_________________________________________________________________________

_________________________________________________________________________

Ruj. Tuan : Ruj.Kami:KKM87/P1/26/1jld.15(38)

Tarikh : 14 Mac 2013 SEPERTI SENARAI EDARAN Y. Bhg. Dato‟/ Tuan/ Puan, JEMPUTAN MENGHADIRI BENGKEL MULTI-DISIPLIN BERKAITAN COMPLICATED PNEUMONIA IN CHILDREN, 29-31 MAC 2013 Dengan hormatnya saya merujuk kepada perkara tersebut di atas. 2. Sukacita dimaklumkan bahawa satu bengkel yang tersebut di atas anjuran Persatuan Toraksik Malaysia (MTS) dengan kerjasama pakar-pakar respiratori di Kementerian Kesihatan Malaysia akan diadakan pada 29 Mac hingga 31 Mac 2013 bertempat di Hotel Seri Pacific Kuala Lumpur. 3. Bengkel ini bertujuan mendapatkan konsensus pendekatan dan rawatan pesakit kanak-kanak yang mengalami “ Complicated Pneumonia” dan digunapakai oleh semua hospital-hospital Kementerian Kesihatan Malaysia. Faedah dari bengkel ini merangkumi 5 perkara utama iaitu :

i. Menjadi platform pertama dan utama untuk pakar-pakar dari disiplin berbeza bekerjasama

ii. Menghasilkan kata sepakat atau konsesus “Approach of Complicated

Pneumonia in Malaysia”

iii. Pengwujudan konsesus ini dapat digunapakai oleh semua pihak terutama hospital-hospital di Kementerian Kesihatan Malaysia

iv. Memperbaiki mutu perkhidmatan kesihatan kanak-kanak terutamanya berkaitan jangkitan sistem respiratori dan “Complicated Pneumonia”

v. Mengurangkan kadar morbiditi dan mortaliti pesakit kanak-kanak berkaitan jangkitan paru-paru

BAHAGIAN PERKEMBANGAN PERUBATAN (MEDICAL DEVELOPMENT DIVISION) KEMENTERIAN KESIHATAN MALAYSIA (MINISTRY OF HEALTH, MALAYSIA) ARAS 7, BLOK E1, PARCEL E, PRESINT 1, PUSAT PENTADBIRAN KERAJAAN PERSEKUTUAN

62590 PUTRAJAYA

Tel : 03-88831487 Faks : 03-88831155

_________________________________________________________________________

4. Sehubungan dengan itu, Y.Bhg. Dato‟/ Tuan/ Puan adalah dijemput untuk menghadiri bengkel tersebut. Bersama-sama ini disertakan borang maklumbalas kehadiran (Lampiran 1) dan aturcara program untuk rujukan. 5. Untuk makluman Y. Bhg. Dato‟/ Tuan/ Puan, kos penginapan, pengangkutan dan makan minum peserta dari luar Lembah Klang ditanggung sepenuhnya oleh pihak penganjur manakala bagi peserta dari Lembah Klang, pihak penganjur hanya menanggung makan minum sahaja sepanjang bengkel berlangsung. 6. Kerjasama dan sokongan Y. Bhg Dato‟/ Tuan/ Puan dalam menjayakan bengkel ini amatlah dihargai dan didahului dengan ribuan terima kasih. Sekiranya terdapat sebarang pertanyaan, sila berhubung dengan pihak urusetia:

i. Dr. Asiah Kassim Pakar Perunding Kanan Paediatrik Institut Paediatrik HKL Tel : 03-26156213 Email : kassimasiah@yahoo.com Sekian, terima kasih. “BERKHIDMAT UNTUK NEGARA” Saya yang menurut perintah, (DATO’ DR. AZMI BIN SHAPIE) Pengarah Perkembangan Perubatan Bahagian Perkembangan Perubatan Kementerian Kesihatan Malaysia

_________________________________________________________________________

s.k Timbalan Ketua Pengarah Kesihatan (P) Kementerian Kesihatan Malaysia - Pengarah Hospital Kuala Lumpur - Pengarah Hospital Umum Sarawak - Pengarah Hospital Sultanah Bahiyah, Alor Star - Pengarah Hospital Melaka - Pengarah Hospital Pulau Pinang - Pengarah Hospital Queen Elizabeth - Pengarah Hospital Serdang - Pengarah Hospital Sultanah Aminah, Johor Bahru - Pengarah Hospital Sultan Ahmad Shah, Temerloh - Pengarah Hospital Sultanah Nur Zahirah, K.Terengganu - Pengarah Hospital Raja Perempuan Zainab (II), Kota Bahru - Pengarah Hospital Raja Permaisuri Bainun, Ipoh

