Special features of diagnostics Special features of diagnostics and management of purulent and management of purulent

inflammation in children.inflammation in children.

Plan:Plan:

1. Systemic Inflammatory Response Syndrome (SIRS) ,Sepsis.

2. Acute hematogenous osteomyelitis.3. Chronic osteomyelitis.4. Neonatal phlegmon5. Neonatal mastitis.6. Lung abscess

OverviewThe problem of management of suppurative infections is one of the longest standing in the history of pediatric surgery. Widespread use of anti-bacterial madication and consequent microbial resistance to these medications has lead to changes in the type and characteristics of infecting microbes. Important aspects of the study of this problem includes early diagnosis with etiopathogenetic treatment and prevention of these infections in childhood.

ІнфекціяInfection

Опіки,панкреонекроз

Burnes,pancreonecrosisss

Синдром системноїзапальної відповіді

(ССЗВ)

Systemic inflammatoryRespound syndrome

(SIRS)Масивна

крововтрата

Massivebleeding

ТравмаTrauma

SYSTEMIC INFLAMMATORY SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS),RESPONSE SYNDROME (SIRS),

BACTERIAL SEPSISBACTERIAL SEPSIS Sepsis can be simply defined as a spectrum

of clinical conditions caused by the immune response of a patient to infection that is characterized by systemic inflammation and coagulation.

It includes the full range of response from systemic inflammatory response (SIRS) to organ dysfunction to multiple organ failure and ultimately death

Factors contributing to the Factors contributing to the increasing incidence of sepsisincreasing incidence of sepsis

chemotherapy and radiation therapy corticosteroid and immunosuppressive therapies diabetics, cancer patients, patients with major

organ failure, and with granulocyopenia. Neonates are more likely to develop sepsis (ex.

group B Streptococcal infections). surgical protheses, inhalation equipment, and

intravenous, umbilical and urinary catheters.

The following is the 1992 Consensus Conference's The following is the 1992 Consensus Conference's

definitions for diagnosis of SIRS to MODSdefinitions for diagnosis of SIRS to MODS – Systemic Inflammatory Response Syndrome

(SIRS) – Sepsis – Severe Sepsis – Septic Shock – Multiple Organ Dysfunction Syndrome

(MODS)

Systemic Inflammatory Response Systemic Inflammatory Response Syndrome (SIRS)Syndrome (SIRS)

heart rate > 90 beats/minute temperature > 38°C or < 36°C respiration > 20/min or PaCO2 < 32mm

Hg leukocyte count > 12,000/mm3, <

4,000/mm3 or > 10% immature (band) cells

SepsisSepsisSIRS plus a documented infection site

(documented by positive culture for organisms from that site).

Blood cultures do NOT need to be positive. Bacteremia may be transient, as is seen

commonly after injury to a mucosal surface, primary (without an identifiable focus of infection), or more commonly secondary, to an intravascular or extravascular focus of infection

Severe SepsisSevere Sepsis Sepsis associated with organ dysfunction, hypoperfusion abnormalities, or hypotension.

Hypoperfusion abnormalities include but are not limited to: – lactic acidosis, – oliguria, – or an acute alteration in mental status

Septic ShockSeptic Shock

hypotension despite fluid resuscitation

plus hypoperfusion abnormalities

Multiple Organ Dysfunction Multiple Organ Dysfunction Syndrome (MODS)Syndrome (MODS)

Presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention

Microbial triggers of sepsisMicrobial triggers of sepsis gram-negative bacteria: endotoxin, formyl

peptides, exotoxins, and proteases gram-positive bacteria: exotoxins,

superantigens (toxic shock syndrome toxin (TSST), streptococcal pyrogenic exotoxin A (SpeA)), enterotoxins, hemolysins, peptidoglycans, and lipotechoic acid

fungal cell wall material

Organ Dysfunctions associated with Organ Dysfunctions associated with Severe Sepsis and Septic ShockSevere Sepsis and Septic Shock

Lungs: early fall in arterial PO2, Acute Respiratory Distress Syndrome (ARDS): capillary-leakage into alveoli; tachypnea, hyperpnea

