Tratamiento de los derrames pleurales paraneumónicos

Levels of lactic acid's concordance with pH in pediatric parapneumonic pleural effusion

Purpose of the article: The indication of pleural drainage in parapneumonic pleural effusion (PPE) is still controversial. Pleural fluid's (PF) pH is widely used as an indicator of the need for pleural drainage. We hypothesized that PF's lactate will have a high concordance with pH, and thus, may be a valuable tool to determine the need for pleural drainage in pediatric PPE.

MATERIALS AND METHODS

We performed a descriptive, prospective study sequentially enrolling those pediatric patients admitted to a tertiary University Hospital with a PPE between 2008 and 2018. Patients were classified in two groups: drainable PPE (pH < 7) and non-drainable PPE (pH > 7). Correlation with the pH, the area under the curve (AUC), and the sensitivity and specificity values for lactate and other parameters (glucose, and LDH) were analysed too.

RESULTS

72 patients with a median age of 4 years (interquartile range 2.25-6) were included. Both groups were homogeneous. Lactate levels were higher in the drainable PPE group (p < 0.001), and a strong inverse correlation between pH and lactate was found (r: -0.7; p < 0.001). A lactate cut-off value of 60.5 mmol/L, exhibit an AUC of 0.86 with a sensitivity of 70% and a high specificity (97.9%) to predict a pH < 7.

CONCLUSIONS

Our data indicates that lactate in PF presents a strong correlation with pH and could potentially serve as a highly specific biomarker of the need for pleural drainage.

[Complicated pleural infection: Analysis of 2 consecutive cohorts managed with a different policy]

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.

[Why are pediatric empyemas on the increase in Spain?]

There is a widespread perception among Spanish pediatricians that the incidence of empyema has significantly increased in the last few years, even though the objective information available is limited, and there is no specific active epidemiological surveillance system for this condition. In the present article, we review the situation of empyema in Spain, and discuss the main hypotheses put forward in the international literature to explain this increase, as well as the limitations of the sources available. Despite the scarcity of information, we draw the following conclusions: 1) the incidence of pediatric empyema is increasing in Spain, both generally and when caused by pneumococcus in particular; 2) the reason for this increase remains unknown, and to date no firm link has been established between this phenomenon and the heptavalent conjugate pneumococcal vaccine; and 3) this situation justifies the establishment of prospective systems for the surveillance and control of empyema and, once again, highlights the importance of developing active surveillance systems for pneumococcal disease.

[Intrapleural streptokinase in the treatment of complicated parapneumonic empyema]

INTRODUCTION

Parapneumonic empyema is a frequent cause of admission in the Pediatric Hospital of the Pereira Rossell Hospital Center. In January 2005, we implemented a treatment protocol that included intrapleural streptokinase (STK) for children with complicated parapneumonic empyema as an alternative to surgery.

OBJECTIVES

To describe the results of intrapleural STK in the treatment of hospitalized children with complicated parapneumonic empyema and to compare these results with those of early thoracotomy.

PATIENTS AND METHODS

Children with complicated parapneumonic empyema admitted between January 1st 2004 and October 1st 2005 were included. The children were divided into two groups: a historical group, composed of children hospitalized between January 1st and December 31st 2004, treated with conventional thoracotomy before day 8 of chest drain placement and a prospective group, composed of children hospitalized between January 1st and October 1st 2005, treated with intrapleural STK before day 8 of chest drain placement. The variables used to compare outcome and treatment complications were duration of chest tube drainage after the treatment procedure, complications, re-admission, length of hospital stay, and death.

RESULTS

The results in both groups were similar. Length of hospital stay showed no significant differences. Duration of chest tube drainage after intrapleural STK was significantly shorter than after thoracotomy (p < 0.001). In the thoracotomy group a significantly higher proportion of patients required partial atypical pneumonectomy (p = 0.051). There were no deaths.

CONCLUSIONS

Intrapleural STK is a valid alternative for the treatment of children with complicated parapneumonic empyema.

Perforation of the left atrium by a chest tube in a patient with cardiomegaly: management of a rare, but life-threatening complication

Perforation of the heart is a rare, but life-threatening complication of chest tube thoracostomy. We report the very unusual case where right-sided insertion of a Matthys catheter (6 F) due to pleural effusion resulted in a left atrium perforation. Heart injury was immediately considered as a continuous flow of bright red blood emerging through the chest drain. Diagnosis was confirmed by computertomography also revealing a massive cardiomegaly due to pre-existing mitral valve regurgitation. In two consecutive thoracotomies, first the Mathys drain was removed and the heart defect closed and then the mitral valve was replaced by a bio prosthesis. The extent of the cardiomegaly and the position of the left atrium were not detected pre-operatively by chest X-ray or ultrasonic device. Despite a nosocomial pneumonia, the patient fully recovered. This case shows that extreme caution is necessary when inserting chest tubes in patients where thorax imaging by X-ray or ultrasonic device does not provide a clear anatomical site. In order to minimise complications, a blunt puncturing procedure or Seldinger technique should be used and assisted by a Doppler ultrasonic device. Also early imaging by CT and Doppler ultrasonic technique should be attempted. This may reduce incidence of severe complications as in this case.

Derrame pleural paraneumónico: revisión de 11 años

INTRODUCTION

In the last few years, the incidence of parapneumonic effusions in children with community-acquired pneumonia seems to have increased. The aim of this study was to determine the clinical features and incidence of parapneumonic effusions throughout an 11-year period.

MATERIAL AND METHODS

We retrospectively reviewed the medical records of patients aged < 15 years old with parapneumonic effusions from 1993 to 2003. Annual incidence rates were calculated per 100,000 children < 15 years old from Health Area 5 of Madrid and per 100 children hospitalized in the Infectious Diseases Department of our hospital. The linear association test was used to compare the incidence rates over the previous 11 years.

RESULTS

There were 130 patients with parapneumonic pleural effusions. The mean age was 4.7 years. Forty-one percent received antibiotics before diagnosis. The causative organisms were identified in 42 patients (32.3%). The most effective diagnostic method was pleural-fluid culture (18/58, 31%). The most common organisms were Streptococcus pneumoniae (18), Mycoplasma pneumoniae (8), Staphylococcus aureus (4), Streptococcus pyogenes (3), Haemophilus influenzae (3) and Mycobacterium tuberculosis (2). Thirty-two percent of the patients required pleural drainage and 16% underwent video-assisted thoracoscopic surgery. Of 12 S. pneumoniae antibiograms available, 91.7% showed full susceptibility to penicillin and 75% were susceptible to erythromycin. The annual incidence of parapneumonic effusions rose from 18.1 in 1993 to 42.9 in 2003 (p < 0.001) per 100,000 children and from 0.76 in 1993 to 3.3 in 2003 (p < 0.001) per 100 children hospitalized in our unit.

CONCLUSION

The incidence of parapneumonic effusions in children with community-acquired pneumonia showed a statistically significant increase between 1993 and 2003. The most common causal organism was S. pneumoniae, with a low rate of penicillin resistance.