Mohon diberi pelepasan kepada pegawai untuk menghadiri bengkel ini

_________________________________________________________________________

SENARAI EDARAN NAMA PESERTA BENGKEL MULTI-DISIPLIN BERKAITAN COMPLICATED PNEUMONIA IN CHILDREN 2013 PESERTA DARI LUAR LEMBAH KLANG

Bil Nama Jawatan/ Gred

Hospital/ Tempat bertugas

1 Dato‟ Mr Mohan Nallusamy

JUSA (B) Pakar Perunding Kanan, Jabatan Pembedahan Pediatrik, Hospital Sultanah Bahiyah, Alor Setar, Kedah

2 Dr Rusanida Awang

JUSA (C) Pakar Perunding, Jabatan Pediatrik, Hospital Pulau Pinang

3 Dr Noor Khatijah Nurani

JUSA (C) Pakar Perunding, Jabatan Pediatrik, Hospital Tengku Bainon, Ipoh, Perak

4 Dr Tam Pui Ying JUSA (B) Pakar Perunding Kanan, Jabatan Pediatrik, Hospital Melaka

5 Dato‟ Mr Rahman Ismail

JUSA (B) Ketua Jabatan dan Pakar Perunding Kanan, Pembedahan Kardio-torasik, Hospital Sultanah Aminah, Johor Bahru, Johor

6 Dr Khatijah Abu Bakar

JUSA (C) Ketua Jabatan dan Pakar Perunding Radiologi, Hospital Sultanah Aminah, Johor Bahru, Johor

7 Dr Susan Pee JUSA ( B) Ketua Jabatan dan Pakar Perunding Kanan, Jabatan Pediatrik, Hospital Sultan Ismail, Johor Bahru, Johor

8 Dr Ahmad Fadzil Abdullah

JUSA ( C) Pakar Perunding, Jabatan Pediatrik, Hospital Ahmad Shah, Temerloh, Pahang

9 Dr Elinah Ali JUSA ( C) Ketua Jabatan dan Pakar Perunding, Jabatan Radiologi, Hospital Sultanah Nur Zahirah, Kuala Trengganu, Terengganu

10 Dr Mariana Daud JUSA (C) Pakar Perunding, Jabatan Pediatrik, Hospital Raja Perempuan Zainab (II), Kota Bahru, Kelantan

11 Mr Mohd Tarmizi Md Nor

JUSA ( C) Pakar Perunding, Jabatan Bedah Pediatrik, Hospital Raja Perempuan Zainab (II), Kota Bahru, Kelantan

12 Dr Tan Su Zet JUSA (C) Ketua Jabatan dan Pakar Perunding, Jabatan Radiologi, Hospital Umum Kuching, Sarawak

13 Dr Lim Cheng Kooi

JUSA (C ) Ketua Jabatan dan Pakar Perunding , Jabatan Radiologi, Hospital Queen Elizabeth, Kota Kinabalu, Sabah

_________________________________________________________________________

SENARAI PESERTA DARI LEMBAH KLANG

14 Dato‟ Dr Zakaria Zahari

JUSA A Ketua Jabatan dan Pakar Perunding Kanan, Jabatan Pembedahan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

15 Dr Norzila Mohamed Zainudin

JUSA B Ketua Unit dan Pakar Perunding Kanan Pediatrik Respiratori, Jabatan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

16 Dr Asiah Kassim JUSA C Pakar Perunding , Jabatan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

17 Dr Che Zubaidah Che Mat

JUSA C Pakar Perunding, Jabatan Radiologi, Institut Pediatrik, Hospital Kuala Lumpur

18 Dr Noryati Mohamad

JUSA C Pakar Perunding, Jabatan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

19 Mr Mughni Bahari JUSA C Pakar Perunding, Jabatan Pembedahan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

20 Mr Mohamed Azlan Mahmud

JUSA C Pakar Perunding, Jabatan Pembedahan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

