Rational treatment of empyema in children.
OBJECTIVE
Efficacious and cost-effective treatment of pediatric empyema can be accomplished following a protocol based on its radiographic appearance. Therapeutic modalities include thoracostomy tube drainage (TTD) with or without fibrinolytic therapy (FT) and video-assisted thoracoscopic debridement (VATD).


METHODS
Retrospective case series.


METHODS
Tertiary referral center.


RESULTS
From 1995 through 1999, 31 children were treated ranging in age from 11 months to 18 years (mean age, 5.1 years). Twenty-seven (87.1%) underwent TTD; of these, 22 (81.5%) received FT with urokinase. The TTD failed in 4 children (14.8%) who required salvage VATD. Primary VATD was performed in another 4 children (12.9%). The mean length of stay was 14.6 days (TTD, 14.1 days; salvage VATD, 20. 0 days; primary VATD, 11.5 days), ranging from 8.0 to 30.0 days. Complications included readmission for fever (2 patients [6.5%]) and gastrointestinal bleeding (1 patient [3.2%]). There were no anaphylactic reactions or bleeding episodes due to urokinase. Two patients (7.4%) treated with TTD and FT developed an air leak that resolved spontaneously. The mean hospital charges were $78,832 (TTD with or without FT, $75,450; salvage VATD, $107,476; primary VATD, $69,634). The procedural charges were highest for salvage VATD.


CONCLUSIONS
Most cases of pediatric empyema can be treated by TTD with or without FT. This therapy is safe and effective for children with nascent disease. Primary VATD is preferred in children with advanced disease. Cost-effectiveness could be further improved through better prediction of those patients likely to fail TTD and require salvage VATD. An algorithmic approach based on findings from computed tomography or (better) ultrasonography of the chest may be the best way to make this distinction and rationalize care.
Division of Pediatric Surgery, Stanford University, 725 Welch Rd, Palo Alto, CA 94304, USA.
A H
AH
Meier
B
B
Smith
A
A
Raghavan
R L
RL
Moss
M
M
Harrison
E
E
Skarsgard
D000293:Adolescent; D015505:Chest Tubes / Q000009:adverse effects / Q000191:economics; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols; D003362:Cost-Benefit Analysis; D003646:Debridement / Q000009:adverse effects / Q000191:economics; D004322:Drainage / Q000009:adverse effects / Q000191:economics / Q000295:instrumentation; D016724:Empyema, Pleural / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000601:surgery*; D005260:Female; D005334:Fever / Q000209:etiology; D005544:Forecasting; D006471:Gastrointestinal Hemorrhage / Q000209:etiology; D017722:Hospital Charges; D006801:Humans; D007223:Infant; D007902:Length of Stay; D008297:Male; D010359:Patient Readmission; D010960:Plasminogen Activators / Q000627:therapeutic use; D011030:Pneumothorax / Q000209:etiology; D011859:Radiography; D012189:Retrospective Studies; D020775:Thoracic Surgery, Video-Assisted / Q000009:adverse effects / Q000191:economics; D013907:Thoracostomy / Q000009:adverse effects / Q000191:economics / Q000295:instrumentation; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000191:economics; D016896:Treatment Outcome; D014568:Urokinase-Type Plasminogen Activator / Q000627:therapeutic use
D010960:Plasminogen Activators; D014568:Urokinase-Type Plasminogen Activator