex TORAX 8069 ZAN BUE gm 111 59 07 000 m 18121 mA dt an E 1 oy E A m a we 140 0 kV bw 00 mA 12 0 mmi 3 1 Tilt 0 0 1205 VWADO Las DFOV 50 0 x 50 0cm La evidencia sobre la cual basar las recomendaciones es pobre ausente Los datos del adulto no son trasladables Los ni os con empiema tienen casi siempre buenos resultados sea cual sea el manejo En nuestra experiencia la STK en util efectiva de bajo costo y de manejo sencillo la estancia hospitalaria es corta y con UN Indice de complicaciones mes y muy bajo 3 59 rash dolor y sangrado leve y con una alta tasa e exitos BTS guidelines for the management of pleural infection in children M Balfour Lynn E Abrahamson G Cohen J Hartley S King D Parikh D Spencer AH Thomson D Urquhart on behalf of the Paedia
11. cing it Consider obtaining further imaging initially CXR and then ultrasound if there is no clinical improvement and or failure to drain the effusion CT may be sometimes be useful discuss with radiology and the surgical respiratory team Consider removing a chest drain when drainage is minimal e g less than 30 mis per 24 hours and there has been significant clinical progress alongside some radiological improvement Request a CXR approximately 4 hours after chest drain removal see separate chest drain guidelines A bubbling chest drain should prompt the consideration of a bronchopleural fistula and discussion with the surgical team Never clamp a bubbling chest drain 2 Intrapleural fibrinolytic therapy see separate Urokinase administration guidelines Intrapleural fibrinolytic therapy shortens hospital stay and should be used for all cases of parapneumonic effusion or empyema given intercostal tube drainage Further surgical intervention thoracotomy or VATS Failure of chest tube drainage antibiotics and fibrinolytic therapy should prompt early discussion with the surgical team Children should be considered for surgical intervention if they have persisting respiratory distress fever or sepsis in association with a persistent pleural collection Video assisted thoracoscopic surgery VATS may be an appropriate alternative to thoracotomy Early VATS as a primary procedure does not appear to offer benefit over a chest drain and
12. effective than the others but only urokinase has been studied in a randomised controlled trial in children so is recommended B N Urokinase should be given twice daily for 3 days 6 doses in total using 40 000 units in 40 ml 0 9 saline for children weighing 10 kg or above and 10 000 units in 10 ml 0 9 saline for children weighing under 10 kg B Surgery N Failure of chest tube drainage antibiotics and fibrinolytics should prompt early discussion with a thoracic surgeon D N Patients should be considered for surgical treatment if they have persisting sepsis in association with a persistent pleural collection despite chest tube drainage and antibiotics D N Organised empyema in a symptomatic child may require formal thoracotomy and decortication D NA lung abscess coexisting with an empyema should not normally be surgically drained D Other management N Antipyretics should be given D N Analgesia is important to keep the child comfortable particularly in the presence of a chest drain D N Chest physiotherapy is not beneficial and should not be performed in children with empyema D N Early mobilisation and exercise is recommended D N Secondary thrombocytosis platelet count 5006109 l is common but benign antiplatelet therapy is not necessary D N Secondary scoliosis noted on the chest radiograph is common but transient no specific treatment is required but resolution must be confirmed D Follow up N Children sh
13. h intravenous antibiotics and must include cover for Streptococcus pneumoniae D N Broader spectrum cover is required for hospital acquired infections as well as those secondary to surgery trauma and aspiration D N Where possible antibiotic choice should be guided by microbiology results B N Oral antibiotics should be given at discharge for 1 4 weeks but longer if there is residual disease D Chest drains N Chest drains should be inserted by adequately trained personnel to reduce the risk of complications C N A suitable assistant and trained nurse must be available D N Routine measurement of the platelet count and clotting studies are only recommended in patients with known risk factors D N Where possible any coagulopathy or platelet defect should be corrected before chest drain insertion D N Ultrasound should be used to guide thoracocentesis or drain placement C N If general anaesthesia is not being used intravenous sedation should only be given by those trained in the use of conscious sedation airway management and resuscitation of children using full monitoring equipment D N Small bore percutaneous drains should be inserted at the optimum site suggested by chest ultrasound C N Large bore surgical drains should also be inserted at the optimum site suggested by ultrasound but preferentially placed in the mid axillary line through the safe triangle D N Since there is no evidence that large bore ches
