empyema thoracic surgery kaplan m.c. empyema. thoracic empyema – an accumulation of pus in the...

EMPYEMA

Thoracic Surgery

Kaplan M.C

Empyema .

Thoracic empyema –

an accumulation of pus in the pleural space .

Etiology. Pneumonia ( 62% ) . Thoracic and other surgery ( 13% ) . Trauma ( 9% ) .

Pulmonary embolism , tumors and lung abscess , fungi , tuberculosis .

Pathophysiology . Direct contamination .Spread of contiguous infection . Pleural fluid accumulation : imbalance

between transpleural hydrostatic pressures , vessel permeability and lymphatics .

Bacteriology . Pneumococci and staphylococci are

predominant . Echerichia coli , Klebsiella ,

Pseudomonas , Enterobacreriaceae are common gram negative organisms .

Mycobacteria and fungi are rare .

Bacteriology .Sterile cultures in 18% to 30% .Single organisms in 29% to 55% .Multiple organisms in 17% to 49% .

High ph ( > 7.3 ), high glucose ( > 60 mg/dL ) , low LDH ( < 500 U/L ) .

Symptoms . Uncontrolled infection : pain , weight

loss , asthenia and fever . Restriction and V/P mismatch :

dyspnea . Signs of infection : leucocytosis , rise

of CRP .

Epidemiology. Elderly and debilitated . 82% of patients had one or more underlying

illnesses . Individuals without access to medical care or

from lowest social class . Mortality ranges from 1% to 19% ( for

immunocompromised up to 40% ) . Prognosis worse with hospital-acquired or

culture-positive empyemas .

Stages . Initial exudative stage ( 7days ) . Fibrinopurulent stage ( 2 weeks ) . Final organizational stage ( 3 weeks to

months ) .

Initial exudative stage . Watery and sterile effusion . Free-flowing on lateral decubitus chest

x-ray . Septations are absent on US or CT .

Fibrinopurulent stage . Fibrin deposition . Septations on lateral decubitus chest x-ray ,

US and CT . Drop of ph ( < 7.1 ) , drop of glucose ( < 40

mg/dL ) , rise of LDH ( > 1000 U/L ) : a. increased utilization of glucose by both

PMN cells and bacteria . b. glucose metabolits ( carbon dioxide and

lactic acid ) increase of purulent collections . c. LDH rises in proportion to cell lysis .

PA chest x-ray .

Final organizational stage .Creation of thick , inelastic membranous

peel . Entrapping and immobilizing the lung . Dense , cohesive collections . Creation of bronchopleural fistulas or

empyema necessitatis . Sepsis .

Diagnosis . Chest radiography . Computed tomography . Ultrasonography . Thoracentesis : a. cell count , glucose , LDH , ph . b. Gram staining and aerobic and anaerobic

cultures . c. mycobacteria and fungi if indicated

clinically .

Goals of treatment . Evacuation of pus . Expansion of lung . Prevention of ongoing infection .

Management . Antimicrobial agents . Tube thoracostomy .CT-guided chest tube insertion and

intrapleural fibrinolytic debridment . VATS thoracoscopy . Surgery ( rib resection , decortication ,

thoracoplasty , open window ) .

Antibiotics . Early empiric treatment . Antibiotics altered according to the

patient clinical course or results of pleural fluid cultures .

Repeat cultures with any deviation of patients clinical status.

Tube thoracostomy . Large thoracostomy tube . Smaller CT-guided chest tubes for

multi-loculated empyemas . Success rates of 50% without further

treatment . Chest tubes kept under suction (?) .

Intrapleural fibrinolitic therapy. Streprokinase / Urokinase . Safe and effective in adults and

children . Intrapleural hemorrhage and

bronchopleural fistula are contraindication .

Keep in mind .Early detection of pleural effusions . Accurate definition of empyemas stage . Appropriate antimicrobial therapy . Effective and complete drainage of

empyema and achievement of lung reexpansion prevents surgery .

Treatment of underlying conditions .Adequate nutrition .

Our experience .133 patients with empyema treated in

our department (7 years). 88 patients treated by chest tubes with

Urokinase installations .23 patients operated due to failure of

fibrinolitic therapy .22 patients operated without initial

fibrinolitic treatment .

Our experience .63 patients with complicated

parapneumonic effusion ( 47.3%) .26 patients after Thoracic Surgery

( 19.6% ) .17 patients with traumatic empyema

( 12.8% ) .27 other causes ( 20.3% ) .

Our experience . 111 pts ( 70R , 41L ) . 85 ( 64.8 ) men and 26 ( 54.8 ) women . 614 Urokinase installations ( 5.5 ) . 68 pts treated with 1 chest tube ; 40 with 2

chest tubes ; 5 with 3 . 17 36F chest tubes ; 37 32F chest tubes ; 10

28F chest tubes ; 28 16F chest tubes ; 58 percutaneous chest tubes .

1688 hospital days ( 15.3 ) .

Microbiology . Enterococcus 14 . Staphylococcus 16 ( MERCA 5 ) . Pseudomonas 15 . Echericia coli 3 . Prevotella 6 . Acinetobacter 4 . Streptococcus 7 . Sterile cultures 39 .

Underlying diseases . 46 pts with Cancer . 20 pts with NIDDM . 19 pts with COPD . 21 pts with IHD . 12 pts with Obesity . 2 pts after CVA . 1 pt with Multiple Sclerosis . 15 pts after chemotherapy .

Social status . 17 pts with lower social status . 9 drug abuse . 3 alcoholics . 1 with epilepsy . 2 with schizophrenia . 1 with hydrocephalus . 1 with TB . 61 smokers .

Complications after surgery . 5 Clagett procedures . 3 AF . 1 DVT . 1 intrahospital mortality ; 2 late mortality . 1 BPF . 2 ARF . 2 air leak . 2 tracheostomy . 8 sepsis .

Complications after fibrinolitic therapy .2 AF .1 RF .2 respiratory failure .7 sepsis .3 open drainage .7 home tubes .3 air leak .

Etiology. Pneumonia ( 62% ) . Thoracic and other surgery ( 13% ) . Trauma ( 9% ) .

Pulmonary embolism , tumors and lung abscess , fungi , tuberculosis .

Stages . Initial exudative stage ( 7days ) . Fibrinopurulent stage ( 2 weeks ) . Final organizational stage ( 3 weeks to

months ) .

Goals of treatment . Evacuation of pus . Expansion of lung . Prevention of ongoing infection .

Thanks