Intrapleural urokinase versus surgical management of childhood empyema

Aim: Empyema can be managed conservatively with intravenous antibiotics or invasively with a drain inserted under image guidance or via surgical evacuation. Both approaches are successful but comparisons of the method of drainage are few. This study compared clinical outcomes for empyema in previously well children from a single centre over a 12 year period. Methods: A retrospective analysis of cases over 12 years from the Children's Hospital at Westmead in Sydney was undertaken. Ethics committee approval was obtained. Results: Seventy two cases were identified from medical records, 12 cases were excluded and 60 cases remained. The mean age was 4.7 ± 4.3 years and there was a slight male preponderance. Treatment was divided into surgical management with a large bore drain alone [n = 25] and minimally invasive management with the use of a “pigtail catheter” and intrapleural fibrinolytic [“Urkoinase”][n = 35]. At presentation the mean heart rate and respiratory rate were not statistically different. The median (range) number of doses of urokinase was 5.66 doses (1–12). More fluid was drained with the use of urokinase [594 ml (25–4575 ml) vs. 195 ml (10–1426 ml); p = 0.006], but this did not influence the rate of resolution of fever or the length of hospital stay. A pathogen was isolated in 42.9% of the urokinase group and 68% of the surgical group which approached statistical significance [p = 0.054]. Conclusions: Both large bore surgical drains and “pigtail catheter” drains with the instillation of urokinase lead to similarly favourable treatment outcomes. Either treatment could be recommended depending on local expertise and preferences.