Michael H Livingston1, Eyal Cohen2, Lucy Giglia3, David Pirrello4, Niraj Mistry2, Sanjay Mahant2, Michael Weinstein2, Bairbre Connolly5, Sharifa Himidan6, Andreana Bütter7, J Mark Walton8. 1. McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada; Clinician Investigator Program, McMaster University, Hamilton, Ontario, Canada. 2. Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada. 3. Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada. 4. McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada. 5. Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada. 6. Division of General & Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada. 7. Division of Pediatric Surgery, Western University, London, Ontario, Canada. 8. McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada; Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada. Electronic address: waltonj@mcmaster.ca.
Abstract
BACKGROUND: Guidelines recommend that children with empyema be treated initially with chest tube insertion and intrapleural fibrinolytics. Some patients have poor outcomes with this approach, and it is unclear which factors are associated with treatment failure. METHODS: Possible risk factors were identified through a review of the literature. Treatment failure was defined as need for repeat pleural drainage and/or total length of stay greater than 2weeks. RESULTS: We retrospectively identified 314 children with empyema treated with fibrinolytics at The Hospital for Sick Children (2000-2013, n=195), Children's Hospital, London Health Sciences Centre (2009-2013, n=39), and McMaster Children's Hospital (2007-2014, n=80). Median length of stay was 11days (range 5-69days). Thirteen percent of children required repeat drainage procedures, and 34% experienced treatment failure. There were no deaths. White blood cell count, erythrocyte sedimentation rate, C-reactive protein, albumin, urea to creatinine ratio, and signs of necrosis on initial chest x-ray were not associated with treatment failure. Multivariable logistic regression demonstrated increased risk with positive blood culture (odds ratio=2.7), immediate admission to intensive care (odds ratio=2.6), and absence of complex septations on baseline ultrasound (odds ratio=2.1). Male gender and platelet count were associated with treatment failure in the univariate analysis but not in the multivariable model. CONCLUSIONS: Predicting which children with empyema are at risk for treatment failure with fibrinolytics remains challenging. Risk factors include positive blood culture, immediate admission to intensive care, and absence of complex septations on ultrasound. Routine blood work and inflammatory markers have little prognostic value.
BACKGROUND: Guidelines recommend that children with empyema be treated initially with chest tube insertion and intrapleural fibrinolytics. Some patients have poor outcomes with this approach, and it is unclear which factors are associated with treatment failure. METHODS: Possible risk factors were identified through a review of the literature. Treatment failure was defined as need for repeat pleural drainage and/or total length of stay greater than 2weeks. RESULTS: We retrospectively identified 314 children with empyema treated with fibrinolytics at The Hospital for Sick Children (2000-2013, n=195), Children's Hospital, London Health Sciences Centre (2009-2013, n=39), and McMaster Children's Hospital (2007-2014, n=80). Median length of stay was 11days (range 5-69days). Thirteen percent of children required repeat drainage procedures, and 34% experienced treatment failure. There were no deaths. White blood cell count, erythrocyte sedimentation rate, C-reactive protein, albumin, urea to creatinine ratio, and signs of necrosis on initial chest x-ray were not associated with treatment failure. Multivariable logistic regression demonstrated increased risk with positive blood culture (odds ratio=2.7), immediate admission to intensive care (odds ratio=2.6), and absence of complex septations on baseline ultrasound (odds ratio=2.1). Male gender and platelet count were associated with treatment failure in the univariate analysis but not in the multivariable model. CONCLUSIONS: Predicting which children with empyema are at risk for treatment failure with fibrinolytics remains challenging. Risk factors include positive blood culture, immediate admission to intensive care, and absence of complex septations on ultrasound. Routine blood work and inflammatory markers have little prognostic value.
Authors: Michael H Livingston; Sanjay Mahant; Felix Ratjen; Bairbre L Connolly; Kevin Thorpe; Muhammad Mamdani; Ian Maclusky; Sophie Laberge; Lucy Giglia; J Mark Walton; Connie L Yang; Ashley Roberts; Anna C Shawyer; Mary Brindle; Simon J Parsons; Cristina A Stoian; Eyal Cohen Journal: Trials Date: 2017-06-24 Impact factor: 2.279