Complicated Pneumonia/Parapneumonic Effusion



100
75% 100% Zoom 125%


Export to PDF
Contribute Edits
Complicated Pneumonia/Parapneumonic Effusion

Continue antibiotics

Obtain ultrasound or CT chest

Repeat US. If reaccumulation of fluid or loculation, go to complicated effusion pathway.

VATS with debridement, or open chest debridement with decortication

If not responding within 24-48 hours or worsening (fever, hypoxemia, respiratory distress, ill-appearing): reassess effusion with ultrasound. Go to moderate to large effusion pathway.

10.5 Fr chest tube with 3 doses of tPA 4mg tPA/40mL saline x 3 with 1 hour dwell 24 hours apart first dose in PICU.

Transfer to floor after first dose of TPA if clinically stable

Transfer to floor if clinically stable

Good clinical response?

Good clinical response?

Loculated, “complicated”

Antibiotic recommendations:

  • First line: ceftaroline IV or cefixime +/- doxycycline or linezolid po Beta-lactam allergy: Disscus with ID.

<1/2 thorax opacified on upright CXR or in respiratory distress?

Not loculated, “simple”

Antibiotic recommendations:

  • First line: ceftaroline IV or cefixime +/- doxycycline or linezolid PO Beta-lactam allergy: Discuss with ID

Good clinical response?

Small effusion: <1/4 thorax opacified on upright chest x-ray

Management of chest tube on Inpatient Floor - pediatric surgery

Antibiotics only:

  • First line: ampicillin
  • Consider azithromycin if at risk for complicated atypical pneumonia.
  • Beta-lactam allergy: doxycycline or levofloxacin.

Moderate to large effusion: > 1/4 thorax opacified on upright chest x-ray; and/or respiratory compromise. Consult Infectious Disease. Consult Pulmonary.

Continue IV antibiotics

  • Consult pediatric surgery and PICU Gold for chest tube insertion fibrinolytic therapy (vs VATS)

Laboratory testing on pleural fluid: Gram stain and bacterial culture. WBC with differential. pH, LDH, glucose and protein.

Inclusion Criteria
  • Immunocompetent patients with community acquired pneumonia with effusion.
  • Diagnosis of pneumonia and parapneumonic effusion on chest x-ray
Exclusion Criteria
  • None

Labs:

  • CBC, CRP and blood culture.
  • If patient produces sputum from coughed or suctioned mucus, also send sputum for bacterial culture.
  • Consider RPP (including Mycoplasma). Consider Tb testing.

  • Call PICU Gold for chest tube insertion and drainage.
  • Consult ID and Pulmonary
  • 10.5 Fr chest tube

Laboratory testing on pleural fluid: Gram stain and bacterial culture. WBC with differential. pH, LDH, glucose and protein.

Monitor with chest x-ray at 48 hrs. Chest tube can be removed if no air leak and drainage <1ml/kg/48hrs

Ultrasound Chest

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway please contact the Clinical Pathway Oversight Committee at CPOC@montefiore.org.

Disclaimer: Clinical pathways are intended as a resource to guide diagnosis, treatment and management in order to improve quality of care and promote better patient outcomes. They are based on available medical evidence at the time of development; the date on the pathway indicates the most recent update. Pathways are not intended to provide medical advice or consultation regarding the care of any individual patient, and should not replace or supersede a practitioner’s professional opinion or clinical judgment. Because medical knowledge is constantly evolving, and accepting the possibility of error, The Children’s Hospital at Montefiore does not warrant or represent that pathways are complete or accurate. Neither the Hospital nor the individuals involved in the development or publication of the pathways is responsible for results or outcomes related to their use.