Retained Hemothorax & Empyema Hassan Bukhari Trauma Fellow 10/12/10

Objectives By the end of this discussion, you will be familiar with Incidence and risk factor Diagnostic tools Treatment options Medical Surgical Timing of intervention

Content Retained Hemothorax Incidence, risk factors & complication Prevention Treatment options Chest tube vs Medical vs Surgical Empyema Incidence & risk factors Diagnosis & stages PCD vs VAT vs Thoracotomy Techniques, timing, outcome

Retained Hemothorax Chest tube fails to drain hemothorax in 5% It can progress into Empyema (<10%) Fibrothorax (3 months) Risk factor for complications Prolonged ventilation Pneumonia Violation of the pleura Chest tube Foreign body (missile)

Diagnosis

Prevention Early drainage Do we have to drain all hemothoraces? Chest tube Sterile technique Prophylactic antibiotics

Chest tube Mainstay of treatment Only needed treatment in >90% of thoracic trauma Success rate can be improved by suction and irrigation (anecdotal) Timing Within 7 days from injury If did not drain it appropriately 2nd chest tube Within 1-2 days

If the 2nd chest tube failed Intrapleural thrombolytics VATS Thoracotomy with decortication

Empyema Hippocrates 1st to describe empyema “In pleuritic afflictions when the disease is not purged off in 14 days, it usually results in an empyema.”

Empyema Surgical management “prepare a warm bath, set him on a stool, which is not wobbly … listen to see on which side a noise is heard; and right at this place, preferably on the left, make an incision, then it produces death more rarely.”

Empyema Pus in the pleural cavity: Exudate effusion (PL/SL >0.6), pH <7.2 Culture is negative in 1/3 of the patients Incidence is increasing (5%) Risk factors Ventilated patient, Pneumonia Poor pain control, Chest tube Extrathoracic infection Diagnosis Clinical + CXR + US +/-CT

Rim enhancement on CT

Stages Stage I (acute, serous) Stage II + III Subacute  chronic Within the 1st week Thin exudate Chest tube is the treatment of choice Stage II + III Subacute  chronic Thick exudate with debris

Stages

Treatment Good evidence is lacking Posttraumatic vs nontraumatic More likely to fail chest tube drainage and more likely to require surgical intervention

Main goals of treatment Antibiotics coverage Complete drainage of empyema Debridement + decortication Full re-expansion of the lung Assess underlying lung Management of residual space

Treatment

Treatment Diamond

Medical therapy Thrombolytic therapy Not superior to chest tube* (MIST) Better success with C. tube Inferior to surgical therapy High failure rate, increase length of stay, higher cost Reserved for High operative risk patient Early post operative intervention Clot is soft and easier to be lysed Maskell NA, et al. U. K. Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med 2005; 352:865–874.

Treatment based on the stage

VAT VATS vs Thoracotomy Better success rate when done during early stages (<4 wks) Conversion rate 8% Techniques Evacuation of the pus Pealing off the visceral pleura (decortication) Elimination of the cavity (lung expansion)

Patient placement + ports

Ports placement

Port placement

VAT

Thoracotomy Method of choice >80% of posttraumatic empyema will need open drainage You have to wait for several week for plane to mature Types Mini muscle-sparing (axillary) thoracotomy vs.Full thoracotomy (FT) Open window (OWT) thoracostomy

Thoracotomy incision 8th rib resection, between MA and PA lines

Rib resection

Decortication

VAT vs. Mini T vs. Full T * Rev Bras Cir Cardiovasc vol.18 no.4 São José do Rio Preto Nov./Dec. 2003

Open window thoracostomy Mastery of Cardiothoracic Surgery 2nd Edition (2007)

Outcome Mortality per procedure Chest tube alone 24% Thoracotomy and decortication up to 6.6% VATS 4.5%

What did we cover? You should be familiar with Incidence and risk factor Diagnostic tools Treatment options Medical Surgical Timing of intervention

References Asensio J, Trunkey D. Current Therapy of Trauma and Surgical Critical Care. Maskell NA, Davies CWH, Nunn AJ, et al. U. K. Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med 2005; 352:865–874. Lee S, et al. Thoracic empyema: current opinions in medical and surgical management. Current Opinion in Pulmonary Medicine 2010,16:194–200 Sabiston D, Spencer F. Surgery of the Chest. 6th edition (1995)