DERRAME PLEURAL PARANEUMONICO EMPIEMA

2. Definici�n Derrame paraneum�nico DPNC EMPIEMA DPNC EMPIEMA Empyema is defined by the presence of intrapleural pus and, for definition purposes, represents an advanced parapneumonic effusion. Complicated parapneumonic effusions (CPE) refer to those fluid collections that require tube thoracostomy or surgery for their resolution. Empyema is defined by the presence of intrapleural pus and, for definition purposes, represents an advanced parapneumonic effusion. Complicated parapneumonic effusions (CPE) refer to those fluid collections that require tube thoracostomy or surgery for their resolution.

5. hepatizaci�n roja. L�bulo superior de aspecto normal y l�bulo inferior compacto, macizo, rojo vinoso e indurado. hepatizaci�n roja. L�bulo superior de aspecto normal y l�bulo inferior compacto, macizo, rojo vinoso e indurado.

6. L�bulo superior en fase de hepatizaci�n roja y l�bulo inferior en fase de hepatizaci�n gris. Aspecto compacto, indurado, rojo-gris�ceo. L�bulo superior en fase de hepatizaci�n roja y l�bulo inferior en fase de hepatizaci�n gris. Aspecto compacto, indurado, rojo-gris�ceo.

7. hepatizaci�n roja. Inflamaci�n exudativa con relleno alveolar difuso y homog�neo. HE. hepatizaci�n roja. Inflamaci�n exudativa con relleno alveolar difuso y homog�neo. HE.

8. hepatizaci�n roja. Alv�olos ocupados por exudado predominantemente fibrinoso y escasos polimorfonucleares neutr�filos. HE, x 200 hepatizaci�n roja. Alv�olos ocupados por exudado predominantemente fibrinoso y escasos polimorfonucleares neutr�filos. HE, x 200

9. hepatizaci�n roja. Exudado fibrinoso intraalveolar que forma una red continua a trav�s de los poros de Kohn. Gram, x 500 hepatizaci�n roja. Exudado fibrinoso intraalveolar que forma una red continua a trav�s de los poros de Kohn. Gram, x 500

10. hepatizaci�n gris. Alv�olos ocupados por exudado polimorfonuclear neutr�filo y escasa fibrina. HE, x 200 hepatizaci�n gris. Alv�olos ocupados por exudado polimorfonuclear neutr�filo y escasa fibrina. HE, x 200

11. hepatizaci�n gris. Exudado alveolar neutrof�lico con escasos bacilos Gram positivo. Gram, x 1250. hepatizaci�n gris. Exudado alveolar neutrof�lico con escasos bacilos Gram positivo. Gram, x 1250.

12. Exudado alveolar reemplazado por tejido granulatorio laxo, sin g�rmenes. Este aspecto es inespec�fico y puede observarse en neumon�a de variadas causas. HE, x 200 Exudado alveolar reemplazado por tejido granulatorio laxo, sin g�rmenes. Este aspecto es inespec�fico y puede observarse en neumon�a de variadas causas. HE, x 200

13. Relaci�n infecci�n Acumulaci�n de l�quido pleural Liberaci�n de mediadores inflamatorios PMNs The accumulation of pleural effusions can rapidly occur in the presence of infection. The pleural surface is a mesothelial membrane that covers the lungs and chest wall. The resultant pleural space is a potential space, containing only small volumes of transudative fluid, with a protein content of less than 1.5 g/dL. This fluid is normally composed of lymphocytes, macrophages, and mesothelial cells, with an absence of neutrophils. Interaction of the mesothelium with the invading bacteria, PMNs, and resultant inflammatory mediators can increase pleural permeability. Further PMN recruitment ensues, which results in the increased production of neutrophil chemotactic mediators, ultimately leading to significant pleocytosis. The accumulation of pleural effusions can rapidly occur in the presence of infection. The pleural surface is a mesothelial membrane that covers the lungs and chest wall. The resultant pleural space is a potential space, containing only small volumes of transudative fluid, with a protein content of less than 1.5 g/dL. This fluid is normally composed of lymphocytes, macrophages, and mesothelial cells, with an absence of neutrophils. Interaction of the mesothelium with the invading bacteria, PMNs, and resultant inflammatory mediators can increase pleural permeability. Further PMN recruitment ensues, which results in the increased production of neutrophil chemotactic mediators, ultimately leading to significant pleocytosis.

15. 

