Despite numerous publications on the management of empyemas, it is still not clear which pediatric patients can be medically managed without video assisted thorascopic decortication (VATS). This likely relates to the heterogeneous nature of the disease process. Our institution has handled each case individually based on recommendations from medical and surgical subspecialists.
A retrospective chart review was performed on all patients discharged from a 20 bed Pediatric intensive care unit with the diagnosis of empyema from 2006–2008. For statistical analysis, a student's t test was performed and values < 0.05 were considered significant.
36 patients were discharged with the diagnosis of empyema. Two patients underwent primary thoracotomy based on the surgeon's decision and were not included in this review. The other 34 patients were analyzed in three groups: nonsurgical, primary VATs and VATS rescue. The hospital median length of stay was 22 days for VATs rescue, 17 days for VATs and 15 days for non-surgically managed empyemas. The median length of time a chest tube was in place was 12 days for VATs rescue, 4 days for VATS and 3.5 days for non-surgically managed empyemas. (See table one).
Patients that underwent VATs after medical management failed had their chest tubes in place longer and had a significantly longer LOS. Unfortunately, this group had the shortest duration of symptoms and that was the primary reason that medical management was the first line therapy. An algorithm has now been developed at our institution that takes into account duration of symptoms, radiographic appearance of the empyema, and early response to non-surgical therapy. It also recommends a shorter course of antibiotics. Data is being collected prospectively after implementation of this algorithm.
A pediatric specific algorithm may improve patient care by properly identifying patients for early VATS and shortening both the duration of chest tube placement and LOS.
Christopher Babbitt, No Financial Disclosure Information; No Product/Research Disclosure Information