Introduction and Objectives In our centre patients are managed using a protocol-driven integrated-care pathway. Intra-pleural urokinase is administered via a fine bore chest-drain as primary therapy for significant pleural disease. We analysed patient outcomes with this approach to benchmark standards of care whilst examining patterns of disease severity with introduction of the pneumococcal conjugate vaccine. In addition we aimed to identify factors associated with failure of fibrinolytic therapy, defined as the need for a second intervention, (second chest-drain, VATS or thoracotomy).
Methods Medical case-records were reviewed on all children managed at a tertiary centre from Jan 2006-Dec 2012. We examined outcomes on all patients including those with significant medical comorbidities. Data were analysed using binary logistic regression in order to try to identify factors associated with therapy failure, (SPSS Version 20). The effect of; age, comorbidities, number of days of intravenous antibiotics prior to drainage, number of doses of urokinase given and whether initial imaging, (plain radiograph, ultrasound or CT), showed evidence of necrotising disease.
Results A total of 242 children were treated; age range 4 months-19 yrs; median 4 yrs. We observed a decreasing number of children presenting year-on-year with complicated pleural infection, (Figure 1). The vast majority of children were managed without surgery using either antibiotics alone (28%), or a fine-bore chest-drain and urokinase (70%), with good outcome. Only 2% children required a primary thoracotomy whilst 14.6% failed fibrinolytic therapy and required a second intervention. The only factor that appeared to predict failure was the suspicion of necrotising disease on initial imaging (p = 0.01, OR 0.11). Median length-of-stay for all children, including those with medical co-morbidity, was 10 days (range 1–118 days).
Conclusions We have observed a decreasing incidence of complicated pleural infection at this centre since 2006. Good patient outcome supports timely management of children using an integrated care-pathway led by a multidisciplinary team. The vast majority of children may be safely managed without surgery.
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