16. Management of pleural space infections: A population-based analysis Farhood Farjah, MDa, Rebecca Gaston Symons, MPHa, Bahirathan Krishnadasan, MDb, Douglas E. Wood, MDc, David R. Flum, MD, MPHd,* a Division of General Surgery, Department of Surgery, University of Washington, Seattle, Washb Division of Cardiothoracic Surgery, Department of Surgery, Veterans Affairs Puget Sound Health Care System, Seattle, Washc Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, Washd Division of General Surgery, Departments of Surgery and Health Services, University of Washington, Seattle, Wash. Read at the Thirty-second Annual Meeting of the Western Thoracic Surgical Association, Sun Valley, Idaho, June 21-24, 2006. Received for publication June 16, 2006; revisions received August 28, 2006; accepted for publication September 29, 2006. * Address for reprints: David R. Flum, MD, Division of General Surgery, University of Washington, 1959 NE Pacific, Box 356410, Seattle, WA 98195-6310. (Email: daveflum@u.washington.edu). OBJECTIVE: Management options for pleural space infections have changed over the last 2 decades. This study evaluated trends over time in the incidence of disease and use of different management strategies and their associated outcomes. METHODS: A retrospective study was performed by using a statewide administrative database of all hospitalizations for pleural space infections between 1987 and 2004. RESULTS: Four thousand four hundred twenty-four patients (age, 57.1 � 18.6 years; 67% male; comorbidity index, 1.1 � 1.9) were hospitalized with pleural space infections. The incidence rate increased 2.8% per year (95% confidence interval, 2.2%-3.4%; P < .001). Overall, 51.6% of patients underwent an operation, and the proportion increased from 42.4% in 1987 to 58.4% in 2004 (P < .001). The risk of death within 30 days was less for patients undergoing operations compared with that for patients not undergoing operations (5.4% vs 16.6%, P < .001); however, patients undergoing operations were younger (52.9 � 17.6 years vs 61.5 � 18.6 years, P < .001) and had a lower comorbidity index (0.8 � 1.6 vs 1.4 � 2.1, P < .001). After adjusting for age, sex, comorbidity index, and insurance status, patients undergoing operative therapy had a 58% lower risk of death (odds ratio, 0.42; 95% confidence interval, 0.32-0.56; P < .001) than those undergoing nonoperative management. CONCLUSIONS: The incidence of pleural space infections and the proportion of patients undergoing operative management have increased over time. Patients undergoing operations were younger and had less comorbid illness than those not undergoing operations but had a much lower risk of early death, even after adjusting for these factors.Management of pleural space infections: A population-based analysis Farhood Farjah, MDa, Rebecca Gaston Symons, MPHa, Bahirathan Krishnadasan, MDb, Douglas E. Wood, MDc, David R. Flum, MD, MPHd,* a Division of General Surgery, Department of Surgery, University of Washington, Seattle, Washb Division of Cardiothoracic Surgery, Department of Surgery, Veterans Affairs Puget Sound Health Care System, Seattle, Washc Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, Washd Division of General Surgery, Departments of Surgery and Health Services, University of Washington, Seattle, Wash. Read at the Thirty-second Annual Meeting of the Western Thoracic Surgical Association, Sun Valley, Idaho, June 21-24, 2006. Received for publication June 16, 2006; revisions received August 28, 2006; accepted for publication September 29, 2006. * Address for reprints: David R. Flum, MD, Division of General Surgery, University of Washington, 1959 NE Pacific, Box 356410, Seattle, WA 98195-6310. (Email: daveflum@u.washington.edu). OBJECTIVE: Management options for pleural space infections have changed over the last 2 decades. This study evaluated trends over time in the incidence of disease and use of different management strategies and their associated outcomes. METHODS: A retrospective study was performed by using a statewide administrative database of all hospitalizations for pleural space infections between 1987 and 2004. RESULTS: Four thousand four hundred twenty-four patients (age, 57.1 � 18.6 years; 67% male; comorbidity index, 1.1 � 1.9) were hospitalized with pleural space infections. The incidence rate increased 2.8% per year (95% confidence interval, 2.2%-3.4%; P < .001). Overall, 51.6% of patients underwent an operation, and the proportion increased from 42.4% in 1987 to 58.4% in 2004 (P < .001). The risk of death within 30 days was less for patients undergoing operations compared with that for patients not undergoing operations (5.4% vs 16.6%, P < .001); however, patients undergoing operations were younger (52.9 � 17.6 years vs 61.5 � 18.6 years, P < .001) and had a lower comorbidity index (0.8 � 1.6 vs 1.4 � 2.1, P < .001). After adjusting for age, sex, comorbidity index, and insurance status, patients undergoing operative therapy had a 58% lower risk of death (odds ratio, 0.42; 95% confidence interval, 0.32-0.56; P < .001) than those undergoing nonoperative management. CONCLUSIONS: The incidence of pleural space infections and the proportion of patients undergoing operative management have increased over time. Patients undergoing operations were younger and had less comorbid illness than those not undergoing operations but had a much lower risk of early death, even after adjusting for these factors.