Kidneys (acute renal failure): oliguria, anuria, azotemia, proteinuria

Liver- elevated levels of serum bilirubin, alkaline phosphatase, cholestatic jaundice

Digestive tract- nausea, vomiting, diarrhea and ileus Heart- cardiac output is initially normal or elevated, Brain - confusion

Skin -Skin - ecthyma gangrenosum

THERAPY: three THERAPY: three prioritiespriorities

1. Immediate Stabilization of the Patient

2. The blood must be rapidly cleared of microorganisms

3. The original focus of infection must be treated

Immediate Stabilization of the Patient.Immediate Stabilization of the Patient.The immediate concern for patients with severe sepsis is reversal

of life-threatening abnormalities (ABCs: airway, breathing, circulation). Altered mental status or depressed level of consciousness secondary to sepsis may require immediate protection of the patient's airway. Intubation may also be necessary to deliver higher oxygen concentrations. Mechanical ventilation may help lower oxygen consumption by the respiratory muscles and increase oxygen availibility for other tissues. Circulation may be compromised and significant decreases in blood pressure may require aggressive combined empiric therapy with fluids (with crystalloids or colloids) and inotropes/vasopressors (dopamine, dobutamine, phenylephrine, epinephrine, or norepinephrine). In severe sepsis monitoring of the circulation may be necessary. Normal CVP (central venous pressure) is 10-15 cm of 0.9% NaCl; normal PAW (pulmonary arterial wedge pressure) is 14-18 mm Hg; maintain adequate plasma volume with fluid infusion.

The blood must be rapidly cleared of The blood must be rapidly cleared of microorganisms.microorganisms.

Certain antimicrobial agents may cause the patients to get worse. It is believed that certain antimicobials cause more LPS to be released cause more problems for the patient. Antimicrobials that do NOT cause the patient to get worse are: carbapenems, ceftriaxone, cefepime, glycopeptides, aminoglycosides, and quinolones.

Prompt institution of empiric treatment with antimicrobials is essential. The early institution of antimicrobials has been shown to decrease the development of shock and to lower the mortality rate. After the appropriate samples are obtained from the patient a regimen of antimicrobials with broad spectrum of activity is needed. This is because antimicrobial therapy is almost always instituted before the organisms causing the sepsis are identified.

The drugs used depends on the source of the The drugs used depends on the source of the sepsis.sepsis.

• Community acquired pneumonia a 2 drug regimen is usually utilized. Usually a third (ceftriaxone) or fourth (cefepime) generation cephalosporin is given with an aminoglycoside.

• Nosocomial pneumonia: Cefipime or Imipenem-cilastatin and an aminoglycoside.

• Abdominal infection: Imipenem-cilastatin or Pipercillin-tazobactam and aminoglycoside.

• Nosocomial abdominal infection: Imipenem-cilastatin and aminoglycoside or Pipercillin-tazobactam and Amphotericin B.

• Skin/soft tissue: Vancomycin and Imipenem-cilastatin or Piperacillin-tazobactam

• Nosocomial skin/soft tissue: Vancomycin and Cefipime • Urinary tract infection: Ciprofloxacin and aminoglycoside • Nosocomial urinary tract infection: Vancomycin and Cefipime • CNS infection: Vancomycin and third generation cephalosporin or

Meropenem • Nosocomial CNS infection: Meropenem and Vancomycin

The original focus of infection must be The original focus of infection must be treatedtreated..

Remove foreign bodies. Drain purulent exudate, particularly for anaerobic infections. Remove infected organs; debride or amputate gangrenous tissues.

Acute hematogenous Acute hematogenous osteomyelitisosteomyelitis

Acute hematogenous osteomyelitis(AHO)-bacterial infections of bones with subsequent involving of the surrounding soft-tissue

Antacedent infections -Immunological disbalance -widesread by way of bloodstream -hematogenous abscess in the marrow cavity

The most common pathogen culture is Staphyloccus aureus

The male: female ratio is 3:2 The most common involving long tubular bones

Hematogenous osteomyelitisHematogenous osteomyelitis

Frequency. The overall prevalence is 1 per 5,000 children.

Neonatal prevalence is approximately 1 per 1,000.

