K.R. Shankar

Evolving experience in the management of empyema thoracis

The optimal management of paediatric empyema thoracis remains controversial. The objective of the study was to analyse evolving experience in clinical presentation, management, outcome and factors contributing to adverse morbidity in thoracic empyema. Forty‐seven patients presenting to a paediatric surgical centre were studied in three consecutive 6‐y periods during 1980‐97 to compare any change in the pattern of disease influencing diagnosis and management. Patients were categorized into two treatment groups: (i) conservative management (antibiotics and/or tube thoracostomy), (ii) thoracotomy. The median duration of illness prior to hospital admission was 10 d (range 1‐42 d). Ultrasound was increasingly utilized in the diagnosis and staging of empyema and played an important role in directing definitive management. The presence of loculated pleural fluid determined the need for thoracotomy. Sixteen of 20 patients (80%) who were initially treated with thoracocentesis or tube thoracostomy eventually needed thoracotomy. There was a positive shift in management towards early thoracotomy resulting in prompt symptomatic recovery. Significant complications were noted in seven children who had delayed thoracotomy. These included recurrent empyema with lung abscess (n= 2), scoliosis (n= 2), restrictive lung disease (n= 1), bronchopleural fistula (n= 1) and sympathetic pericardial effusion (n= 1). An unfavourable experience with delayed thoracotomy during the study period has led us to adopt a more aggressive early operative approach to empyema thoracis. The decision to undertake thoracotomy has been influenced by the ultrasound findings of organized loculated pleural fluid. Delayed surgery was associated with adverse outcome.

The Usefulness of Surveillance Cultures: a Prospective Cohort Study on the ICU

Surveillance samples are defined as samples obtained from body sites where potentially pathogenic micro-organisms (PPM) are carried, i.e., the digestive tract comprising the oropharyngeal cavity and rectum [1]. Surveillance swabs are to be distinguished from surface and diagnostic samples. Surface samples are swabs from the skin such as axilla, groin and umbilicus, and from the nose, eye and ear. They do not belong to a surveillance sampling protocol, because positive surface swabs merely reflect oropharyngeal and rectal carrier state. Diagnostic samples are samples from internal organs that are normally sterile, such as lower airways, blood, bladder, and skin lesions. They are only taken on clinical indication. The endpoint of diagnostic samples is clinical, as they aim to microbiologically prove a clinical diagnosis of inflammation, both generalized and/or local.