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James CA, Lewis PS, Moore MB, Wong K, Rader EK, Roberson PK, Ghaleb NA, Jensen HK, Pezeshkmehr AH, Stroud MH, Ashton DJ. Efficacy of standardizing fibrinolytic therapy for parapneumonic effusion. Pediatr Radiol 2022; 52:2413-2420. [PMID: 35451632 PMCID: PMC9023697 DOI: 10.1007/s00247-022-05365-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/15/2021] [Accepted: 03/21/2022] [Indexed: 10/25/2022]
Abstract
BACKGROUND While chest tube placement with pleural fibrinolytic medication is the established treatment of pediatric empyema, treatment failure is reported in up to 20% of these children. OBJECTIVE Standardizing fibrinolytic administration among interventional radiology (IR) physicians to improve patient outcomes in pediatric parapneumonic effusion. MATERIALS AND METHODS We introduced a hospital-wide clinical pathway for parapneumonic effusion (1-2 mg tissue plasminogen activator [tPA] twice daily based on pleural US grade); we then collected prospective data for IR treatment May 2017 through February 2020. These data included demographics, co-morbidities, pediatric intensive care unit (PICU) admission, pleural US grade, culture results, daily tPA dose average, twice-daily dose days, skipped dose days, pleural therapy days, need for chest CT/a second IR procedure/surgical drainage, and length of stay. We compared the prospective data to historical controls with IR treatment from January 2013 to April 2017. RESULTS Sixty-three children and young adults were treated after clinical pathway implementation. IR referrals increased (P = 0.02) and included higher co-morbidities (P = 0.005) and more PICU patients (P = 0.05). Mean doses per day increased from 1.5 to 1.9 (P < 0.001), twice-daily dose days increased from 38% to 79% (P < 0.001) and median pleural therapy days decreased from 3.5 days to 2.5 days (P = 0.001). No IR patients needed surgical intervention. No statistical differences were observed for gender/age/weight, US grade, need for a second IR procedure or length of stay. US grade correlated with greater positive cultures, need for chest CT/second IR procedure, and pleural therapy days. CONCLUSION Interventional radiology physician standardization improved on a clinical pathway for fibrinolysis of parapneumonic effusion. Despite higher patient complexity, pleural therapy duration decreased. There were no chest tube failures needing surgical drainage.
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Affiliation(s)
- Charles A James
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA.
| | - P Spencer Lewis
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA
| | - Mary B Moore
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA
| | - Kevin Wong
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA
| | - Emily K Rader
- Quality, Risk, and Safety Department, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Paula K Roberson
- Biostatistics Department, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Nancy A Ghaleb
- Anesthesia Department, Detroit Medical Center and Wayne State University, Detroit, MI, USA
| | - Hanna K Jensen
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA
| | - Amir H Pezeshkmehr
- Radiology Department, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Michael H Stroud
- Pediatrics Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Daniel J Ashton
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA
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Turan Ciftci T, Akinci D, Unal E, Tanır G, Artas H, Akhan O. Percutaneous management of complicated parapneumonic effusion and empyema after surgical tube thoracostomy failure in children: a retrospective study. ACTA ACUST UNITED AC 2021; 27:401-407. [PMID: 34003128 DOI: 10.5152/dir.2021.20331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to evaluate the results of percutaneous management of complicated parapneumonic effusions (PPE) and empyema after surgical tube thoracostomy failure in children. METHODS A total of 84 children treated percutaneously after surgical tube thoracostomy failure between 2004 and 2019 were included to this retrospective study. Technical success was defined as appropriate placement of the drainage catheter. Clinical success was defined as complete resolution of infection both clinically and radiologically. Management protocol included imaging-guided pigtail catheter insertion, fibrinolytic therapy, serial ultrasonographic evaluation, catheter manipulations as necessary (revision, exchange, or upsizing), and appropriate antibiotherapy. All patients were followed up at least 6 months. RESULTS Technical success rate was 100%. Unilateral single, unilateral double, and bilateral catheter insertions were performed in 73, 9, and 2 patients, respectively. Inserted catheter sizes ranged from 8 F to 16 F. Streptokinase, urokinase, and tissue plasminogen activator were used as fibrinolytic agent in 29 (34%), 14 (17%), and 41 (49%) patients, respectively. In order to maintain effective drainage, 42 additional procedures (catheter exchange, revision, reposition, or additional catheter placement) were performed in 20 patients (24%). Clinical success was achieved in 83 of 84 patients (99%). Median catheter duration was 8 days (4-32 days). Median hospital stay during percutaneous management was 11.5 days (7-45 days). Factors affecting the median catheter duration were the presence of necrotizing pneumonia (p < 0.001) and bronchopleural fistulae (p < 0.001). CONCLUSION Percutaneous imaging-guided catheterization with fibrinolytic therapy should be the method of choice in pediatric complicated PPE and empyema patients with surgical tube thoracostomy failure. Percutaneous treatment is useful in avoiding more aggressive surgical options.