17. Management of pleural space infections: A population-based analysisFarjah et al. J Thorac Cardiovasc Surg.2007; 133: 346-351 Management of pleural space infections: A population-based analysis Farhood Farjah, MDa, Rebecca Gaston Symons, MPHa, Bahirathan Krishnadasan, MDb, Douglas E. Wood, MDc, David R. Flum, MD, MPHd,* a Division of General Surgery, Department of Surgery, University of Washington, Seattle, Washb Division of Cardiothoracic Surgery, Department of Surgery, Veterans Affairs Puget Sound Health Care System, Seattle, Washc Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, Washd Division of General Surgery, Departments of Surgery and Health Services, University of Washington, Seattle, Wash. Read at the Thirty-second Annual Meeting of the Western Thoracic Surgical Association, Sun Valley, Idaho, June 21-24, 2006. The most controversial area in the management of parapneumonic effusions is the identification of patients who would benefit from pleural drainage and the selection of the appropriate drainage intervention. No clinical studies have effectively contrasted antibiotic treatment without drainage to currently available drainage techniques. However, long-term follow-up studies show no differences in pulmonary function or exercise capacity between the groups. The therapeutic discussion rests on available clinical, radiologic, and laboratory evidence; host factors; and individualization to make the appropriate decision. The pulmonologist, intensivist, interventional radiologist, or surgeon can perform simple tube thoracostomy with an underwater seal. Diagnostic thoracentesis and chest tube drainage are effective therapies in more than 50% of patients. Prompt drainage of a free-flowing effusion prevents the development of loculations and a fibrous peel. Remove the tube when the lung re-expands and drainage ceases. If the fluid is not free flowing, undertake further radiologic imaging to better define the pleural space disorder. The most controversial area in the management of parapneumonic effusions is the identification of patients who would benefit from pleural drainage and the selection of the appropriate drainage intervention. No clinical studies have effectively contrasted antibiotic treatment without drainage to currently available drainage techniques. However, long-term follow-up studies show no differences in pulmonary function or exercise capacity between the groups. The therapeutic discussion rests on available clinical, radiologic, and laboratory evidence; host factors; and individualization to make the appropriate decision. The pulmonologist, intensivist, interventional radiologist, or surgeon can perform simple tube thoracostomy with an underwater seal. Diagnostic thoracentesis and chest tube drainage are effective therapies in more than 50% of patients. Prompt drainage of a free-flowing effusion prevents the development of loculations and a fibrous peel. Remove the tube when the lung re-expands and drainage ceases. If the fluid is not free flowing, undertake further radiologic imaging to better define the pleural space disorder.

18. Efficacy and Complications of Small-Bore, Wire-Guided Chest Drains* Alex Horsley, MRCP; Llinos Jones, MRCP; John White, FRCP and Michael Henry, FRCP * From Western General Hospital (Dr. Horsley), Edinburgh; Leeds General Infirmary (Drs. Jones and Henry), Leeds; and York District Hospital (Dr. White), York, UK. (Chest. 2006;130:1857-1863.)� 2006 American College of Chest Physicians Efficacy and Complications of Small-Bore, Wire-Guided Chest Drains* Alex Horsley, MRCP; Llinos Jones, MRCP; John White, FRCP and Michael Henry, FRCP * From Western General Hospital (Dr. Horsley), Edinburgh; Leeds General Infirmary (Drs. Jones and Henry), Leeds; and York District Hospital (Dr. White), York, UK. Correspondence to: Alex Horsley, MRCP, Molecular Medicine Centre, Western General Hospital, Crewe Rd South, Edinburgh, EH4 2XU, UK; e-mail: alex.horsley@ed.ac.uk(Chest. 2006;130:1857-1863.)� 2006 American College of Chest Physicians Efficacy and Complications of Small-Bore, Wire-Guided Chest Drains* Alex Horsley, MRCP; Llinos Jones, MRCP; John White, FRCP and Michael Henry, FRCP * From Western General Hospital (Dr. Horsley), Edinburgh; Leeds General Infirmary (Drs. Jones and Henry), Leeds; and York District Hospital (Dr. White), York, UK. Correspondence to: Alex Horsley, MRCP, Molecular Medicine Centre, Western General Hospital, Crewe Rd South, Edinburgh, EH4 2XU, UK; e-mail: alex.horsley@ed.ac.uk

