title: Experience with an evidence-based protocol using fibrinolysis as first line treatment for empyema in children.
abstract: BACKGROUND
  We previously reported a prospective, randomized trial comparing video-assisted thoracoscopic decortication (VATS) to fibrinolysis for the treatment of empyema. In that study no advantages to VATS were identified, although VATS resulted in significantly higher hospital charges. We subsequently implemented the algorithm from the trial utilizing primary fibrinolytic therapy in all children diagnosed with empyema. In this study, we reviewed our experience to examine the clinical efficacy of this protocol.
  
  
  METHODS
  After IRB approval, we conducted a retrospective review of all children diagnosed with empyema as all were treated with the fibrinolysis protocol utilized in the prospective trial since the completion of the trial.
  
  
  RESULTS
  In 102 consecutive patients treated with fibrinolysis, 16 patients (15.7%) required subsequent VATS. No patients were treated with initial VATS. No major side effects were seen from fibrinolytic therapy. Mean operative time for VATS after fibrinolysis was 62 minutes. The length of stay after VATS was 5.9 days.
  
  
  CONCLUSIONS
  The results of an evidence-based protocol using fibrinolysis to treat empyema have replicated the results of the trial that led to the implementation of the protocol. The pediatric empyema population can be successfully treated without an operation in the majority of cases.
authors.affiliation: Department of Pediatric Surgery, The Children's Mercy Hospital Kansas City, MO 64108, USA.
authors.forename: Alessandra C
authors.initials: AC
authors.lastname: Gasior
authors.forename: E Marty
authors.initials: EM
authors.lastname: Knott
authors.forename: Susan W
authors.initials: SW
authors.lastname: Sharp
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Ostlie
authors.forename: George W
authors.initials: GW
authors.lastname: Holcomb
authors.forename: Shawn D
authors.initials: SD
authors.lastname: St Peter
mesh_terms: D000465:Algorithms; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols; D003131:Combined Modality Therapy; D003661:Decision Support Techniques; D004334:Drug Administration Schedule; D016724:Empyema, Pleural / Q000188:drug therapy* / Q000601:surgery; D019317:Evidence-Based Medicine; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D007223:Infant; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D012189:Retrospective Studies; D013396:Suction; D020775:Thoracic Surgery, Video-Assisted; D013907:Thoracostomy; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Children; Empyema; Fibrinolysis; VATS; tPA