Massive Pleural Effusion as a Rare Manifestation in Severe Neonatal Sepsis

BACKGROUND: Neonatal sepsis can be severe and has mortality rate. The pleural effusion is a rare sign of severe sepsis in newborn and only few studies that reported it. CASE PRESENTATION: We report a case of newborn who referred to our hospital because of dependent mechanical ventilator and severe sepsis. We found a massive pleural effusion and did the pleural drainage. After the drainage, the baby was extubate and discharge well with no signs of respiratory distress. CONCLUSION: Massive pleural effusion might be considered as a cause of dependent ventilator in severe neonatal sepsis.

Management of pleural empyema in a 12-year-old obese patient with COVID-19: a pediatric case report

Background With the ongoing coronavirus disease (COVID-19) pandemic, along with the development of new mutations of the virus and an increase in the number of cases among pediatrics, physicians should be aware and alerted on the atypical presentations of the disease, especially in less expected individuals. Case presentation Here we present a 12-year-old obese boy (BMI = 37.5 kg/m2) who presented with empyema, which was following SARS-CoV-2 infection. The patient had no history of fever. Due to the onset of dyspnea, a chest tube was inserted for him which was later altered to a pleural drainage needle catheter. Conclusion Our case is the first report of COVID-19 presenting as empyema among pediatrics. Pleural empyema should be considered as a rare complication of COVID-19. Since there is still no guideline in the management of empyema in the context of COVID-19, delay in diagnosis and intervention may cause morbidity and mortality in children.

Surgical Management of Pleural Space Infection

Pleural space infections are a common clinical entity affecting a large number of patients. These are associated with considerable morbidity and mortality rate and they require significant healthcare resources. In this chapter, we discuss the disease characteristics with regards to the etiology (primary and secondary), clinical presentation, radiological findings, different stages of the condition and treatment options according to stage at presentation. Conservative management (medical treatment, pleural drainage, with or without intrapleural fibrinolytic) may be effective in management of simple pleural space infections, but surgical management may be required in loculated complex empyema to prevent acute sepsis, deterioration and trapped lung. Surgical treatment of complicated pleural infections either by VATS or thoracotomy will be discussed in order to understand when to perform debridement/decortication of the pleural cavity or less frequently a thoracostomy.

Challenges in diagnosis and treatment of pneumothorax and giant bullae

Spontaneous pneumothorax is the most common acute chest disease. Often, giant bullae give the impression of the presence of air in the pleural cavity. Inadequate differential diagnosis leads to vain drainage of the pleural cavity, damage to the lung with its collapse and pneumothorax.The aim. Analyze diagnostic and tactical mistakes in patients with pulmonary emphysema, which manifests with giant bullae, and outline the ways to prevent complications.Methods. The analysis of the treatment of 1,636 patients with pulmonary emphysema and its complications undergoing treatment in the thoracic surgical department of the Samara Regional Clinical Hospital named after V.D.Seredavin in the period from 2001 to 2018 is presented.Results. Giant bulla were diagnosed in 35 (2.1%) patients, 16 of them were hospitalized ungently. In 6 patients, the diagnosis of a giant bulla of the lung was correct, and the patients were referred to the thoracic surgical department. In 10 patients, a giant bulla of the lung was regarded as pneumothorax, and pleural drainage was performed before referral to the thoracic surgical department.Conclusion. The correct interpretation of the radiological data and comparison with the clinical picture allows avoiding diagnostic errors and the associated danger and complications.

Population-Based Cohort of Children With Parapneumonic Effusion and Empyema Managed With Low Rates of Pleural Drainage