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Affiliation(s)
- Turkmen Turan Ciftci
- Department of Radiology, Hacettepe University School of Medicine. Ankara, Turkey
| | - Devrim Akinci
- Department of Radiology, Hacettepe University School of Medicine. Ankara, Turkey
| | - Emre Unal
- Department of Radiology, Hacettepe University School of Medicine. Ankara, Turkey
| | - Gonul Tanır
- Department of Pediatric Infectious Disease, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Hakan Artas
- Department of Radiology, Firat University School of Medicine, Elazig, Turkey
| | - Okan Akhan
- Department of Radiology, Hacettepe University School of Medicine. Ankara, Turkey
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James CA, Braswell LE, Pezeshkmehr AH, Roberson PK, Parks JA, Moore MB. Stratifying fibrinolytic dosing in pediatric parapneumonic effusion based on ultrasound grade correlation. Pediatr Radiol 2017; 47:89-95. [PMID: 27709281 DOI: 10.1007/s00247-016-3711-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 06/29/2016] [Accepted: 09/13/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Complicated pleural effusion prolongs the hospital course of pneumonia. Chest tube placement with instillation of fibrinolytic medication allows efficient drain output and decreases hospital stay. OBJECTIVE To evaluate experience with lower fibrinolytic dose for parapneumonic effusions and to assess potential dose stratification based on a simple ultrasound grading system. MATERIALS AND METHODS We retrospectively reviewed the medical record to identify children and young adults who received fibrinolytic therapy for parapneumonic effusion and had chest tube placement by an interventional radiology service at a single children's hospital. We assessed tissue plasminogen activator (tPA) dosing and treatment duration, as well as the need for a second pleural procedure or surgical drainage. Diagnostic US images were classified as showing less than 50% pleural echogenicity (grade 1) or greater than 50% pleural echogenicity (grade 2) and were correlated with clinical parameters. RESULTS Of 32 patients with parapneumonic effusion, all except one received at least some 1-mg tPA doses. Dosing was solely 1-mg tPA in 81% of subjects; 19% of subjects also received 2-mg tPA doses. Mean fibrinolytic duration was 3.1 days for grade 1 effusions compared to 5.4 days for grade 2 effusions. A second pleural procedure was required in 15.6% of children. Pleural drainage with fibrinolytic therapy was successful in 97%; only one child required surgical drainage. Grade 2 US differed significantly from grade 1 US, with grade 2 occurring in younger patients (P < 0.0001), smaller patients (P < 0.0001), those needing a second procedure (P = 0.001), those with positive pleural culture or polymerase chain reaction test (P = 0.006), and those with longer treatment duration (P = 0.03). CONCLUSION A lower 1-mg dosing regimen of tissue plasminogen activator was effective in all children with less complex (grade 1 US imaging) parapneumonic effusions. Grade 2 US images correlated with younger and smaller children, presence of a pleural organism, and longer or more complicated chest tube duration.