21 Mr Mohd Yusof Abdullah

JUSA C Pakar Perunding, Jabatan Pembedahan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

22 Ms Shona Allison Edmonds

UD54 Pakar Bedah, Jabatan Pembedahan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

23 Dr Rohazly Ismail UD54 Pakar Radiologi, Hospital Selayang, Selayang, Selangor

24 Dr Dg Zuraini Sahadan

UD54 Pakar Pediatrik, Hospital Serdang, Serdang, Selangor

25 Prof Ramanujam TM

JUSA B Pakar Perunding Kanan, Jabatan Bedah Pediatrik, Pusat Perubatan Universiti Malaya, Kuala Lumpur

26 A. Prof Jessie deBruyne

UD54 Pakar Perunding Pedaitrik dan Pediatrik Respiratori, Pusat Perubatan Universiti Malaya, Kuala Lumpur

27 A. Prof Hamzaini Abd Hamid

UD 54 Pakar Perunding, Jabatan Radiologi, Pusat Perubatan Universiti Kebangsaan Malaysia, Cheras, Selangor

28 Dato‟ Dr Azizi B Hj Omar

- Pengarah Perubatan dan Pakar Perunding Kanan Pediatrik dan Pediatrik Respiratoi, Pusat Perubatan Damansara, Petaling Jaya, Selangor

_________________________________________________________________________

29 Dr Patrick Chan Wai Kiong

- Pakar Perunding Kanan Pediatrik dan Pediatrik Respiratori, Pusat Perubatan Gleneagles, Kuala Lumpur

URUSETIA :

30 PPP Rosdi Md Fauzi

UD32 Jabatan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

31 KJ Faridah Derani UD32 Jabatan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

32 KJ Azizah Musa UD32 Jabatan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

33 JT Norlisyapina Shamsudin

UD29 Jabatan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

34 JT Parameswari AP Ratnasamy

UD29 Jabatan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

35 PPP Juhairy Razmin

UD29 Jabatan Radiologi, Institut Pediatrik, Hospital Kuala Lumpur

36 PPP Raziman Che Omar

UD29 Jabatan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

37 PPP Mohd „Aizat B Mohd Basari

UD29 Jabatan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

_________________________________________________________________________

_________________________________________________________________________

Ruj. Tuan : Ruj.Kami:KKM87/P1/26/1jld.15(38)

Tarikh : 14 Mac 2013 SEPERTI SENARAI EDARAN Y. Bhg. Dato‟/ Tuan/ Puan, JEMPUTAN MENGHADIRI BENGKEL MULTI-DISIPLIN BERKAITAN COMPLICATED PNEUMONIA IN CHILDREN, 29-31 MAC 2013 Dengan hormatnya saya merujuk kepada perkara tersebut di atas. 2. Sukacita dimaklumkan bahawa satu bengkel yang tersebut di atas anjuran Persatuan Toraksik Malaysia (MTS) dengan kerjasama pakar-pakar respiratori di Kementerian Kesihatan Malaysia akan diadakan pada 29 Mac hingga 31 Mac 2013 bertempat di Hotel Seri Pacific Kuala Lumpur. 3. Bengkel ini bertujuan mendapatkan konsensus pendekatan dan rawatan pesakit kanak-kanak yang mengalami “ Complicated Pneumonia” dan digunapakai oleh semua hospital-hospital Kementerian Kesihatan Malaysia. Faedah dari bengkel ini merangkumi 5 perkara utama iaitu :

i. Menjadi platform pertama dan utama untuk pakar-pakar dari disiplin berbeza bekerjasama

ii. Menghasilkan kata sepakat atau konsesus “Approach of Complicated

Pneumonia in Malaysia”

iii. Pengwujudan konsesus ini dapat digunapakai oleh semua pihak terutama hospital-hospital di Kementerian Kesihatan Malaysia

iv. Memperbaiki mutu perkhidmatan kesihatan kanak-kanak terutamanya berkaitan jangkitan sistem respiratori dan “Complicated Pneumonia”

v. Mengurangkan kadar morbiditi dan mortaliti pesakit kanak-kanak berkaitan jangkitan paru-paru

