Retained Hemothorax Empyema Hassan Bukhari Trauma Fellow 101210
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 • Treatment options • 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 • 2 nd chest tube • Within 1 -2 days
If the 2 nd chest tube failed • Intrapleural thrombolytics • VATS • Thoracotomy with decortication
Empyema • Hippocrates • 1 st 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), p. H <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) • Within the 1 st 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
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 2 nd 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. 6 th edition (1995)
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