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Affiliation(s)
- Charles A James
- Radiology Department, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 105, Little Rock, AR, 72202, USA.
| | - Leah E Braswell
- Radiology Department, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 105, Little Rock, AR, 72202, USA
| | - Amir H Pezeshkmehr
- Radiology Department, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 105, Little Rock, AR, 72202, USA
| | - Paula K Roberson
- Biostatistics Department, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - James A Parks
- Pharmacy Department, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Mary B Moore
- Radiology Department, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 105, Little Rock, AR, 72202, USA
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Generali JA, Cada DJ. Alteplase: pleural effusion (parapneumonic) and empyema in children. Hosp Pharm 2014; 48:912-21. [PMID: 24474831 DOI: 10.1310/hpj4811-912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This Hospital Pharmacy feature is extracted from Off-Label Drug Facts, a publication available from Wolters Kluwer Health. Off-Label Drug Facts is a practitioner-oriented resource for information about specific drug uses that are unapproved by the US Food and Drug Administration. This new guide to the literature enables the health care professional or clinician to quickly identify published studies on off-label uses and determine if a specific use is rational in a patient care scenario. References direct the reader to the full literature for more comprehensive information before patient care decisions are made. Direct questions or comments regarding Off-Label Drug Uses to jgeneral@ku.edu.
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Affiliation(s)
- Joyce A Generali
- Editor-in-Chief, Hospital Pharmacy, and Clinical Professor, Emeritus, Department of Pharmacy Practice, University of Kansas, School of Pharmacy, Kansas City/Lawrence, Kansas, e-mail:
| | - Dennis J Cada
- Founder and Contributing Editor, The Formulary, and Editor, Off-Label Drug Facts, e-mail:
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Israel EN, Blackmer AB. Tissue Plasminogen Activator for the Treatment of Parapneumonic Effusions in Pediatric Patients. Pharmacotherapy 2014; 34:521-32. [DOI: 10.1002/phar.1392] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Emily N. Israel
- Department of Pharmacy Services; University of Michigan Health System; Ann Arbor Michigan
- Department of Clinical, Social, and Administrative Sciences; University of Michigan College of Pharmacy; Ann Arbor Michigan
| | - Allison B. Blackmer
- Department of Pharmacy Services; University of Michigan Health System; Ann Arbor Michigan
- Department of Clinical, Social, and Administrative Sciences; University of Michigan College of Pharmacy; Ann Arbor Michigan
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Quality improvement guidelines for pediatric abscess and fluid drainage. Pediatr Radiol 2012; 42:1527-35. [PMID: 23114633 DOI: 10.1007/s00247-012-2499-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 08/22/2012] [Indexed: 10/27/2022]
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Hogan MJ, Marshalleck FE, Sidhu MK, Connolly BL, Towbin RB, Saad WA, Cahill AM, Crowley J, Heran MK, Hohenwalter EJ, Roebuck DJ, Temple MJ, Walker TG, Cardella JF. Quality Improvement Guidelines for Pediatric Abscess and Fluid Drainage. J Vasc Interv Radiol 2012; 23:1397-402. [DOI: 10.1016/j.jvir.2012.06.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 06/13/2012] [Accepted: 06/14/2012] [Indexed: 10/27/2022] Open
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Paraskakis E, Vergadi E, Chatzimichael A, Bouros D. Current evidence for the management of paediatric parapneumonic effusions. Curr Med Res Opin 2012; 28:1179-92. [PMID: 22502916 DOI: 10.1185/03007995.2012.684674] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Parapneumonic effusions (PPE) and empyema, secondary to bacterial pneumonia, are relatively uncommon but their prevalence is increasing lately. Even if their prognosis is generally good, they may still cause significant morbidity. The traditional treatment of PPE has been intravenous antibiotics and, when necessary, chest tube drainage. Open thoracotomy with decortication has usually been applied in case of failure of the traditional approach. Lately, the use of fibrinolysis and/or video-assisted thoracoscopic surgery (VATS) are utilized in the management of PPE; however, there is still little consensus on the most effective primary treatment. SCOPE In this article our goal was to summarize, based on up-to-date evidence, all the management options for PPE available to physicians and weigh the benefits and risks of the most popular ones, in an effort to figure out which one is superior as a first-line approach in children. FINDINGS A literature search of randomized and retrospective studies that pinpoint methods of evaluation and treatment of PPE was carried out in Medline and Scopus databases. Chest X-ray, ultrasound as well as microbiology and biochemical characteristics of the pleural fluid will facilitate decision-making. Small uncomplicated effusions resolve with antibiotics alone, larger ones require small-bore chest tube drainage and in case of complicated loculated PPE, fibrinolysis or VATS should be considered. Both methods promote faster drainage, reduce hospital stay and obviate the need for further interventions when used as first-line approach. However, primary treatment with VATS is not advised by the majority of studies as a first choice intervention, unless medical treatment has failed. CONCLUSION The main steps in treatment are diagnostic thoracocentesis and imaging, small percutaneous drainage, and considering fibrinolysis in complicated PPE. In case of failure, VATS should be the surgical method to be applied.