Introduction: The most appropriate treatment for parapneumonic effusion (PPE), including empyema, is controversial. We analyzed the experience of our center and the hospitals in its reference area after adopting a more conservative approach that reduced the use of chest tube pleural drainage (CTPD).Methods: Review of the clinical documentation of all PPE patients in nine hospitals from 2010 to 2018.Results: A total of 318 episodes of PPE were reviewed; 157 had a thickness of <10 mm. The remaining 161 were 10 mm or thicker and were subdivided into three increasing sizes: PE+1, PE+2, and PE+3. There was a strong relationship between the size of the effusion and complicated effusion/empyema, defined by its appearance on imaging studies or by the physical or bacteriological characteristics of the pleural fluid. The size of effusion was also strongly related to the duration of fever and intravenous treatment and was the best independent predictor of the length of hospital stay (LHS) (p < 0.001). CTPD was placed in 2.9% of PE+1 patients, 19.3% of PE+2, and 63.9% of PE+3 (p < 0.001). The referral of patients with PE+1 decreased over time (p = 0.033), as did the use of CTPD in the combined PE+1/PE+2 group (p = 0.018), without affecting LHS (p = 0.814). There were no changes in the use of CTPD in the PE+3 group (p = 0.721).Conclusions: The size of the PPE is strongly correlated with its severity and with LHS. Most patients can be treated with antibiotics alone.

Limited Clinical Utility of Chest Radiography in Asymptomatic Patients after Interventional Radiology-Performed Ultrasound-Guided Thoracentesis: Analysis of 3,022 Consecutive Patients

Purpose The aim of this study was to report the utility of chest radiography following interventional radiology-performed ultrasound-guided thoracentesis. Materials and Methods A total of 3,998 patients underwent thoracentesis between 2003 and 2018 at two institutions. A total of 3,022 (75.6%) patients were older than 18 years old, underwent interventional radiology-performed ultrasound-guided thoracentesis, and had same-day post-procedure chest radiograph evaluation. Patient age (years), laterality of thoracentesis, procedural technical success, volume of fluid removed (mL), method of post-procedure chest imaging, absence or presence of pneumothorax, pneumothorax size (mm), pneumothorax management measures, and clinical outcomes were recorded. Technical success was defined as successful aspiration of pleural fluid. Post-procedure clinical outcomes included new patient-perceived dyspnea and hypoxia (oxygen saturations < 90% on room air). Costs associated with radiographs were estimated using Medicare and Medicaid fee schedules. Results Mean age was 56.7 ± 15.5 years. Interventional radiology-performed ultrasound-guided thoracentesis was performed on the left (n = 1,531; 50.7%), right (n = 1,477; 48.9%), and bilaterally (n = 14; 0.5%) using 5-French catheters. Technical success was 100% (n = 3,022). Mean volume of 940 ± 550 mL of fluid was removed. Post-procedure imaging was performed in the form of posteroanterior (PA) (2.6%; 78/3,022), anteroposterior (AP) (17.0%; 513/3,022), PA and lateral (77.9%; 2,355/3,022), or PA, lateral, and left lateral decubitus (2.5%; 76/3,022) chest radiographs. Post-procedural pneumothorax was identified in 21 (0.69%) patients. Mean pneumothorax size, measured on chest radiograph as the longest distance from the chest wall to the lung, was 18.8 ± 10.2 mm (range: 5.0–35.0 mm). Of the 21 pneumothoraces, 7 (33.3%) were asymptomatic, resolved spontaneously, and had a mean size of 6.4 ± 2.4 mm. Fourteen pneumothoraces, of mean size 25.0 ± 5.8 mm, required management with a pleural drainage catheter (66.6%). The overall incidence of pneumothorax requiring pleural drainage catheter placement following interventional radiology-performed ultrasound-guided thoracentesis was 0.46% (14/3,022). Of the patients requiring drainage catheter placement, 12/14 (85.7%) and 13/14 (92.9%) had dyspnea and hypoxia, respectively. Potential costs to Medicare and Medicaid, for chest radiographs, in this study, were $27,547 and $10,581, respectively. Conclusion The incidence of clinically significant pneumothorax requiring catheter drainage following interventional radiology-operated ultrasound-guided thoracentesis is exceedingly low (0.46%), and routine post-procedure chest radiographs in asymptomatic patients provide little value. Reserving post-procedure chest radiographs for patients with post-procedure dyspnea or hypoxia will result in more efficient resource utilization and health care cost savings.