50 % are preschool-aged children

Classification of AHO by clinical Classification of AHO by clinical pictures:pictures:

Toxic (adynamic) typeSeptico-pyemic typeLocal

Pathogenetic stages of AHOPathogenetic stages of AHO

Bone marrow phlegmonPeriosteal abscessSoft tissue phlegmoneDermal fistula

Classification of AHO by localization

•Epiphyseal•Metaphyseal•Diaphyseal•Metadiaphyseal•Pelvic•Other localization

Bacterial causes of acute Bacterial causes of acute hematogenous osteomyelitis: hematogenous osteomyelitis:

– Newborns (younger than 4 mo): S aureus, Enterobacter species, and group A and B Streptococcus species;

– Children (aged 4 mo to 4 y): S aureus, group A Streptococcus species, Haemophilus influenzae, and Enterobacter species;

– Children, adolescents (aged 4 y to adult): S aureus (80%), group A Streptococcus species, H influenzae, and Enterobacter species;

– Adult: S aureus and occasionally Enterobacter or Streptococcus species

Bacterial causes Bacterial causes of direct osteomyelitisof direct osteomyelitis

– Generally: S aureus, Enterobacter species, and Pseudomonas species;

– Puncture wound through an athletic shoe: S aureus and Pseudomonas species.

Clinical manifestationsClinical manifestations (1(1stst phase) phase)

Acute hematogenous osteomyelitis is often preceded by the signs and symptoms of bacteremia:

fever, inflammation, malaise, cephalgia, myalgia, anorexia

The 2The 2ndnd phase of the osteomyelitis is the phase of the osteomyelitis is the clinical onset of clinical onset of involvement of boneinvolvement of bone::

restricted motion, pseudoparalysis, soft tissue around the inflamed bone

which is, hyperemic, warm, edematous, tender,

bone tenderness

Findings at physical Findings at physical examination examination

Fever (present in only 50% of neonates) Edema Warmth Fluctuance Tenderness to palpation Reduction in the use of the extremity (eg, reluctance

to ambulate, if the lower extremity is involved or pseudoparalysis of limb in neonates)

Sinus tract drainage (usually a late finding or one that occurs with chronic infection)

pseudoparalysispseudoparalysis

Lab StudiesLab Studies

The WBC count may be elevated, but it frequently is normal. A leftward shift is common with increased polymorphonuclear leukocyte counts

The C-reactive protein level usually is elevated and nonspecific

The erythrocyte sedimentation rate usually is elevated (90%)

Imaging Studies:Imaging Studies: RadiographRadiograph

X-ray evidence of acute osteomyelitis first is suggested by overlying soft-tissue edema at 3-5 days after infection.

Bony changes are not evident for 10-14 days and initially manifest as periosteal elevation followed by cortical or medullary lucencies.

Approximately 40-50% focal bone loss is necessary to cause detectable lucency on plain films.

Radiographic image depicting long-bone regions (left labels) and bony changes (right labels) due to Staphylococcus aureus osteomyelitis occurring in the distal right humerus of a 12-

month-old infant.

Conrad D A Pediatrics in Review 2010;31:464-471

©2010 by American Academy of Pediatrics

osteomyelitis of osteomyelitis of the tibiathe tibia(X-ray)(X-ray)

periosteal elevation

medullary lucencies

The involucrum-subperiosteal new boneThe involucrum-subperiosteal new bone

Imaging StudiesImaging Studies ((osteomyelitis)osteomyelitis)Magnetic resonance imaging (MRI) can be

extremely helpful in unclear situations. Sensitivity ranges from 90-100%

An ultrasound examination can detect fluid collections (e.g., an abscess) and surface abnormalities of bone (e.g., periostitis)

Computed tomographic (CT) scanning can reveal small areas of osteolysis in cortical bone, small foci of gas and minute foreign bodies

Magnetic resonance image (short T1 inversion recovery pulse sequence) depicting long-bone regions (left femur) and extensive marrow edema and significant enhancement of the periosteum and adjacent soft tissues (right femur) due to Staphylococcus aureus osteomyelitis occurring in

the distal right femur of a 26-month-old infant.

Conrad D A Pediatrics in Review 2010;31:464-471

©2010 by American Academy of Pediatrics

ProceduresProceduresNeedle aspiration: During this test, a needle is

used to remove a sample of fluid and cells from the vertebral space or bony area. It is then sent to the lab to be evaluated by allowing the infectious agent to grow on media.