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Affiliation(s)
- Emmanouil Paraskakis
- Department of Paediatrics, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece.
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9
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Coley BD. Chest Sonography in Children: Current Indications, Techniques, and Imaging Findings. Radiol Clin North Am 2011; 49:825-46. [DOI: 10.1016/j.rcl.2011.06.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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10
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Rahman NM, Maskell NA, West A, Teoh R, Arnold A, Mackinlay C, Peckham D, Davies CWH, Ali N, Kinnear W, Bentley A, Kahan BC, Wrightson JM, Davies HE, Hooper CE, Lee YCG, Hedley EL, Crosthwaite N, Choo L, Helm EJ, Gleeson FV, Nunn AJ, Davies RJO. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med 2011; 365:518-26. [PMID: 21830966 DOI: 10.1056/nejmoa1012740] [Citation(s) in RCA: 468] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND More than 30% of patients with pleural infection either die or require surgery. Drainage of infected fluid is key to successful treatment, but intrapleural fibrinolytic therapy did not improve outcomes in an earlier, large, randomized trial. METHODS We conducted a blinded, 2-by-2 factorial trial in which 210 patients with pleural infection were randomly assigned to receive one of four study treatments for 3 days: double placebo, intrapleural tissue plasminogen activator (t-PA) and DNase, t-PA and placebo, or DNase and placebo. The primary outcome was the change in pleural opacity, measured as the percentage of the hemithorax occupied by effusion, on chest radiography on day 7 as compared with day 1. Secondary outcomes included referral for surgery, duration of hospital stay, and adverse events. RESULTS The mean (±SD) change in pleural opacity was greater in the t-PA-DNase group than in the placebo group (-29.5±23.3% vs. -17.2±19.6%; difference, -7.9%; 95% confidence interval [CI], -13.4 to -2.4; P=0.005); the change observed with t-PA alone and with DNase alone (-17.2±24.3 and -14.7±16.4%, respectively) was not significantly different from that observed with placebo. The frequency of surgical referral at 3 months was lower in the t-PA-DNase group than in the placebo group (2 of 48 patients [4%] vs. 8 of 51 patients [16%]; odds ratio for surgical referral, 0.17; 95% CI, 0.03 to 0.87; P=0.03) but was greater in the DNase group (18 of 46 patients [39%]) than in the placebo group (odds ratio, 3.56; 95% CI, 1.30 to 9.75; P=0.01). Combined t-PA-DNase therapy was associated with a reduction in the hospital stay, as compared with placebo (difference, -6.7 days; 95% CI, -12.0 to -1.9; P=0.006); the hospital stay with either agent alone was not significantly different from that with placebo. The frequency of adverse events did not differ significantly among the groups. CONCLUSIONS Intrapleural t-PA-DNase therapy improved fluid drainage in patients with pleural infection and reduced the frequency of surgical referral and the duration of the hospital stay. Treatment with DNase alone or t-PA alone was ineffective. (Funded by an unrestricted educational grant to the University of Oxford from Roche UK and by others; Current Controlled Trials number, ISRCTN57454527.).
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Affiliation(s)
- Najib M Rahman
- UKCRC Oxford Respiratory Trials Unit, Oxford Centre for Respiratory Medicine, Nuffield Department of Medicine, University of Oxford, Churchill Hospital Site, Headington, Oxford OX3 7LJ, United Kingdom.