Optimal protamine dosing after cardiopulmonary bypass: The PRODOSE adaptive randomised controlled trial

Background The dose of protamine required following cardiopulmonary bypass (CPB) is often determined by the dose of heparin required pre-CPB, expressed as a fixed ratio. Dosing based on mathematical models of heparin clearance is postulated to improve protamine dosing precision and coagulation. We hypothesised that protamine dosing based on a 2-compartment model would improve thromboelastography (TEG) parameters and reduce the dose of protamine administered, relative to a fixed ratio. Methods and findings We undertook a 2-stage, adaptive randomised controlled trial, allocating 228 participants to receive protamine dosed according to a mathematical model of heparin clearance or a fixed ratio of 1 mg of protamine for every 100 IU of heparin required to establish anticoagulation pre-CPB. A planned, blinded interim analysis was undertaken after the recruitment of 50% of the study cohort. Following this, the randomisation ratio was adapted from 1:1 to 1:1.33 to increase recruitment to the superior arm while maintaining study power. At the conclusion of trial recruitment, we had randomised 121 patients to the intervention arm and 107 patients to the control arm. The primary endpoint was kaolin TEG r-time measured 3 minutes after protamine administration at the end of CPB. Secondary endpoints included ratio of kaolin TEG r-time pre-CPB to the same metric following protamine administration, requirement for allogeneic red cell transfusion, intercostal catheter drainage at 4 hours postoperatively, and the requirement for reoperation due to bleeding. The trial was listed on a clinical trial registry (ClinicalTrials.gov Identifier: NCT03532594). Participants were recruited between April 2018 and August 2019. Those in the intervention/model group had a shorter mean kaolin r-time (6.58 [SD 2.50] vs. 8.08 [SD 3.98] minutes; p = 0.0016) post-CPB. The post-protamine thromboelastogram of the model group was closer to pre-CPB parameters (median pre-CPB to post-protamine kaolin r-time ratio 0.96 [IQR 0.78–1.14] vs. 0.75 [IQR 0.57–0.99]; p < 0.001). We found no evidence of a difference in median mediastinal/pleural drainage at 4 hours postoperatively (140 [IQR 75–245] vs. 135 [IQR 94–222] mL; p = 0.85) or requirement (as a binary outcome) for packed red blood cell transfusion at 24 hours postoperatively (19 [15.8%] vs. 14 [13.1%] p = 0.69). Those in the model group had a lower median protamine dose (180 [IQR 160–210] vs. 280 [IQR 250–300] mg; p < 0.001). Important limitations of this study include an unblinded design and lack of generalisability to certain populations deliberately excluded from the study (specifically children, patients with a total body weight >120 kg, and patients requiring therapeutic hypothermia to <28°C). Conclusions Using a mathematical model to guide protamine dosing in patients following CPB improved TEG r-time and reduced the dose administered relative to a fixed ratio. No differences were detected in postoperative mediastinal/pleural drainage or red blood cell transfusion requirement in our cohort of low-risk patients. Trial registration ClinicalTrials.gov Unique identifier NCT03532594.

Small Drainage Volumes of Pleural Effusions Are Associated with Complications in Critically Ill Patients: A Retrospective Analysis

Pleural effusions are a common finding in critically ill patients and small bore chest drains (SBCD) are proven to be efficient for pleural drainage. The data on the potential benefits and risks of drainage remains controversial. We aimed to determine the cut-off volume for complications, to investigate the impact of pleural drainage and drained volume on clinically relevant outcomes. Medical records of all critically ill patients undergoing insertion of SBCD were retrospectively examined. We screened 13,003 chest radiographs and included 396 SBCD cases in the final analysis. SBCD drained on average 900 mL, with less amount in patients with complications (p = 0.003). A drainage volume of 975 mL in 24 h represented the optimal threshold for complications. Pneumothorax was the most frequent complication (4.5%), followed by bleeding (0.8%). Female and lighter-weighted patients experienced a higher risk for any complication. We observed an improvement in the arterial partial pressure of oxygen and respiratory quotient (p < 0.001). We conclude that the small drainage volumes are associated with complications in critically ill patients—the more you drain, the safer the procedure gets. The use of SBCD is a safe and efficient procedure, further investigations regarding the higher rate of complications in female and lighter-weighted patients are desirable.