B. L. Spencer1, D. M. Lotakis1, A. Vaishnav1, J. Carducci1, L. Hoff1, K. Speck1, E. E. Perrone1 1University Of Michigan, Section Of Pediatric Surgery, Ann Arbor, MI, USA
Introduction: Randomized control trials in the pediatric population, first published in 2009, have shown no therapeutic advantage of video-assisted thoracoscopic surgery (VATS) over fibrinolytic therapy (tPA) for empyema management. However, literature detailing changes in practice management and protocol implementation is limited, despite publication of Consensus Guidelines in 2012. In 2018, we instituted clinical practice guidelines (CPG) for empyema management utilizing tPA instillation via a small-bore chest tube as initial therapy. Our aim was to determine differences in treatment and outcomes before and after institutional CPG implementation.
Methods: A single institution retrospective study (2002-2022) examined patients 0-18 years diagnosed with pneumonia and associated empyema (loculated pleural fluid on ultrasound or computed-tomographic scan). Comparison groups were pre- and post-CPG implementation. Comparative statistics were performed using significance level p<0.05.
Results: Sixty-one patients met inclusion criteria: 33(54%) pre-implementation and 28(46%) post. Demographics including age, gender, race, as well as diagnostic imaging modalities were similar between groups. There were no significant differences in time to initiate antibiotics (1.94 vs 5.53 days, p=0.08), antibiotic duration (21.4 vs 20.3 days, p=0.08), intensive-care-unit (ICU) length of stay (LOS) (5.9 vs 7.04 days, p=0.58), nor total hospital LOS (13.8 vs 15 days, p=0.47). Utilization of VATS as initial intervention significantly decreased from 66% to 10% after protocol implementation (p<0.01); failure rates of initial therapy choice were similar (12% vs 10%, p=0.87). Marked reduction in total patients undergoing operative intervention at any point during course of therapy was observed, 79% pre-implementation vs 21% post (p<0.01). Total number of patients undergoing operative intervention remained higher despite consensus guidelines publication in 2012 (p=0.44), however following CPG implementation primary tPA therapy was significantly more prominent (p <0.00001) (Figure 1).
Conclusion: In children being treated for empyema the overall incidence of operative intervention was significantly lower following CPG implementation in which chest tube placement with tPA administration was the primary therapy of choice. Changes in antibiotic usage, ICU and total LOS, and initial therapy failure rates were unaffected. In our experience,