BAHAGIAN PERKEMBANGAN PERUBATAN (MEDICAL DEVELOPMENT DIVISION) KEMENTERIAN KESIHATAN MALAYSIA (MINISTRY OF HEALTH, MALAYSIA) ARAS 7, BLOK E1, PARCEL E, PRESINT 1, PUSAT PENTADBIRAN KERAJAAN PERSEKUTUAN

62590 PUTRAJAYA

Tel : 03-88831487 Faks : 03-88831155

_________________________________________________________________________

4. Sehubungan dengan itu, Y.Bhg. Dato‟/ Tuan/ Puan adalah dijemput untuk menghadiri bengkel tersebut. Bersama-sama ini disertakan borang maklumbalas kehadiran (Lampiran 1) dan aturcara program untuk rujukan. 5. Untuk makluman Y. Bhg. Dato‟/ Tuan/ Puan, kos penginapan, pengangkutan dan makan minum peserta dari luar Lembah Klang ditanggung sepenuhnya oleh pihak penganjur manakala bagi peserta dari Lembah Klang, pihak penganjur hanya menanggung makan minum sahaja sepanjang bengkel berlangsung. 6. Kerjasama dan sokongan Y. Bhg Dato‟/ Tuan/ Puan dalam menjayakan bengkel ini amatlah dihargai dan didahului dengan ribuan terima kasih. Sekiranya terdapat sebarang pertanyaan, sila berhubung dengan pihak urusetia:

i. Dr. Asiah Kassim Pakar Perunding Kanan Paediatrik Institut Paediatrik HKL Tel : 03-26156213 Email : kassimasiah@yahoo.com Sekian, terima kasih. “BERKHIDMAT UNTUK NEGARA” Saya yang menurut perintah, (DATO’ DR. AZMI BIN SHAPIE) Pengarah Perkembangan Perubatan Bahagian Perkembangan Perubatan Kementerian Kesihatan Malaysia

_________________________________________________________________________

s.k Timbalan Ketua Pengarah Kesihatan (P) Kementerian Kesihatan Malaysia - Pengarah Hospital Kuala Lumpur - Pengarah Hospital Umum Sarawak - Pengarah Hospital Sultanah Bahiyah, Alor Star - Pengarah Hospital Melaka - Pengarah Hospital Pulau Pinang - Pengarah Hospital Queen Elizabeth - Pengarah Hospital Serdang - Pengarah Hospital Sultanah Aminah, Johor Bahru - Pengarah Hospital Sultan Ahmad Shah, Temerloh - Pengarah Hospital Sultanah Nur Zahirah, K.Terengganu - Pengarah Hospital Raja Perempuan Zainab (II), Kota Bahru - Pengarah Hospital Raja Permaisuri Bainun, Ipoh

Mohon diberi pelepasan kepada pegawai untuk menghadiri bengkel ini

_________________________________________________________________________

SENARAI EDARAN NAMA PESERTA BENGKEL MULTI-DISIPLIN BERKAITAN COMPLICATED PNEUMONIA IN CHILDREN 2013 PESERTA DARI LUAR LEMBAH KLANG

Bil Nama Jawatan/ Gred

Hospital/ Tempat bertugas

1 Dato‟ Mr Mohan Nallusamy

JUSA (B) Pakar Perunding Kanan, Jabatan Pembedahan Pediatrik, Hospital Sultanah Bahiyah, Alor Setar, Kedah

2 Dr Rusanida Awang

JUSA (C) Pakar Perunding, Jabatan Pediatrik, Hospital Pulau Pinang

3 Dr Noor Khatijah Nurani

JUSA (C) Pakar Perunding, Jabatan Pediatrik, Hospital Tengku Bainon, Ipoh, Perak

4 Dr Tam Pui Ying JUSA (B) Pakar Perunding Kanan, Jabatan Pediatrik, Hospital Melaka

5 Dato‟ Mr Rahman Ismail

JUSA (B) Ketua Jabatan dan Pakar Perunding Kanan, Pembedahan Kardio-torasik, Hospital Sultanah Aminah, Johor Bahru, Johor

6 Dr Khatijah Abu Bakar

JUSA (C) Ketua Jabatan dan Pakar Perunding Radiologi, Hospital Sultanah Aminah, Johor Bahru, Johor

7 Dr Susan Pee JUSA ( B) Ketua Jabatan dan Pakar Perunding Kanan, Jabatan Pediatrik, Hospital Sultan Ismail, Johor Bahru, Johor

