Decortication for childhood empyema. The primary provider's peccadillo
A. S. Kennedy, M. Agness, L. Bailey and J. J. White
Division of Pediatric Surgery, Loma Linda University Medical Center, Calif. 92354.
Of the 31 children treated for empyema thoracis secondary to pneumonitis at
the Loma Linda University Medical Center, Loma Linda, Calif, from 1980 to
1990, 23 responded to prompt directed antibiotic therapy coupled with
drainage, usually tube thoracostomy. All patients were cured clinically;
some demonstrated residual pleural reaction with chest roentgenography or
computed tomography that resolved over time. Decortication was necessary in
eight severely ill children; three required concurrent lung resection for
abscess. Distinct from the nonoperated group, there was a pattern of
initial antibiotic trials in these patients averaging 6.5 different drugs
plus delayed drainage of effusions. Delay in the initiation of antibiotic
therapy was six times longer for the operated vs the nonoperated group.
Delay to tube thoracostomy was 18 days for the decorticated children
compared with 5.4 days for the nondecorticated children. All eight children
responded completely and rapidly to their decortications. Roentgenographic
changes lagged considerably behind the clinical course of the child, and
computed tomographic scans provided better identification of chest tube
placement but little information predictive of the need for decortication.
Decortication for empyema seldom is necessary when a child is treated
promptly with appropriate antibiotics directed by thoracentesis findings,
and drainage, usually tube thoracostomy. The criterion for decortication is
persistent sepsis, not the roentgenographic appearance of the chest.