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Roebuck DJ, Hogan MJ, Connolly B, McLaren CA. Interventions in the Chest in Children. Tech Vasc Interv Radiol 2011; 14:8-15. [DOI: 10.1053/j.tvir.2010.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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12
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Ben-Or S, Feins RH, Veeramachaneni NK, Haithcock BE. Effectiveness and Risks Associated With Intrapleural Alteplase by Means of Tube Thoracostomy. Ann Thorac Surg 2011; 91:860-3; discussion 863-4. [DOI: 10.1016/j.athoracsur.2010.10.082] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Revised: 10/27/2010] [Accepted: 10/29/2010] [Indexed: 11/26/2022]
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Goralski JL, Bromberg PA, Haithcock B. Intrapleural hemorrhage after administration of tPA: a case report and review of the literature. Ther Adv Respir Dis 2010; 3:295-300. [PMID: 19934281 DOI: 10.1177/1753465809350748] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Intrapleural fibrinolytic enzymes have been used for over 60 years in the treatment of complicated pleural effusions to lyse loculations and promote resolution. Despite this extensive history of use, however, little is known about complications that may arise with the use of this therapy. Here we discuss a patient with chronic renal failure on hemodialysis who developed an intrapleural hemorrhage after the administration of intrapleural tPA to treat a complicated parapneumonic effusion. A review of the literature examines the efficacy and safety of this therapy, focusing on bleeding complications. Specific attention is paid to patients who have underlying coagulopathies or who are receiving anticoagulation. DATA SOURCES A review of the literature, as indexed in PubMed, was undertaken using the following search terms in combination: tPA, pleural effusion, complications of thrombolytics, and intrapleural hemorrhage. The search was inclusive of patients under the age of 18, but was limited by English language and human subjects. STUDY SELECTION/DATA EXTRACTION All relevant articles identified during the search were reviewed. Those studies that reported on bleeding complications, or lack thereof, were included in this review. Limitations of each article are noted in the text. CONCLUSIONS Multiple studies, including a 2000 ACP consensus statement and a 2008 Cochrane review, indicate the need for further investigations to evaluate the safety and efficacy of intrapleural thrombolytics for the treatment of complicated pleural effusions and empyemas. Limited studies specifically address bleeding complications, especially in subpopulations of patients receiving concurrent anticoagulant therapy.
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Affiliation(s)
- Jennifer L Goralski
- University of North Carolina at Chapel Hill, Division of Pulmonary and Critical Care Medicine, Chapel Hill, NC, USA.
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15
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Antibiothérapie des pleuropneumopathies de l’enfant : quelles leçons tirer des études cliniques publiées et propositions thérapeutiques. Arch Pediatr 2008; 15 Suppl 2:S84-92. [DOI: 10.1016/s0929-693x(08)74222-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
Pneumonias in children can be complicated by pleural effusions, empyema and abscesses. The incidence of these complications is increasing, correlated to an increased virulence of the pneumococcal bacterium. These complications may prolong morbidity and lead to decreased pulmonary function. Traditionally, patients were treated medically with antibiotics, and refractory complications were treated surgically with large bore chest tube placement and thoracotomy. Improvements included instilling fibrinolytics into the chest tubes and video-assisted thoracoscopic surgery, which expedited recovery and improved outcomes. Image guided techniques from interventional radiology have been developed as an alternative to treat these patients with minimal invasiveness. These therapies have achieved high success and low complication rates, and are the preferred first-line procedures when available.
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Affiliation(s)
- Mark J Hogan
- Section of Vascular and Interventional Radiology, Nationwide Children's Hospital, Departmentof Radiology, 700 Children's Drive, Columbus, OH 43205, USA.
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Abstract
The ability to recognize, understand, and treat pleural effusions in the pediatric population is important for pediatric health care providers. The topic of pleural effusions has been extensively studied in the adult population. In recent years, these studies have extended into the pediatric population. This review describes pleural effusions in detail, including the different types and underlying pathophysiology. We then go on to provide a comprehensive review of the recent literature regarding the diagnosis and treatment of pleural effusions in the pediatric population.
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Affiliation(s)
- Sara L Beers
- Children's Medical Center Dallas, Pediatric Emergency Medicine, Dallas, TX 75235, USA.