8 Dr Ahmad Fadzil Abdullah

JUSA ( C) Pakar Perunding, Jabatan Pediatrik, Hospital Ahmad Shah, Temerloh, Pahang

9 Dr Elinah Ali JUSA ( C) Ketua Jabatan dan Pakar Perunding, Jabatan Radiologi, Hospital Sultanah Nur Zahirah, Kuala Trengganu, Terengganu

10 Dr Mariana Daud JUSA (C) Pakar Perunding, Jabatan Pediatrik, Hospital Raja Perempuan Zainab (II), Kota Bahru, Kelantan

11 Mr Mohd Tarmizi Md Nor

JUSA ( C) Pakar Perunding, Jabatan Bedah Pediatrik, Hospital Raja Perempuan Zainab (II), Kota Bahru, Kelantan

12 Dr Tan Su Zet JUSA (C) Ketua Jabatan dan Pakar Perunding, Jabatan Radiologi, Hospital Umum Kuching, Sarawak

13 Dr Lim Cheng Kooi

JUSA (C ) Ketua Jabatan dan Pakar Perunding , Jabatan Radiologi, Hospital Queen Elizabeth, Kota Kinabalu, Sabah

_________________________________________________________________________

SENARAI PESERTA DARI LEMBAH KLANG

14 Dato‟ Dr Zakaria Zahari

JUSA A Ketua Jabatan dan Pakar Perunding Kanan, Jabatan Pembedahan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

15 Dr Norzila Mohamed Zainudin

JUSA B Ketua Unit dan Pakar Perunding Kanan Pediatrik Respiratori, Jabatan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

16 Dr Asiah Kassim JUSA C Pakar Perunding , Jabatan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

17 Dr Che Zubaidah Che Mat

JUSA C Pakar Perunding, Jabatan Radiologi, Institut Pediatrik, Hospital Kuala Lumpur

18 Dr Noryati Mohamad

JUSA C Pakar Perunding, Jabatan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

19 Mr Mughni Bahari JUSA C Pakar Perunding, Jabatan Pembedahan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

20 Mr Mohamed Azlan Mahmud

JUSA C Pakar Perunding, Jabatan Pembedahan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

21 Mr Mohd Yusof Abdullah

JUSA C Pakar Perunding, Jabatan Pembedahan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

22 Ms Shona Allison Edmonds

UD54 Pakar Bedah, Jabatan Pembedahan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

23 Dr Rohazly Ismail UD54 Pakar Radiologi, Hospital Selayang, Selayang, Selangor

24 Dr Dg Zuraini Sahadan

UD54 Pakar Pediatrik, Hospital Serdang, Serdang, Selangor

25 Prof Ramanujam TM

JUSA B Pakar Perunding Kanan, Jabatan Bedah Pediatrik, Pusat Perubatan Universiti Malaya, Kuala Lumpur

26 A. Prof Jessie deBruyne

UD54 Pakar Perunding Pedaitrik dan Pediatrik Respiratori, Pusat Perubatan Universiti Malaya, Kuala Lumpur

27 A. Prof Hamzaini Abd Hamid

UD 54 Pakar Perunding, Jabatan Radiologi, Pusat Perubatan Universiti Kebangsaan Malaysia, Cheras, Selangor

28 Dato‟ Dr Azizi B Hj Omar

- Pengarah Perubatan dan Pakar Perunding Kanan Pediatrik dan Pediatrik Respiratoi, Pusat Perubatan Damansara, Petaling Jaya, Selangor

_________________________________________________________________________

29 Dr Patrick Chan Wai Kiong

- Pakar Perunding Kanan Pediatrik dan Pediatrik Respiratori, Pusat Perubatan Gleneagles, Kuala Lumpur

URUSETIA :

30 PPP Rosdi Md Fauzi

UD32 Jabatan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

31 KJ Faridah Derani UD32 Jabatan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

32 KJ Azizah Musa UD32 Jabatan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

33 JT Norlisyapina Shamsudin

UD29 Jabatan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

34 JT Parameswari AP Ratnasamy

UD29 Jabatan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

35 PPP Juhairy Razmin

UD29 Jabatan Radiologi, Institut Pediatrik, Hospital Kuala Lumpur

36 PPP Raziman Che Omar

UD29 Jabatan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

37 PPP Mohd „Aizat B Mohd Basari

UD29 Jabatan Pediatrik, Institut Pediatrik, Hospital Kuala Lumpur

KIDZ Respiratory Care 2013: Invitation letter Inbox x

Asiah Kassim <kassimasiah@yahoo.com> 2/14/13to me

Dear Prof,

Thanks for your support for this event.