Biopsy: A biopsy (tissue sample) of the infected bone may be taken and tested for signs of an invading organism. This can be accomplished by needle core often accomplished under radiographic control (fluoroscopy or CT scan).

The diagnosis of osteomyelitis The diagnosis of osteomyelitis requires 2 of the 4 following requires 2 of the 4 following

criteriacriteria 1. Pus on aspiration2. Positive bacterial culture from bone or

blood3. Presence of classic signs and symptoms

of acute osteomyelitis4. Radiographic changes typical of

osteomyelitis

Differential diagnosis Differential diagnosis Rheumatic fever Monoarthritic rheumatoid arthritisPoliomyelitis Septic arthritis Bacterial cellulitis In newborns and infants in whom osteomyelitis

may present as a pseudoparalysis, also consider nervous system disease, cerebral hemorrhage, trauma, scurvy, and child abuse

Features of neonatal Features of neonatal osteomyelitisosteomyelitis

– S. aureus, enteric gram-negative bacilli (eg, Escherichia coli, Klebsiella species), and group B streptococci are common pathogens.

– IV sites, scalp electrodes, and puncture wounds are often predisposing factors.

– Diagnosis may be delayed because swelling and erythema may not be evident at onset.

– Decreased movement (pseudoparalysis) of the affected area may be the only symptom.

Features of neonatal osteomyelitisFeatures of neonatal osteomyelitisAs many as 50% of affected newborns may

have multiple bone involvement. Associated arthritis also is common. Unlike radiographic findings in older children,

plain radiographs of newborns often have a lytic area at the time of diagnosis.

A significant number of patients develop permanent sequelae due to involvement of the adjacent joint and damage to the cartilaginous growth plate

X-ray findings of neonatal acute X-ray findings of neonatal acute hematogenous osteomyelitishematogenous osteomyelitis

TreatmentTreatmentMedications Drainage Splinting or cast

immobilization Surgery Alternative

treatment

Initial Antibiotic Regimens for Patients with OsteomyelitisInitial Antibiotic Regimens for Patients with OsteomyelitisOrganism Antibiotic(s) of first choice Alternative antibioticsStaphylococcus aureus or coagulasenegative (methicillin-sensitive) Staphylococci

Nafcillin (Unipen), 2 g IV every 6 hours, or clindamycin phosphate (Cleocin Phosphate), 900 mg IV every 8 hours

First-generation cephalosporin or vancomycin (Vancocin)

S. aureus or coagulase-negative (methicillin-resistant) staphylococci

Vancomycin, 1 g IV every 12 hours Teicoplanin (Targocid),* trimethoprim- sulfamethoxazole (Bactrim, Septra) or minocycline (Minocin) plus rifampin (Rifadin)

Various streptococci (groups A and B β-hemolytic organisms or penicillin-sensitive Streptococcus pneumoniae)

Penicillin G, 4 million units IV every 6 hours

Clindamycin, erythromycin, vancomycin or ceftriaxone (Rocephin)

Intermediate penicillin-resistant S. pneumoniae

Cefotaxime (Claforan), 1 g IV every 6 hours, or ceftriaxone, 2 g IV once daily

Erythromycin or clindamycin

Penicillin-resistant S. pneumoniae Vancomycin, 1 g IV every 12 hours Levofloxacin (Levaquin)Enterococcus species Ampicillin, 1 g IV every 6 hours, or

vancomycin, 1 g IV every 12 hoursAmpicillin-sulbactam (Unasyn)

Enteric gram-negative rods Fluoroquinolone (e.g., ciprofloxacin [Cipro], 750 mg orally every 12 hours)

Third-generation cephalosporin

Serratia species or Pseudomonas aeruginosa

Ceftazidime (Fortaz), 2 g IV every 8 hours (with an aminoglycoside given IV once daily or in multiple doses for at least the first 2 weeks)

Imipenem (Primaxin I.V.), piperacillin-tazobactam (Zosyn) or cefepime (Maxipime; given with an aminoglycoside)

Anaerobes Clindamycin, 600 mg IV or orally every 6 hours

For gram-negative anaerobes: amoxicillin-clavulanate (Augmentin) or metronidazole (Flagyl)

Mixed aerobic and anaerobic Organisms

Amoxicillin-clavulanate, 875 mg and 125 mg, respectively, orally every 12 hours

Imipenem

Splinting or cast Splinting or cast immobilization immobilization

This may be necessary to immobilize the affected bone and nearby joints in order to avoid further trauma and to help the area heal adequately and as quickly as possible. Splinting and cast immobilization are frequently done in children. However, eventually early motion of joints after initial control is important to prevent stiffness and atrophy.

