[Intrapleural urokinase in the treatment of parapneumonic effusions]. / Utilidad de la urocinasa intrapleural en el tratamiento del derrame pleural paraneumónico.

INTRODUCTION: Intrapleural fibrinolytic instillation has been used in the treatment of loculated pleural effusions and empyemas and has reduced the need for surgical intervention. Currently, the most commonly used fibrinolytic is urokinase, although the doses have not yet been standardized in children. The aim of the present study was to evaluate the utility of urokinase in the treatment of infectious pleural effusions in children. MATERIAL AND METHODS: A retrospective study was performed of children with infectious pleural effusions admitted to the pediatric intensive care unit (PICU) between January 2000 and December 2003. Age, sex, clinical features, laboratory tests, response to urokinase treatment and clinical course during hospital stay were analyzed. RESULTS: Thirty-one children were treated. The mean age was 38.1 months (SD: 22). There were 18 boys and 13 girls. The most frequent month of diagnosis was November and the number of admission significantly increased from 2002 onwards. The most frequent antibiotic therapy used before admission to the PICU was cefotaxime associated with vancomycin (41 %), followed by cefotaxime alone (16 %). Positive cultures for Streptococcus pneumoniae were found in 11 patients (35 %). Pleural loculation was found in 14 patients (45 %). Treatment with intrapleural urokinase was used in 23 patients (74 %). The mean chest tube drainage was 140 ml (SD: 175) in the 24 hours before urokinase instillation and was 406 ml (SD: 289) in the 48 hours after fibrinolytic therapy (p < 0.05). Twenty-one patients (91 %) who received urokinase treatment had a good response. There were no complications during the treatment. The mean length of stay in the PICU was 5.8 days (SD: 2.6). CONCLUSIONS: The incidence of complicated pleural effusions due to S. pneumoniae has increased in the last few years, despite antibiotic therapy. Intrapleural urokinase is an effective treatment, including in empyemas without loculation. None of our patients required thoracotomy and there were few adverse effects.

Utilidad de la urocinasa intrapleural en el tratamiento del derrame pleural paraneumónico / Intrapleural urokinase in the treatment of parapneumonic effusions

Introducción: La instilación intrapleural de agentes fibrinolíticos se ha utilizado como tratamiento de derrames pleurales tabicados y de empiemas, disminuyendo la necesidad de intervención quirúrgica. La urocinasa es el fibrinolítico más utilizado aunque en pediatría las dosis no están claramente estandarizadas. El objetivo del estudio fue evaluar la utilidad de la urocinasa intrapleural como tratamiento de los derrames pleurales complicados. Material y métodos: Se realizó un estudio retrospectivo de los derrames pleurales ingresados en la unidad de cuidados intensivos pediátricos (UCIP) entre enero de 2000 y diciembre de 2003. Se recogieron las variables de edad, sexo, sintomatología, pruebas complementarias, respuesta al tratamiento con urocinasa y evolución durante su ingreso. Resultados: Se estudiaron 31 casos, la edad media fue de 38,1 meses (desviación estándar [DE]: 22); 18 varones y 13 mujeres. El mes de mayor incidencia fue noviembre, y existió un aumento significativo del número de ingresos a partir del año 2002. El tratamiento antibiótico más frecuente antes del ingreso en UCIP fue la asociación de cefotaxima y vancomicina (41 %), seguido de cefotaxima (16 %). Se obtuvieron cultivos positivos a S. pneumoniae en 11 casos (35 %). Se demostró derrame tabicado en 14 casos (45 %). El tratamiento con urocinasa intrapleural se realizó en 23 casos (74 %), observándose un aumento significativo del drenaje pleural tras su aplicación, con un drenaje medio 24 h previo a la urocinasa de 140 ml (DE: 175) frente a 406 ml (DE: 289) 48 h después (p < 0,05). Respondieron favorablemente al tratamiento 21 casos (91 %) y no existieron complicaciones importantes durante su administración. La duración media del drenaje torácico fue de 5,2 días (DE: 2,97). La estancia media en la UCIP fue de 5,8 días (DE: 2,6). Conclusiones: Existe una mayor incidencia en los últimos años de derrames pleurales complicados secundarios a S. pneumoniae a pesar del tratamiento antibiótico. La urocinasa intrapleural es un tratamiento efectivo incluso en empiemas no tabicados, no precisando en ningún caso la intervención quirúrgica y con escasos efectos secundarios

Introduction: Intrapleural fibrinolytic instillation has been used in the treatment of loculated pleural effusions and empyemas and has reduced the need for surgical intervention. Currently, the most commonly used fibrinolytic is urokinase, although the doses have not yet been standardized in children. The aim of the present study was to evaluate the utility of urokinase in the treatment of infectious pleural effusions in children. Material and methods: A retrospective study was performed of children with infectious pleural effusions admitted to the pediatric intensive care unit (PICU) between January 2000 and December 2003. Age, sex, clinical features, laboratory tests, response to urokinase treatment and clinical course during hospital stay were analyzed. Results: Thirty-one children were treated. The mean age was 38.1 months (SD: 22). There were 18 boys and 13 girls. The most frequent month of diagnosis was November and the number of admission significantly increased from 2002 onwards. The most frequent antibiotic therapy used before admission to the PICU was cefotaxime associated with vancomycin (41 %), followed by cefotaxime alone (16 %). Positive cultures for Streptococcus pneumoniae were found in 11 patients (35 %). Pleural loculation was found in 14 patients (45 %). Treatment with intrapleural urokinase was used in 23 patients (74 %). The mean chest tube drainage was 140 ml (SD: 175) in the 24 hours before urokinase instillation and was 406 ml (SD: 289) in the 48 hours after fibrinolytic therapy (p < 0.05). Twenty-one patients (91 %) who received urokinase treatment had a good response. There were no complications during the treatment. The mean length of stay in the PICU was 5.8 days (SD: 2.6). Conclusions: The incidence of complicated pleural effusions due to S. pneumoniae has increased in the last few years, despite antibiotic therapy. Intrapleural urokinase is an effective treatment, including in empyemas without loculation. None of our patients required thoracotomy and there were few adverse effects

[Effect of inhaled nitric oxide on the first 24 hours of assisted respiration in the critically ill child]. / Efecto del óxido nítrico inhalado sobre las primeras 24 horas de asistencia respiratoria en el niño críticamente enfermo.

OBJECTIVE: Our aim was to analyze if inhaled nitric oxide (NO) allows a reduction in respiratory assistance during the first 24 hours of treatment of children with acute respiratory distress syndrome (ARD) and/or pulmonary hypertension (PHT). PATIENTS AND METHODS: We studied 53 children with ARDS and/or PHT refractory to conventional therapy who were treated with inhaled nitric oxide at least 24 hours at 1.5 to 45 ppm. We compared respiratory assistance (peak pressure, PEEP and FiO2) and oxygenation parameters (PaO2/FiO2 ratio and oxygenation index) before and after 6 and 24 hours of treatment. RESULTS: In 45 of 53 children NO improved oxygenation (increase of PaO2/FiO2 > 20%). At six hours of treatment the PaO2/FiO2 ratio increased 31 points, the oxygenation index diminished 4.5 points, and the FiO2 was decreased 11 points without significant changes in peak pressure and PEEP. At 24 hours the PaO2/FiO2 ratio was increased 4 points, the oxygenation index diminished 7.3 points and the FiO2 decreased 18 points in relationship to the initial parameters. CONCLUSIONS: The effect of inhaled nitric oxide on oxygenation remains during the first 24 hours and permits a decrease in the FiO2.