For this event, KRC 2013 will be held in Seri Pacific Hotel,Kuala Lumpur i.e. old Pan Pacific Hotel next to PWTC on 29­31st march 2013, As a speaker, we have exclude yourregistration fee. Do you need hotel room to stay?

The workshop on 29th March 203 will involve about 30specialists and consultants from paediatric (respiratory) ,paed surgical and radiology. 3 groups will discuss theapproach accordingly and hopefully we will reach concensusat the end of the day. 

I'm sending you the formal invitation letter for your reference.Appreciate if you can send me your abstract and presentationfor me to send for printing and compilation.

Thank you again.

BW

Dr Asiah Kassim

Empyema Thoracis in children 2013 document Inbox x

Asiah Kassim <kassimasiah@yahoo.com> Jan 30to zakariazahari, rahman, Mohan, me, Yusof, Mughni, Shona, Tarmizi, Yik

Dear Dato', Prof and colleague,

Following our consensus meeting in March last year onEmpyema Thoracis, I've send a document to Ministry of Health.MOH has distributed the attached document to all healthfacilities under MOH. I'm sending you a copy of the documentfor your reference. I hope it is also relevant to be used in othercentres like university hospital.I would like to thank everyone for your contributions to thisdocument. (direct and indirectly)I hope it will be useful to everyone.

Thank you

Best of regards,Dr Asiah Kassim

Empyema thoraci…

APPROACH ANDMANAGEMENT OFEMPYEMA THORACISIN CHILDRENA CONSENSUS GUIDELINE FROM THEPAEDIATRIC EMPYEMA WORKING GROUP2013

2013

KEMENTERIAN KESIHATAN MALAYSIA

1Asiah Kassim, 1Norzila Mohamed Zainudin,2Rus Anida Awang,3Ahmad FadzilAbdullah, 4Mariana Daud, 5Dg ZurainiSahadan,6 Patrick Chan WaiKiong,7Jessie AnnedeBruyne,8Hasniah Abdul Latif, 9 Noor KhatijahNurani, 10Susan Pee, 11Tam Pui Ying,

12Zakaria Zahari, 13Abdul Rahman Ismail , 14Yee Ian Yik, 15Mohd TarmiziMd Nor,12Mughni Bahari, 12Mohd Yusof Abdullah, 16Tan Su Zet,17 Lim Cheng Kooi, 18Che

Zubaidah Che Daud, 18Noryati Mohamad , 19Khatijah Abu Bakar, 20Rohazly Ismail,21Elinah Ali, 22Hamzaini Abd Hamid, 23Ramanujam Muthurangam

1. Consultant Paediatrician and Paediatric Respiratory Physician, Institute ofPaediatric, Kuala Lumpur Hospital

2. Consultant Paediatrician and Paediatric Respiratory Physician, Pulau PinangHospital

3. Consultant Paediatrician and Paediatric Respiratory Physician, TemerlohHospital, Temerloh

4. Consultant Paediatrician and Paediatric Respiratory Physician, RajaPerempuan Zainab II Hospital, Kota Bahru

5. Respiratory Paediatrician, Serdang Hospital, Serdang6. Consultant Paediatrician and Paediatric Respiratory Physician, Gleneagles

Hospital, Kuala Lumpur7. Associate Professor, Paediatrician and Paediatric Respiratory Physician,

Medical Faculty, University of Malaya, Kuala Lumpur8. Associate Professor, Paediatric and Paediatric Respiratory Physician, Medical

Faculty, University Kebangsaan Malaysia9. Consultant Paediatrician, Raja Permaisuri Bainon Hospital, Ipoh, Perak10. Consultant Paediatrician and Paediatric Nephrology Physician, Sultan Ismail

Hospital, Johor Bahru11. Consultant Paediatrician, Malacca Hospital12. Consultant Paediatric Surgeon, Institute of Paediatric, Kuala Lumpur

Hospital13. Consultant Cardiothoracic Surgeon, Sultanah Aminah Hospital, Johor Bahru14. Associate Professor, Consultant Paediatric Surgeon, Division of Paediatric

Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur15. Consultant Paediatric Surgeon, Raja Perempuan Zainab II Hospital, Kota

Bahru16. Consultant Radiologist, Kuching General Hospital, Kuching17. Consultant Radiologist, Queen Elizabeth Hospital, Kota Kinabalu18. Consultant Paediatric Radiologist, Institute of Paediatric, Hospital Kuala

Lumpur19. Consultant Radiologist, Sultanah Aminah Hospital, Johor Bahru, Johor Bahru20. Paediatric Radiologist, Selayang Hospital, Selayang21. Consultant Radiologist, Tunku Zahirah Hospital, Kuala Terengganu22. Associate Professor of Radiology, Medical Faculty, University Kebangsaan

Malaysia23. Professor, Consultant Paediatric Surgeon, Division of Paediatric Surgery,

Faculty of Medicine, University of Malaya, Kuala Lumpur

A CONSENSUS GUIDELINE FROM THE PAEDIATRIC EMPYEMAWORKING GROUP 2013

Empyema thoracis is a condition with pus formation in the pleural cavity

commonly due to bacterial pneumonia. There is no current available data on the

prevalence and incidence of empyema thoracis in children in Malaysia.

In Malaysia, the approach and management of empyema thoracis varies from

centre to centre depending on the availability of clinical expertiseresources. The

most significant morbidity encountered appears to be the prolonged hospital stay

and a noticeable trend where the majority of them had surgical intervention at a

delayed phase requiring intensive care support and resulting in more serious

sequelae.

The objective of this document is to outline a practical approach in the

management of empyema thoracis in children which is applicable in most hospitals

(with paediatrician and radiologist) in Malaysia. This document is a consensus

guideline which was produced after joint discussion of Paediatricians, Radiologists,

Cardiothoracic Surgeon and Paediatric Surgeons.

INTRODUCTION

OBJECTIVE

Figure 1: Stages of parapneumonic effusion.

The principle of management involves good and adequate anti-microbial

therapy, pleural fluid drainage and supportive care which include oxygen therapy,

fluid and nutritional management.

ANTI-MICROBIAL THERAPY

The common pathogens causing Empyema Thoracis in children are

Streptococcus pneumoniae, Staphylococcus aureus, Streptococcus pyogenes,

Hemophilus influenza and occasionally gram negative bacilli like Salmonella spp.

Tuberculosis should be considered in cases with unresolving empyema thoracis. The

anti-microbial of choice is therefore will be Penicillin or Cephalosporins like

Cefuroxime and Ceftriaxone. In young children, Cloxacillin may be considered for

Staphylococus infection. Carbapenem may be considered in cases not responding to

Penicillin or Cephalosporins.

EXUDATIVE: 24-72 HoursSTAGE 1 -Pleuritis and inflammation

-Simple exudative fluid, clear

FIBROPURULENT: 7-10 daysSTAGE 2 - Complicated pleural effusion or pus fluid

-Deposition of fibrin clots or fibrin membrane-Septation or Loculation

ORGANIZING : 2-4 weeksSTAGE 3 -Fibroblast grows on parietal and pleural

surface-Intra-pleural fibrin membrane transform toweb of thick and non-elastic pleural peel

PATHOPHYSIOLOGY OF PARAPNEUMONIC EFFUSION

MANAGEMENT OF EMPYEMA THORACIS

Parenteral administration of anti-microbial is essential during initial phase of

anti-microbial therapy. However, the total duration of therapy including oral therapy

varies from 3-6 weeks determined by the severity of cases.

PLEURAL FLUID DRAINAGE

Pleural fluid must be drained as soon as possible for both diagnostic

evaluation and therapeutic purposes. Evaluation of pleural fluid is paramount in

identifying the causal pathogens including Mycobacterium tuberculosis and in the

staging of the para-pneumonic fluid.

Indications for continuous pleural drainage include respiratory distress,

moderate amount of pleural fluid and septicemia.

PLEURAL DRAINAGE WITH INTRA-PLEURAL FIBRINOLYTIC AGENT

THERAPY

In late Stage 1 or early Stage 2, additional intra-pleural fibrinolytic agent like

Urokinase or Streptokinase will facilitate the drainage of fluid, reduce hospital stay

and avoid surgical intervention in some group of children.