14. ing to treatment Treat with IV abx alone or Obtain chest US and obtain pleuralfluid for culture by throracentesis or by placement of a chest tube fibrinolytics Reassess ntinue i Continue abx effusion size If clinical condition is worsening despite appropriate IV abx then proceed to the algorithm for large effusion Is the effusion still small If the effusion is now moderated or large then follow the algorithm for moderate or large effusion size If the effusion is still small then continue abx and do not attempt pleural drainage Moderate effusion size gt 14 but lt thorax opacified Respiratory Compromise High Large effusion size gt Y thorax opacified Obtain a achest US or CT US preferred to assess effusion size and degree of loculation Obtain pleuralfluid for culture and drain the pleural space of fluid Follow the treatment T algorithm for large effusions Options for drainage Fluid is loculated complicated Fluid is not loculated simple 2 options Options for drainage 1 Chest tube alone 2 Chest tube vvifibrinolytics 3 VATS Chest tube vvifibrinolytics if not responding approx 15 of patients then proceed to VATS Proceed directly to VATS Revised SIGN grading system levels of evidence I High quality meta analyses systematic reviews of randomised controlled trials RCTs or RCTs with a very low risk
15. irugia 12 2 02 Neumonia necrotizante Atb 29 dias 16 40 Mortalidad 5 de 905 pac 0 55 Ninguno tratado con STK 4 en el primer per odo Gill 51 55 60 88 dias 1 enel segundo Gill gt 50 d as PIVOT Trial Pneumonia Intravenous Versus Oral Treatment Multi Centre Randomised Controlled Trial Of Oral Versus Intravenous Treatment For Community Acauired Pneumonia In Children M Atkinson M Lakhanpaul A Smyth H Vyas V Weston J Sithole V Owen K Halliday H Sammons J Crane N Guntupalli L Walton T Ninan A Morjaria T Stephenson Department of Child Health University of Nottingham THORAX 2007 62 1102 Se suglere 10 a 14 d as para neumococo y 21 d as para S aureus Cuando tenga tolerancia por via oral el antibiotico podr administrarse por sta vla EMPIEMA PLEURAL Sociedad Argentina de Pediatria Dr Hugo Paganini 2010 TAIS Tratamiento Ambulatorio de Infecciones Severas Conclusiones En nuestra experiencia la STK es util efectiva de bajo costo y de manejo sencillo sin requerimiento de gran infraestructura La estancia hospitalaria es corta Presenta un Indice de complicaciones bajo ninguna de gravedad evidenciada por nosotros Alta tasa de xito terap utico sin la necesidad de procedimientos adicionales quir rgicos MUCHAS GRACIAS Duracion de la fiebre antes de la admision 4 250 11 80 Duraci n de la fiebre despu s de la colocaci n del drenaje 2 6 d 3 14 Neumonia necrotiz
16. licada con empiema Community acguired pneumonia CAP in children in Oslo Norway Senstad et al Acta Paediatrica Volume 98 Issue 2 pages 332 336 February 2009 The Management of Gommunity Acauired Pneumonia in Infants and Children Older Than 3 Months of Age Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America IDSA John S Bradley 1 a Carrie L Byington 2 a Samir S Shah 3 a Brian Alverson 4 Edward R Carter 5 Christopher Harrison 6 Sheldon L Kaplan 7 Sharon E Mace 8 George H McCracken Jr 9 Matthew R Moore 10 Shawn D St Peter 11 Jana A Stockwell 12 and Jack T Swanson13 Clinical Infectious Diseases Advance Access published August 301 2011 Un estudio prospectivo en ni os realizado en Europa y America sobre neumonia adquirida de la comunidad demostro que el empiema se presento entre un 2 yun 12 Boletin oficial 2010 Ministerio de Salud Argentina Total 37 602 Neumonias en ni os Estimaci n de Neumon a complicada 2 al 6 152 2256 pac 12 Yo 4512 pac La tasa de mortalidad fue de 3 68 1 387 nihos fallecidos por esta enfermedad Treatment of Complicated Parapneumonic Pleural Effusion With Streptokinase Intrapleural in Children CHEST Chih Ta Yao 2004 Surgery No of patients total 2120 Drainage Fibrinolytics or Surgery A Comparison of Treatment Options in Pediatric Empyema Robert L Gates Mark Hogan Samuel Weinstein
17. o de empleo Se instila STK con 50 100 cc de Solucion fisiol gica Glampeo del drenaje durante 2 4 Hs cada 24 hs Cantidad de liquido obtenido Con d bito positivo se administra STK 100 550 cc Suspende STK y Retiro del drenaje d bito es nulo menor 40 cc en 24 Hs 1 mili Kg citrino Dias de uso de STK 1 dia 2 dias 3 dias 4 dias 5 dias 6 dias 7 dias 8 dias 18 61 217 166 102 20 O Ol n 594 2005 2012 3 04 7o 10 26 KJE AAT NENNE o a hnmumununmumuEEEHEHHNHHEEHEHEREEEHENHERE GI 16 G Il 340 G Ill 178 TEE TER EI TE a Conan Ea A E H RB BH BOE EH HUBER HEU A ea AG L e M s 12 79 91 23 Vo 29 96 Yo Efectos adversos fiebre 0 lt 38 2 C Dificil de valorar urticaria rash 3 0 59 dolor toracico 3 0 59 sangrado leve 12 2 35 Alteracion de la coagulacion 0 TOTAL 3 53 Se altera la coagulacion en pacientes tratados con STK intrapleural Estudio en 100 pac consecutivos 2007 2008 Dra Bellapianta y col Aba Vol 72 2008 Dias de drenaje G I 1 20 G Il 2 5d G III 4 8d Dias de internaci n Dependi de la duraci n de la duraci n del trat Atb EV G 2 4d G Il 4 10 G III 7 140 Neumonia necrotizante Atb 29 dias n 40 Indicaciones de cirugia Persistencia de fiebre sepsis No mejoria de clinica respiratoria Fracaso del tratamiento Aparicion de otras complicaciones n 594 C