19. Ready for the Frontline: Is Early Thoracoscopic Decortication the New Standar... Adam M Suchar; Amer H Zureikat; Loretto Glynn; Mindy B Statter; et al The American Surgeon; Aug 2006; 72, 8; ProQuest Medical Library pg. 688

29. 11/04/2012 ESTREPTOQUINASA INTRAPLEURAL:UNA OPCION TERAPEUTICA

30. Historia

31. 11/04/2012 Planteo Cambio conceptual de mentalidad Explorar otras opciones terap�uticas Elegir un grupo de pacientes M�todo de referencia o �Gold Standard� Sin aumentar los costos terap�uticos

32. 11/04/2012 Aspectos a resolver Drenajes Sistemas colectores

33. 11/04/2012 Objetivos Primario Determinar efectividad del uso de STK intrapleural DPNC EP Procesos tabicados o multiloculados

34. 11/04/2012 Objetivos Secundario Demostrar superioridad del manejo conservador Disminuir la morbimortalidad que la cirug�a agrega a la propia enfermedad

35. 11/04/2012 Objetivos Tercer objetivo Demostrar que los principios terap�uticos se pueden cumplir Con drenajes finos Asociados a STK Con los medios adecuados

36. 11/04/2012 Objetivos Cuarto objetivo Demostrar que mediante el uso de la terap�utica propuesta se disminuyen los costos asistenciales en nuestro medio.

37. Diferencias No nos propusimos demostrar que el uso STK logra en forma directa un descenso de la mortalidad Mortalidad esta determinada por la gravedad de la neumonia o del proceso que di� origen a la patolog�a pleural

38. Material y m�todos Protocolo Julio 2000 a Mayo 2005 Pacientes con DPNC Tabicados EP Multiloculados

39. Material y M�todosClasificaci�n ASA II. Paciente con enfermedad sist�mica leve, controlada y no incapacitante. Puede o no relacionarse con la causa de la intervenci�n. III. Paciente con enfermedad sist�mica grave, pero no incapacitante. Por ejemplo: cardiopat�a severa o descompensada, diabetes mellitus no compensada acompa�ada de alteraciones org�nicas vasculares sist�micas (micro y macroangiopat�a diab�tica), insuficiencia respiratoria de moderada a severa, angor pectoris, infarto al miocardio antiguo, etc. IV. Paciente con enfermedad sist�mica grave e incapacitante, que constituye adem�s amenaza constante para la vida, y que no siempre se puede corregir por medio de la cirug�a. Por ejemplo: insuficiencias cardiaca, respiratoria y renal severas (descompensadas), angina persistente, miocarditis activa, diabetes mellitus descompensada con complicaciones severas en otros �rganos, etc.

40. Criterios diagn�sticos Cl�nica RxTx TAC Bioqu�micos Bacteriol�gicos Material y m�todos

41. Dosis de STK: 250000 U Diluida en SF Volumen variable Volumen estimado por TAC Volumen evacuado en primer drenaje Clampeo del drenaje 2 horas Material y m�todos

42. Sistema colector variable Frasco de vac�o Trampa de agua convencional N�mero de dosis 6 Algunos pacientes se resolvieron con menos dosis Posibilidad de reiterar la serie Material y m�todos

43. Hemograma Tiempo de protrombina / INR Hemocultivos al inicio RxTx TAC de t�rax Material y m�todos

44. CONTROLES DIARIOS Gasto diario del drenaje Curva t�rmica Control cl�nico CONTROLES PERIODICOS RxTx TAC Material y m�todos

46. Resultados

47. Resultados

48. Resultados Resoluci�n parcial : 7 pacientes 3 Toracotom�as 1 Videotoracoscop�a 3 drenajes de 6 Fr. Resoluci�n

49. Ineficaz: 3 pacientes 2 Toracotom�as 1 Videotoracoscop�a Recidiva: 1 paciente Toracotom�a Resultados

50. 7.69 % requirieron Anestesia general y cirug�a 91.4 % resueltos sin anestesia general Resultados

51. Resultados

52. Costos

56. Puntos en discusi�n Oportunidad Tipo de procedimiento Calibre del drenaje a utilizar Uso de fibrinol�ticos