Thoracostomy and fibrinolysis for the management of empyema

A little throw back to 2009 prompted by a discussion on management of parapneumonic effusion/empyema.

In the frequently quoted study out of The Center for Prospective Clinical Trials in Kansas City, the authors compared the effectiveness of VATS vs thoracostomy/fibrinolysis in 36 patients.  Empyema was defined based on imaging characteristics or WBC content and then managed with either VATS or thoracostomy (chest catheter drainage with a12 F tube) with fibrinolysis using 3 doses of 4 mg of Altase given over a 48 hour period.

No significant difference was found in the outcomes assessed, which were days of hospitalization (6.9 vs. 6.8 days), days of oxygen requirement (2.3 days), days until afebrile (3.1 vs. 3.8), or analgesic requirements. The difference in cost was $11.7K vs $7.6K between VATS and thoracostomy /fibrinolysis, respectively.

Although fibrinolysis was sufficient for most patients, 16.6% still needed VATS; an important point to mention to parents when discussing the procedure.

Another important point to stress here is that in many institutions, the most common chest catheters available are 8.5 Fr (and not 12 Fr), and one should make sure the appropriate catheter is used to optimize the chance for success.

Is a bowel prep necessary before colostomy reversal?

Another paper that supports omitting bowel preps before pediatric bowel operations came out in this month’s issue of JPS. In this study, the authors conducted a retrospective, multi-institution study and compared the outcome of 272 children who underwent colostomy reversal with and without (187 vs. 85) a polyethylene glycol bowel prep.

The authors noted a significantly higher rate of wound infection (14.4% vs. 5.8%), as well as a longer hospital stay (5.6% vs. 4.4%) in the group who underwent a bowel prep. Additionally, they noted that the risk for other complications such as abdominal abscess formation (~1%) and ansastomotic leak (~1%) was the same whether a bowel prep was used or not.

Reasons given for the potential deleterious effects of the bowel prep included the characteristics of liquid stool (bowel prep) that make it more difficult to contain, the fact that the bacterial load in prep’d stool is not necessarily lower than unprepped stool (papers sited), and the potential harmful effect of the bowel prep on the integrity of the bowel mucosa.

As with all retrospective studies, the authors acknowledged the limitations of their results, but stressed that, except for intra-pelvic rectal surgery, a bowel prep is likely unnecessary for colonic surgery in children.

Reference:
Serrurier K et al. A multicenter evaluation of the role of mechanical bowel preparation in pediatric colostomy takedown. JPS (2012);47:190-193

Avoiding placement of implanted central venous catheters in neutropenic patients decreases complication rates

The authors of this study evaluated the outcome of the implementation of a protocol that restricts the placement of implanted central venous catheters to patients with an ANC greater or equal to 500. This was based on previous findings that suggested that placement of implantable central venous devices in neutropenic patients is associated with higher rate of complications.

The authors found a higher rate of complications (infectious and technical) in neutropenic patients. Additionally, the rate of these complications was substantially decreased after implementation of a protocol that excludes neutropenic from device placement.

Gollin G, Gutierrez I. Exclusion of neutropenic children form implanted central venous catheter placement: impact on early catheter removal. J Pediatr Surg 2010;45:1115-1119

When is prophylaxis against infectious endocarditis indicated?

Infectious endocarditis (IE) occurs when nonbacterial thrombotic endocarditis (NBTE) becomes infected after an episode of transient bacteremia. NBTE results from platelet/fibrin deposition at areas of abnormal and turbulent blood flow. Any event that can cause transient bacteremia (eg. violation of the GI tract) can transform NBTE to IE.

The AHA recommendations for endocarditis prophylaxis were modified in 2007 [Circulation (2007);116:1736-54) in light of the understanding that most IE results from random episodes of bacteremia not related to specific procedures and the concern for the potential harmful effects of unwarranted antibiotic administration

Only patients with specific cardiac IE risk factors [table] should be considered for prophylactic antibiotic administration.

Recommendations for respiratory tract procedures:
Single pre-procedure antibiotic dose (Cefazolin/clindamycin/ceftriaxone or Vanco if MRSA suspected) for any procedure expected to violate (incision/biopsy) the mucosa or for procedures intended to treat an existing infection (drainage of empyema/abscess).

Recommendations for GI or GU tract procedures:
Single pre-procedure antibiotic dose effective against enterococci should be used, when indicated, since these are the only organisms likely to cause IE.
Prophylaxis is NOT indicated for diagnostic GI/GU procedures (endoscopy, cycstoscopy etc..).

When patients are receiving antibiotics for a GI/GU infection or to prevent wound infection, it is suggested that the antibiotics used include an agent effective against enterococci (PCN, ampicillin, piperacillin, or Vanco).

Recommendations for infected skin/skin structure/musculoskeletal tissue
Only staph and B-hemolytic strep are likely causes of IE in this situation. Prudent to use antistaphylococcal agents.

Mediports and neutropenia

As pediatric surgeons, we are frequently faced with the the request for an "urgent" line to be placed in children with a newly diagnosed ALL. Having been involved in several situations where I am asked to place a mediport in a neutropenic child in order to start induction therapy, I decided to look at the available literature addressing the risk of line placement this patient population.

Understandably, the presence of a central line in any child increases the risk of infection. Rackoff et al (J Ped Heme Onc (1999) 21(4):260) in a study looking at the risk of infection in patients with ALL, showed that the presence of a line increases the risk of infection 4 fold.
Another study by Saul et al. (J Am Col Surg (1998) 186(6):654-8) looking at the risk of infection of line placement in children in general (most of whom had ALL), showed that the two main risk factors for line infection are neutropenia (ANC<1,000/mm) and failure to administer perioperative antibiotics.
Finally, as a direct answer my main question regarding whether we should place lines in neutropenic ALL patients or not, McLean et al (J Clin Onc (2005) 23(13):3024) looked at the risk of complications in lines placed early (<15 days) vs late (>15days) after initiation of induction therapy and noted that early placement was associated with a higher risk of positive blood cultures (OR 2.2) ,with the mean ANC being significantly lower in patients whose lines had to be removed (601/mm vs. 1,390/mm).

The way I see it, the best way to manage patients with newly diagnosed ALL (particularly if they are neutropenic), is to place a PICC line to start induction therapy then schedule an elective mediport placement at day 28 when these patients routinely get a repeat BM biopsy under general anesthesia as part of the protocol.