Thoracoscopic decortication as first-line therapy for pediatric parapneumonic empyema. A case series.

STUDY OBJECTIVES: Previous articles have promoted the early use of thoracotomy and decortication for refractory empyema. This study examines thoracoscopy and decortication at the time of initial chest tube placement in pediatric patients with parapneumonic empyema. DESIGN: We reviewed the medical records of 16 consecutive patients who were children with parapneumonic empyema. RESULTS: Thirteen children (group 1) underwent thoracoscopic decortication and tube thoracostomy as their initial operative procedures; 3 children (group 2) had tube thoracostomy alone. In both groups, chest tubes were removed prior to their discharge to home. The mean (+/- SD) operative time for thoracoscopy was 81 +/- 19 min with no complications. On average, chest tubes were removed by postoperative day 4. The mean time to discharge was 8.3 days. Two children eventually required lobectomy. The mean operative time for chest tube placement alone was 21 +/- 3 min. Children required chest tube drainage for an average of 12.3 days. The mean time to discharge was 16.6 days. Two patients required a total of five additional operative procedures, including two additional chest tube placements, two open decortications, and one lobectomy. CONCLUSIONS: Thoracoscopic decortication is effective in the early treatment of pediatric parapneumonic empyema. It facilitates visualization, evacuation, and mechanical decortication of the pleural space with no additional morbidity and may lead to reduced time for chest tube drainage, shorter hospitalization, and more rapid clinical recovery.

Blunt intestinal injury in children: the role of the physical examination.

PURPOSE: Although blunt intestinal injury in children is uncommon, prompt recognition and treatment is imperative. Because the best method for diagnosis remains undetermined, the authors reviewed their experience with this injury in children to determine the most reliable diagnostic method and to identify factors associated with treatment delays. METHODS: From January 1989 through December 1995, 2,284 children were admitted to the level I trauma center after sustaining blunt abdominal trauma. Of these, 32 (1.4%) had intestinal injury confirmed during laparotomy. Each case was reviewed with particular attention to the initial physical examination, abdominal computed tomography (CT) scan, laparotomy observations, complications, and the hospital at which the child was initially treated, if applicable. Fisher's Exact test and Wilcoxon's rank sum test were used for statistical analyses, with P < .05 considered significant. RESULTS: Twenty-five patients (78%) had major intestinal injuries that required repair or resection; seven had minor intestinal injuries only. Two-thirds of the 32 were restrained passengers in motor vehicle crashes. The initial physical examination was suggestive of intestinal injury in 94% of children. Twenty-one children (84%) with major bowel injuries had diffuse abdominal tenderness at the time of initial physical examination, and only one of the seven (14%) with minor intestinal injury had generalized tenderness (P = .0014). Sixteen of 21 restrained passengers had seat-belt ecchymoses, and 13 of the 16 sustained major intestinal injuries. Only 1 of 13 abdominal CT scans performed was diagnostic of intestinal injury. Ten of 12 patients (83%) who underwent delayed laparotomy (more than 12 hours after injury) were initially evaluated at hospitals without trauma center designation; whereas 6 of the 20 nondelayed patients were evaluated at these hospitals (P = .0091). All four major complications occurred in the delayed group. CONCLUSION: The authors conclude that signs suggestive of major intestinal injury are present in children at the time of initial physical examination or shortly thereafter. The decision to operate can be based on this examination alone in the pediatric population. Abdominal CT scan is not reliable for the diagnosis of blunt intestinal injury in children. To expedite diagnosis and treatment, children who sustain blunt abdominal trauma should be examined immediately by a physician experienced in pediatric trauma care or be transferred to a designated trauma center where this service is available.

Morphometry and histochemistry of pulmonary arteries in a hypoplastic lung model.