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Byington CL, Korgenski K, Daly J, Ampofo K, Pavia A, Mason EO. Impact of the pneumococcal conjugate vaccine on pneumococcal parapneumonic empyema. Pediatr Infect Dis J 2006; 25:250-4. [PMID: 16511389 DOI: 10.1097/01.inf.0000202137.37642.ab] [Citation(s) in RCA: 174] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric pneumococcal parapneumonic empyema (PPE) has become increasingly common. In the last decade, Utah has had one of the highest rates of PPE in the United States, 14/100,000 children, attributed primarily to Streptococcus pneumoniae serotype 1. Our objective was to describe the temporal trends in PPE in Utah before and after the availability of the 7-valent pneumococcal conjugate vaccine (PCV-7). METHODS The Intermountain Health Care (IHC) data warehouse was queried for all cases of empyema in children younger than 18 years, defined as International Classification of Diseases, 9th revision, Clinical Modification code 510.9, for the study period March 1996-June 2005. We also retrieved and serotyped all blood and pleural fluid isolates of S. pneumoniae from children younger than 18 years with a diagnosis of PPE at Primary Children's Medical Center (PCMC) between March 1996 and June 2005. The pre-PCV-7 period (PRE) included 57 months (March 1996-December 2000) and the post-PCV-7 period (POST) included 54 months (January 2001-June 2005). RESULTS We identified 776 cases of pediatric empyema in the IHC system, and 478 (62%) were managed at PCMC. In the years 1996-2000, we managed a mean of 38 cases of empyema per year compared with 71.5 cases per year between 2001 and 2004 (P = 0.006). At PCMC, there were 295 cases of invasive pneumococcal disease (IPD), and 74 (25%) were PPE. During the PRE period, PPE represented 24 of 137 (17.5%) cases of IPD compared with 50 of 158 (32%) in the POST period (P = 0.008). One-half of the children with PPE required intensive care and 4 died. During the PRE and POST periods, PPE was most often caused by serotype 1 (46 and 34%, respectively), but in the POST period serogroups 3 (20%), and 19A (14%) were also prevalent. PPE in PCV-7-immunized children was caused exclusively by nonvaccine serotypes. CONCLUSIONS PPE in the post-PCV-7 era is more common, representing one-third of the IPD in children in UT. PPE is associated with significant morbidity and mortality. Serotype 1 remains the most common cause of PPE, but serotypes 3 and 19A are emerging.
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Abstract
Ultrasound examination of the thorax can be quite rewarding in children, because their unique thoracic anatomy provides many acoustic windows into the chest. With only a modest effort, chest ultrasonography can provide many clinically relevant answers, without the radiation exposure from CT, or the need for sedation sometimes required for CT and MR imaging.
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Affiliation(s)
- Brian D Coley
- Section of Ultrasound, Department of Radiology, Columbus Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
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Skeete DA, Rutherford EJ, Schlidt SA, Abrams JE, Parker LA, Rich PB. Intrapleural Tissue Plasminogen Activator for Complicated Pleural Effusions. ACTA ACUST UNITED AC 2004; 57:1178-83. [PMID: 15625447 DOI: 10.1097/01.ta.0000141879.67441.52] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study is aimed at evaluating the safety and efficacy of intrapleural tissue plasminogen activator (TPA) for complicated pleural effusions, including posttraumatic hemothorax. METHODS Data were retrospectively collected from hospitalized patients over a 4-year period (1999-2003) who were treated with intrapleural TPA after failing drainage by tube thoracostomy. Pre- and post-TPA imaging studies were reviewed and scored by a blinded radiologist. RESULTS Forty-one consecutive patients with 42 effusions were identified with the following indications: 6 traumatic hemothoraces (14%), 22 loculated pleural effusions (52%), 2 line-associated hemothoraces (5%), and 12 empyemas (29%). Nine patients (22%) required operative drainage including two with posttraumatic hemothoraces. All patients managed nonoperatively demonstrated radiographic improvement after TPA administration. One patient (2.4%) developed hematuria, requiring transfusion. No trauma patient required TPA-related blood transfusion and no deaths were attributable to TPA therapy. CONCLUSION Intrapleural TPA administration appears safe for use in complicated pleural effusions and may decrease the need for operative intervention.
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Affiliation(s)
- Dionne A Skeete
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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