Treatment of neonatal AHO:ShadeTreatment of neonatal AHO:Shade’’s s reduction traction reduction traction

Immobilization-wide diapering as a Immobilization-wide diapering as a prophylactic management of prophylactic management of acquired dislocation of the hipacquired dislocation of the hip

Surgical CareSurgical Care Immediate bone aspiration If signs and symptoms do not resolve within

48-72 hours of initiation of appropriate antimicrobial treatment, consider repeat bone aspiration to drain the pus

Joint aspiration Most well-established bone infections are

managed through open surgical procedures during which the destroyed bone is scraped out

Alternative treatment of Alternative treatment of OsteomyelitisOsteomyelitis

General recommendations for the treatment of infections include increasing vitamin supplements, such as vitamins A and C.

Liquid garlic extract Herbs such as echinacea (Echinacea spp.),

goldenseal (Hydrastis canadensis), Siberian ginseng (Eleutherococcus senticosus), and myrrh (Commiphora molmol)

Juice therapists recommend drinking combinations of carrot, celery, beet, and cantaloupe juices

ComplicationsComplications

Bone abscessSepsisFractureOverlying soft-tissue cellulitisDraining soft-tissue sinus tracts

Further complication of AHO:varus Further complication of AHO:varus deformation and limb contractiondeformation and limb contraction

Symptomatology of the primary Symptomatology of the primary subacute haematogenous subacute haematogenous

osteomyelitisosteomyelitis insidious in onset, looks a systemic reaction and mimics

various benign and malignant condition symptoms for 2 weeks or more, negative blood cultures positive findings on plain x-rays

CHRONIC OSTEOMYELITIS:CHRONIC OSTEOMYELITIS: Clinical FeaturesClinical Features

With progressive osteonecrosis a large mass of dead bone forms and detaches from healthy bone as “sequestrum”

The living bone surrounding it is known as “involucrum”

The sinus continues to discharge pus and small pieces of dead bone

CHRONIC OSTEOMYELITISCHRONIC OSTEOMYELITISX-RayX-Ray

Treatment of Chronic Treatment of Chronic Osteomyelitis:Osteomyelitis:

removal of all dead bone (may be very extensive and require external fixation and later grafting)

and long periods of antibiotic therapy

Serious Complications of Chronic Serious Complications of Chronic Osteomyelitis:Osteomyelitis:

Damage to epiphyseal plates results in growth arrest and deformity

Chronic infection can lead to amyloid disease

Skin margins can undergo malignant change – Squamous Cell Carcinoma (Marjolin's ulcer)

Risk of septic arthritis in nearby joints

Atypical forms of osteomyelitisAtypical forms of osteomyelitis

Brodie’s abscess Albuminous osteomyelitis Sclerosing osteomyelitis “Antibiotic” osteomyelitis

Brodie's Brodie's abscessesabscesses

radiolucent radiolucent with with

adjacent adjacent sclerosissclerosis

Neonatal phlegmonNeonatal phlegmon

Neonatal phlegmon-acute soft-tissue infections in childhood. Types: simple, toxic and septicopyemic.

Etiology: most common-Staphylococcus epidermidis

Typical localizations: lumbar area, back, anterior and lateral superficies of the thorax

Local symptoms: pain, local rise in temperature, hyperemia, swelling.