Persistent pulmonary hypertension (PPH) is a common consequence of many neonatal respiratory diseases. The pathophysiology of PPH remains unknown. To study PPH, a rat model of pulmonary hypoplasia was used. Lung mass and body mass were recorded and lungs were prepared for frozen section examination and stained with hematoxylin and eosin, elastin, anti-Factor VIII, and nitro blue tetrazolium to identify nicotinamide adenine dinucleotide phosphate (NADPH) diaphorase. The lungs were analyzed for air space volume, pulmonary artery wall thickness, total pulmonary arterial cross-sectional area, and density of tissue NADPH diaphorase staining. The mass of hypoplastic lungs was less than that of normal lungs (mean mass 85.93 mg vs 142.97 mg, P < 0.0001). The measured fraction of airspace volume was significantly less in hypoplastic lungs compared to controls (17.7% vs 30.8%, P < 0.0001). There was a significant difference in the pulmonary artery wall thickness ratio between the two groups (control 0.46 vs hypoplastic 0.487, P = 0.001). The arterial cross-sectional area was identical (control 1.25% vs hypoplastic 1.37%, P = 0.47). Staining density for NADPH diaphorase activity was determined using an intensity staining index (ISI). The experimental group showed increased staining for NADPH diaphorase (ISI = 54 in hypoplastic lungs vs 38 in controls, P < 0.01). Lung mass, appearance, and measured volume of airspace and tissue were all consistent with hypoplasia. In this model, arterial wall thickness was measurably greater in the hypoplastic group, while arterial cross-sectional area was not different. Staining for NADPH diaphorase showed significantly greater levels of enzyme in the hypoplastic lung.(ABSTRACT TRUNCATED AT 250 WORDS)

Appendicitis: usefulness of US in diagnosis in a pediatric population.

One hundred eighty pediatric patients with suspected appendicitis were prospectively examined with graded compression ultrasonography (US) to assess the sensitivity, specificity, and accuracy of graded compression US in the diagnosis of appendicitis in children and to compare those results with results of clinical assessment in the diagnosis of this disorder. Patients were assigned to one of three groups prior to US based on the clinical level of confidence that appendicitis was present and on the planned management decision. Of 141 patients in the low- and intermediate-clinical risk categories, 20 (14%) had appendicitis: US had a sensitivity of 100%, specificity of 97%, and accuracy of 97% in these two groups. Of 39 patients in the high-clinical risk category, 32 (82%) had appendicitis: US had a sensitivity of 81%, specificity of 86%, and accuracy of 82%. Of 52 patients with surgically proved appendicitis, the initial management decision was to discharge to home or admit for observation and further testing in 18 (35%). Results at US were positive for appendicitis in all 18 patients in the latter two categories.

Laparoscopic cholecystectomy in pediatric patients.

Laparoscopic cholecystectomy has gained increasing application as an operative approach for adults with gallbladder disease. We assessed the safety and feasibility of this technique in five pediatric patients with symptomatic cholelithiasis, two of whom had sickle cell disease. With several technical modifications, we found that laparoscopic cholecystectomy was safe and effective in children. This technique permitted early discharge with expedient return to full activity.

Extracorporeal membrane oxygenation for pediatric cardiopulmonary failure.

Extracorporeal membrane oxygenation is now standard treatment of severe respiratory failure in newborn infants in our center (200 cases) and worldwide (over 2500 cases), but there are few reports of such trials in older children. We reviewed our experience with extracorporeal membrane oxygenation in 33 children aged 1 week to 18 years between 1971 and 1989. The modality was used when all other treatment failed. Extracorporeal membrane oxygenation provided excellent cardiopulmonary support for 1 to 25 days (average 7 1/2 days). The survival rate was 25% for cardiac support patients and 47% for respiratory failure patients (36% overall survival). Mechanical complications included membrane lung failure, tubing rupture, and pump failure, all managed without mortality. Physiologic complications included bleeding, pneumothorax, cardiac arrest, renal failure, hepatic failure, and brain injury. The major cause of death was irreversible injury to lung, heart, or brain. Extracorporeal life support is a reasonable approach for children with serious but reversible cardiopulmonary failure.

Laboratory evaluation of a double lumen catheter for venovenous neonatal ECMO.

The authors designed and tested a 14F outside diameter thin-walled double lumen catheter (DLC) for neonatal venovenous (VV) extracorporeal membrane oxygenation (ECMO). In vitro tests with water and dye solution showed capacity of the drainage lumen was 1,096 ml/min at 100 cm siphon, and pressure drop across the perfusion lumen was 300 mmHg at 500 ml/min flow. Recirculation at 500 ml/min flow ranged from 5 to 29%, depending upon simulated cardiac output. The highest serum hemoglobin during 12 hour 400 ml/min flow VV bypass in five dogs was 49 mg/dl. Typical oxygen transport in four dogs was 25 cc/min at 400 ml/min flow. This catheter is well suited for clinical VV ECMO in neonates.