18. ould be followed up after discharge until they have recovered completely and their chest radiograph has returned to near normal D N Underlying diagnoses for example immunodeficiency cystic fibrosis may need to be considered D BTS guidelines for the management of pleural infection in children Grados de recomendaci n A Basada en una categor a de evidencia Extremadamente recomendable B Basada en una categoria de evidencia ll Recomendacion favorable C Basada en una categoria de evidencia III Recomendacion favorable pero no concluyente D Basada en una categoria de evidencia IV Consenso de expertos sin evidencia adecuada de investigacion Ill La evidencia proviene de estudios descriptivos no experimentales bien disehados como los estudios comparativos estudios de correlacion o esiudios de casos y controles IV La evidencia proviene de documentos u opiniones de comit s de expertos o experiencias clinicas de autoridades de prestigio o los estudios de series de CASOS Levels of evidence Grades of recommendations SIGN ratings BEI n 165 n 57 Management of pneumonia with parapneumonic effusion Confirm the dx of pneumonia and parapneumonic effusion then categorize the size of the effusion Small effusion size lt 10mm rim or lt Y thorax opacified Treat with antibiotics Do not obtain pleuralfluid for culture and do not attempt pleural drainage Degree of Low Is the patient respond
19. t drains confer any advantage small drains including pigtail catheters should be used whenever possible to minimise patient discomfort C A chest radiograph should be performed after insertion of a chest drain D N All chest tubes should be connected to a unidirectional flow drainage system such as an undervvater seal bottle which must be kept below the level of the patient s chest at all times D N Appropriately trained nursing staff must supervise the use of chest drain suction DI N A bubbling chest drain should never be clamped D N A clamped drain should be immediately unclamped and medical advice sought if a patient complains of breathlessness or chest pain D N The drain should be clamped for 1 hour once 10 ml kg are initially removed D N Patients with chest drains should be managed on specialist wards by staff trained in chest drain management D N When there is a sudden cessation of fluid draining the drain must be checked for obstruction blockage or kinking by flushing D N The drain should be removed once there is clinical resolution D N A drain that cannot be unblocked should be removed and replaced if significant pleural fluid remains D Intrapleural fibrinolytics N Intrapleural fibrinolytics shorten hospital stay and are recommended for any complicated parapneumonic effusion thick fluid with loculations or empyema overt pus B N There is no evidence that any of the three fibrinolytics are more
20. tion Clinical suspicion parapneumonic effusion Section 3 1 3 Chest radiograph Pleural effusion _ Yes Confirm on chest ultrasour Refer to respiratory poediatri Suggestion of malignancy No Suggestion of infection y Yes Intravenous antibiotics Medical option Insert chest drain Section 4 5 Pleural fluid microbiology and cell differential Section 3 7 Echogenic or loculated on ultrasound Thick fluid draining Sechan Intra pleural fibrinolytics Is the patient bett i F m THORAX Balfour Lynn I M et al Thorax 2010 60 11 1 02010 by BMJ Publishing Group Ltd and British Thoracic Society Chest drains ongoing management See the section below on the use of fibrinolytic therapy Good analgesia is extremely important Children should receive regular paracetamol and NSAIDs additional oral analgesia and or morphine infusion may be necessary in some children Children with chest drains should only be managed on wards by staff trained in chest drain management A clamped drain should be immediately unclamped and medical advice sought if a child has any unexplained deterioration becomes breathless or has chest pain If there is a sudden cessation of fluid drainage the drain should be checked for obstruction blockage or kinking the drain may need to be manipulated or flushed If there is still significant remaining pleural fluid and a drain is not draining consider repla
21. tric Pleural Diseases Subcommittee of the BTS Standards of Care Committee Thorax 2005 60 Suppl 1 i1 i21 doi 10 1136 thx 2004 030676 Postero anterior or antero posterior radiographs should be taken there is no role for a routine lateral radiograph D Ultrasound must be used to confirm the presence of a pleural fluid collection D Chest CT scan should not be performed routinely D Diagnostic imaging If GA is not being used IV sedation should only be given by those trained in the use of conscious sedation airvay management amp resuscitation of children using full monitoring equipment D Since there is no evidence that large bore chest drains confer any advantage small drains including pigtail catheters should be used whenever possible to minimise patient discomfort C Ultrasound should be used to guide thoracocentesis or drain placement C Chest drains Intrapleural fibrinolytics shorten hospital stay and are recommended for any complicated parapneumonic effusion thick fluid with loculations or empyema overt pus B Streptokinase should be given daily for 3 days using 10 000 Kg units in 40 mis 0 9 saline for children aged 1 year or above B Thomson et al Thorax 2009 57 343 7 mtrapleural fibrinolytics Estancia hospitalaria entre 7 2 y 9 4 dias Algorithm for the management of pleural infection in children Algorithm for the management of pleur New presenta
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