Neonatal phlegmonNeonatal phlegmon

Neonatal phlegmonNeonatal phlegmon

Neonatal phlegmon-surgical Neonatal phlegmon-surgical treatmenttreatment

Neonatal mastitisNeonatal mastitis Neonatal mastitis is a local bacterial infection

during the first mounth (first weeks) of life Causative organisms. Staphylococcal organisms

(S.epidermidis,S.aures) The male:female ratio is 1:1 Physiological enlargement of mammalian glands

is a prepodisposatary factor for the development of the disease

General symptoms Local symptoms (tenderness, swelling,

hyperemia, local rise in temperature, fluctuation)

Neonatal mastitisNeonatal mastitis

Neonatal mastitis.Surgical Neonatal mastitis.Surgical managementmanagement

Special features of conservative treatment of neonates with acute suppurative infections

1. Anti-bacterial therapy.2. Intensive infusive therapy of hemostatic dysbalance

(IV and IM administration of drugs)3. Passive and active immunization4. Symptomatic treatment5. Desensitization and hormonal therapy6. Administration of physiotherapeutic procedures

(compresses, warm baths, ultraviolet therapy)7. Hyperbaric oxygen therapy.

Special features of surgical methods of management of acute suppurative

infections in childhood

Operative aproach (wide excision of the infection site) Drainage Collection of pus for culture Special features of surgical management of neonatal

phlegmon (multiple cuts in the zone of the lesion including the border with healthy tissue and frequent dressing every 6 - 8 hours)

Special features of surgical management of neonatal mastitis depending on clinical type

Peculiarities of placement and removal of sutures

Pneumothorax

General considerations Air within the pleural space Spontaneous pneumothorax is especially common in male teenagers,

caused for example by rupture of a small lung bubble without any lung disease

Risk of recurrence is 16% after the first and 80% after the third episode

Pneumothorax may be caused by trauma (lung injured by broken ribs), a penetrating chest wall injury (sucking chest wound), injury to the tracheobronchial tree, a severe asthma attack, pulmonary infections with development of an air fistula, artificial ventilation, resuscitation, or by a congenital cystic lung disease

Induced by a valve-like mechanism, tension pneumothorax is caused by increasing accumulation of air within the pleural cavity leading to a mediastinal shift which develops into a dangerous situation

Signs

- Mild dyspnea or no signs in cases of mild spontaneous pneumothorax

- Chest pain and shortness of breath - Varying degrees of respiratory distress - Reduced or absent breath sounds on the side of the

pneumothorax - In patients suffering from tension pneumothorax (in

addition to respiratory insufficiency) hemodynamic deterioration (neck vein distension in normovolemic patients) occurs

Preoperative work-up

- Chest X-ray (misinterpretation of medial margin of the scapula with the lung surface)

- CT scan if necessary

Therapy

- Observation in cases of minimally closed stable pneumothorax. Supplemental oxygen may be necessary

Chest tube insertion If significant signs occur insert a chest tube [2nd or 3rd intercostal space in the

midclavicular line (classic technique) or in the midaxillary line at the level of the breast nipples] to provide a water seal drainage (Bulau drainage)

• Make a small skin incision with the patient under general anesthetic • Perforate the intercostal space slowly via the upper edge of the rib with the tip

of a clamp • Remove the clamp and insert the chest tube (reinforced by a trocar) through

the prepared canal • Remove the trocar and fix the tube with sutures (size: 3-0 to 1). A second purse suture is placed to close the skin after the chest tube has been removed • Connect the chest tube to the water-sealed drainage system (Bulau system) • Induced by breathing movements, air bubbles should pass through the water-

sealed drainage system

Operation - Surgical therapy should be considered under the following conditions: • If the air leak is persistent over a period of 1 week of water-

sealed drainage • If the CT scan shows an underlying lung disease • In the case of a second episode • If full lung expansion is not possible Surgical methods • Closure of the air leak (suture or stapling with bleb resection) and/or

parietal pleurectomy (apical and anterolateral areas) via thoracotomy or thoracoscopic surgery. Pulmonary blebs may be overlooked when using just the thoracoscopic approach

• In cases of multiple recurrence, intrapleural instillation of tetracycline (for pain control instill 2% lidocaine into the chest tube 30min beforehand) to obliterate the pleural cavity (pleurodesis) may beindicated

Postoperative care - Chest tubes may be removed if the lung is fully expanded and drainage

volumes decrease to below 20-50 ml within a 24-h period - Start respiratory exercises and physiotherapy as soon as possible