The role of intra-pleural fibrinolytic agent in advanced stage like Stage 3 was

found to be not beneficial. Complications of intrapleural fibrinolytic therapy are

uncommon include fever, haemorrhage, pain and allergic reaction. It’s generally safe

when used cautiously. Contra-indication of intrapleural fibrinolytic therapy are

hemothorax,pneumothorax and hypersensitive to intra-pleural fibrinolytic agents.

Technique for intrapleural fibrinolytic therapy is described in Appendix 1.

SURGICAL INTERVENTION IN EMPYEMA THORACIS

There are two surgical managements of Empyema Thoracis in Malaysia i.e.

Video-assisted Thoracoscopic Surgery (VATS) and thoracotomy with debridement

and decortication.

Appendix 1

1. To confirmed the presence of intrapleural fluid collection by chest radiograph

and ultrasound of the thorax.

2. To insert chest drainage under sedation (general anesthesia if available) on

the site of fluid collection. The type of pleuraldrain may be the pigtail catheter

(under USG guidance) or conventional chest tube determined by the

availability and expertise.

3. Identification of intra-pleural fibrinolytic agent is required and adjust the

dosage according to patient’s weight (Table 1)

4. Instillation of the fibrinolytic agent.

5. Clamping of the chest drainage for 4 hours

6. During the period of clamping, ambulate the patient or reposition the patient

regularly

7. After 4 hours, release the clamp and drain the fluid

8. Monitor for side effects

9. Repeat the procedure (Step 4-7) once or twice a day according to patient’s

condition

10.Repeat the chest radiograph after the last drainage. Daily chest radiograph or

ultrasound is not recommended

11.Remove the chest drain when it drains less than 1-2 ml/kg/day

INTRAPLEURALFIBRINOLYTIC

AGENT

DOSE(PATIENT LESSTHAN 10 KG)

DOSE(PATIENT MORE

THAN 10 KG)

DURATION

UROKINASE 10,000 u in 40 mlnormal saline.Twice a day

40,000 u in 40 mlnormal saline.Twice a day

3 days

STREPTOKINASE 25,000 u/ kg in 50ml normal saline.Daily

250,000 u in 50 mlnormal saline.Daily

3-5 days

ALTEPLASE(Tissue plasminogen activator)

0.1 mg/kg in 10 mlnormal saline.Daily

0.1mg/kg (Max 6mg) in 1ml/kgnormal saline (Max50 ml)Daily

3 days

Table 1: Recommended dosage for intra-pleural fibrinolytic therapy

INTRA-PLEURAL FIBRINOLYTIC THERAPY

SUSPECT EMPYEMA THORACIS

Children with signs and symptoms of lower respiratory tract infectionsTreatment commenced including anti-microbial

Non-responding or worsening of signs and symptomsespecially fever after 48 hours of initiation of therapyLocalizing signs e.g. dullness, reduced breath sound

Investigations:Blood Culture, Blood count, CRP, Se albumin

Chest Radiograph :Presence of pleural fluid

Management:Refer patient to hospital with paediatrician

1. Intravenous anti-microbial like Penicillin,Cefuroxime or Ceftriaxone

2. Good hydration and nutrition3. Oxygen support

Pleural tap and pleural fluid send fori. Gram stain and bacteriology cultureii. Tuberculosis AFB stain and cultureiii. Biochemistryiv. Cell counts

Indication for chest drainage:1. Moderate to severe amount of pleural fluid2. Respiratory distress3. Clinical sepsis

If USG Thorax suggestive of Stage II with evidence of fibrin clotsand membranes, there are two options:

1. Intrapleural fibrinolysis therapy or2. Video assisted thoracoscopy (if available)

Successful medical therapyRemoval of chest drain whendrainage is less than1- 2 ml/kg/dayChange intravenous antibiotic to oralantibiotic after 48-72 hours afebrileTotal duration of anti-microbial for 3-6 weeks depending on severity

Failure of medical therapyRefer for surgical interventionEnsure Intravenous antimicrobialuntil after surgery

Ultrasound of thorax to estimate the amount and type of fluidcollection. Distinguish Stage 1, 2 and 3

SUGGESTED APPROACH FOR CHILDREN WITH EMPYEMATHORACIS IN MALAYSIA