Abordagem cirúrgica da efusão pleural parapneumônica e suas complicações

Abstract

Objective: surgical treatment of parapneumonic pleural effusion in children is controversial. The type of intervention is based mainly on personal experience and on the small number of reported cases. This article aims at presenting a literature review and the authors' experience in the surgical management of parapneumonic pleural effusion in children.Sources: data were searched in the Medline and Lilacs databases.Summary of the findings: complicated parapneumonic effusion should be surgically drained if thoracentesis reveals the presence of pus, positive Gram stain or culture, or pH less than 7.0 or glucose less than 40 mg/dl. The surgical drainage depends on the stage of parapneumonic pleural effusion: at the acute stage closed thoracostomy drainage is enough; at the fibrinopurulent stage thoracoscopy is indicated; at organizational stage thoracotomy can be performed in children with stable anesthetic conditions, and open thoracostomy drainage should be used in patients in a poor state of health. Echography is very important to evaluate the staging of parapneumonic effusion.Conclusions: surgical treatment of complicated parapneumonic effusion should be done as early as possible, and the kind of procedure depends on the stage of pleural effusion. In children with complicated parapneumonic effusion echography is very important to evaluate the staging of parapneumonic effusion.J Pediatr (Rio J) 2002; 78 (Supl.2): S161-S170: pleural effusion, surgical drainage, surgery. ResumoObjetivo: o tratamento cirúrgico do derrame parapneumônico na criança é controverso, sendo a abordagem baseada fundamentalmente na experiência pessoal e no pequeno número de casos relatados. O objetivo deste artigo é o de apresentar uma revisão bibliográ-fica dos principais trabalhos e experiência dos autores no tratamento cirúrgico do derrame parapneumônico na criança. Fonte dos dados: foram utilizados dados de artigos científicos pesquisados através dos bancos de dados Medline e Lilacs.Síntese dos dados: o derrame parapneumônico tem indicação de drenagem cirúrgica quando apresenta, à toracocentese, aspecto purulento, bactéria no Gram ou cultura, e análise bioquímica com pH menor que 7,0 e glicose menor que 40mg/dl. A drenagem cirúrgica depende da fase do derrame. Na fase aguda, é suficiente a drenagem torácica fechada; na fase fibrinopurulenta, é indicada toracoscopia; na fase organizada, a toracotomia é realizada em crianças com condições anestésicas, e a pleurostomia, naquelas debilitadas e com estado geral comprometido. A ecografia é útil, e, na maioria das vezes, fundamental, para definir a fase do derrame pleural.Conclusões: o tratamento cirúrgico do derrame parapneumôni-co complicado deve ser feito o mais precocemente possível, e o tipo de procedimento a ser realizado depende da fase do derrame pleural. Nas crianças que necessitam de drenagem cirúrgica, a ecografia é fundamental, para determinar a fase evolutiva do derrame parapneumônico.J Pediatr (Rio J) 2002; 78 (Supl.2): S161-S170: derrame pleural, drenagem postural, cirurg...

Toracoscopia em crianças com derrame pleural parapneumônico complicado na fase fibrinopurulenta: estudo multi-institucional

“…(28) In the present study, isolation of germs in pleural fluid occurred in a small number of patients-only 23 children (Table 1). This is in agreement with findings reported in the literature, (4) In fact, this can result from the use of antibiotics prior to pleural fluid culture, since most of the children in our sample were receiving antibiotics at the time of pleural fluid collection.…”

“…The management of these patients was performed following the same treatment algorithm (Figures 1 and 2). (4) At each hospital studied, the following data were collected from the medical charts: age; gender; use of thoracentesis; use of antibiotics prior to surgery; macroscopic aspect, biochemical analysis, microscopy and culture of pleural fluid; time elapsed from the onset of the clinical symptoms to thoracoscopy; duration of chest tube drainage; length of hospital stay; efficacy of thoracoscopy; and need for a second surgical procedure.…”

“…Complicated parapneumonic pleural effusion is that in which pus or germs are seen in pleural fluid samples, either under microscopy or in culture, or in which biochemical analysis of the pleural fluid reveals a pH < 7.0, glucose < 40 mg/dL and lactate dehydrogenase > 1,000 IU/L. (3,4) When there is pus in the pleural space, the condition is designated pleural empyema.…”

“…At this stage, even after the pleural fluid is completely removed, complete lung expansion is not achieved. The treatment for complicated parapneumonic pleural effusion is surgery, (7) and the type of drainage depends on the stage of the effusion (4,8) : at the acute stage, closed chest tube drainage is indicated; at the fibrinopurulent stage, removal of the pleural content by minithoracotomy or thoracoscopy, together with costal space, in the posterior axillary line, in the lowest part of the fluid cavity. The last patients in our sample received insufflation with carbon dioxide through one of the trocars, with reduced intrathoracic pressure (3-5 mmHg), which allowed lung collapse and better viewing during thoracoscopy.…”

“…(4) Although thoracoscopy is currently the procedure of choice for children with complicated parapneumonic pleural effusion at the fibrinopurulent stage, (9)(10)(11) there have been no well-designed studies involving a significant number of patients and assessing the true effectiveness of this method in the management of complicated parapneumonic pleural effusion in children. (12,13) The objective of this multi-institutional study was to determine the efficacy of thoracoscopy in the management of a significant number of children with complicated parapneumonic pleural effusion at the fibrinopurulent stage.…”