Post-traumatic empyema: aetiology, surgery and outcome in 125 consecutive patients

[Occult and Retained Haemothorax - Recommendations of the Interdisciplinary Thoracic Trauma Task Group of the German Trauma Society (DGU - Section NIS) and the German Society for Thoracic Surgery (DGT)]

The management of occult and retained haemothorax is challenging for all involved in the care of polytrauma patients in terms of diagnosis and treatment. The focus of decision making is preventing sequelae such as pleural empyema and avoiding a trapped lung. An interdisciplinary task force of the German Society for Thoracic Surgery (DGT) and the German Trauma Society (DGU) on thoracic trauma offers recommendations for post-trauma care of patients with occult and/or retained haemothorax, as based on a comprehensive literature review.

ERS/ESTS statement on the management of pleural infection in adults

Pleural infection is a common condition encountered by respiratory physicians and thoracic surgeons alike. The European Respiratory Society (ERS) and European Society of Thoracic Surgeons (ESTS) established a multidisciplinary collaboration of clinicians with expertise in managing pleural infection with the aim of producing a comprehensive review of the scientific literature. Six areas of interest were identified: 1) epidemiology of pleural infection, 2) optimal antibiotic strategy, 3) diagnostic parameters for chest tube drainage, 4) status of intrapleural therapies, 5) role of surgery and 6) current place of outcome prediction in management. The literature revealed that recently updated epidemiological data continue to show an overall upwards trend in incidence, but there is an urgent need for a more comprehensive characterisation of the burden of pleural infection in specific populations such as immunocompromised hosts. There is a sparsity of regular analyses and documentation of microbiological patterns at a local level to inform geographical variation, and ongoing research efforts are needed to improve antibiotic stewardship. The evidence remains in favour of a small-bore chest tube optimally placed under image guidance as an appropriate initial intervention for most cases of pleural infection. With a growing body of data suggesting delays to treatment are key contributors to poor outcomes, this suggests that earlier consideration of combination intrapleural enzyme therapy (IET) with concurrent surgical consultation should remain a priority. Since publication of the MIST-2 study, there has been considerable data supporting safety and efficacy of IET, but further studies are needed to optimise dosing using individualised biomarkers of treatment failure. Pending further prospective evaluation, the MIST-2 regimen remains the most evidence based. Several studies have externally validated the RAPID score, but it requires incorporating into prospective intervention studies prior to adopting into clinical practice.

Shock, Not Blood Pressure or Shock Index, Determines the Need for Thoracic Damage Control Following Penetrating Trauma

BACKGROUND

Damage control laparotomy has increased survival for critically injured patient with penetrating abdominal trauma. There has been a slower adoption of a damage control strategy for thoracic trauma despite the considerable mortality associated with emergent thoracotomy for patients in profound shock. We postulated admission physiology, not blood pressure or shock index, would identify patients who would benefit from thoracic damage control.

STUDY DESIGN

Retrospective trauma registry review from 2002 to 2017 at a busy, urban trauma center. Three hundred one patients with penetrating thoracic trauma operated on within 6 h of admission were identified. Of those 66 (21.9%) required thoracic damage control and comprise the study population.

RESULTS

Compared with the non-damage control group, the 66 damage control patients had significantly higher Injury Severity Score, chest Abbreviated Injury Scale, lactate and base deficit, and lower pH and temperature. In addition, the damage control thoracic surgery group had significantly more gunshot wounds, transfusions, concomitant laparotomies, vasoactive infusions, and shorter time to the operating room. Notably, however, there were no significant differences in admission systolic blood pressure or shock index between the groups. Once normal physiology was restored, chest closure was performed 1.7 (0.7) days after the index operation. Mortality for thoracic damage was 15.2%, significantly higher than the 4.3% in the non-damage control group. Over two-thirds of damage control deaths occurred prior to chest closure.

CONCLUSIONS

Mortality in this series of severely injured, profoundly physiologically altered patients undergoing thoracic damage control is substantially lower than previously reported. Rather than relying on blood pressure and shock index, early recognition of shock identifies patients in whom thoracic damage control is beneficial.

Thoracic Trauma, Nonaortic Injuries

Trauma is one of the leading causes of death worldwide. Approximately two-thirds of trauma patients have thoracic injuries. Nonvascular injury to the chest is most common; however, while vascular injuries to the chest make up a small minority of injuries in thoracic trauma, these injuries are most likely to require intervention by interventional radiology (IR). IR plays a vital role, with much to offer, in the evaluation and management of patients with both vascular and nonvascular thoracic trauma; in many cases, IR treatments obviate the need for these patients to go to the operating room. This article reviews the role of IR in the treatment of vascular an nonvascular traumatic thoracic injuries.

Hemothorax: A Review of the Literature

Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.^1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.

The microbiology of pleural infection in adults: a systematic review

BACKGROUND AND OBJECTIVES

Pleural infection is a major cause of morbidity and mortality among adults. Identification of the offending organism is key to appropriate antimicrobial therapy. It is not known whether the microbiological pattern of pleural infection is variable temporally or geographically. This systematic review aimed to investigate available literature to understand the worldwide pattern of microbiology and the factors that might affect such pattern.

DATA SOURCES AND ELIGIBILITY CRITERIA

Ovid MEDLINE and Embase were searched between 2000 and 2018 for publications that reported on the microbiology of pleural infection in adults. Both observational and interventional studies were included. Studies were excluded if the main focus of the report was paediatric population, tuberculous empyema or post-operative empyema.

STUDY APPRAISAL AND SYNTHESIS METHODS

Studies of ≥20 patients with clear reporting of microbial isolates were included. The numbers of isolates of each specific organism/group were collated from the included studies. Besides the overall presentation of data, subgroup analyses by geographical distribution, infection setting (community versus hospital) and time of the report were performed.

RESULTS

From 20 980 reports returned by the initial search, 75 articles reporting on 10 241 patients were included in the data synthesis. The most common organism reported worldwide was Staphylococcus aureus. Geographically, pneumococci and viridans streptococci were the most commonly reported isolates from tropical and temperate regions, respectively. The microbiological pattern was considerably different between community- and hospital-acquired infections, where more Gram-negative and drug-resistant isolates were reported in the hospital-acquired infections. The main limitations of this systematic review were the heterogeneity in the method of reporting of certain bacteria and the predominance of reports from Europe and South East Asia.

CONCLUSIONS

In pleural infection, the geographical location and the setting of infection have considerable bearing on the expected causative organisms. This should be reflected in the choice of empirical antimicrobial treatment.

A systematic review of comorbidities and outcomes of adult patients with pleural infection

Background

Pleural infection remains an important cause of mortality. This study aimed to investigate worldwide patterns of pre-existing comorbidities and clinical outcomes of patients with pleural infection.

Methods

Studies reporting on adults with pleural infection between 2000 and 2017 were identified from a search of Embase and MEDLINE. Articles reporting exclusively on tuberculous, fungal or post-pneumonectomy infection were excluded. Two reviewers assessed 20 980 records for eligibility.

Results

211 studies met the inclusion criteria. 134 articles (227 898 patients, mean age 52.8 years) reported comorbidity and/or outcome data. The majority of studies were retrospective observational cohorts (n=104, 78%) and the most common region of reporting was East Asia (n=33, 24%) followed by North America (n=27, 20%). 85 articles (50 756 patients) reported comorbidity. The median (interquartile range (IQR)) percentage prevalence of any comorbidity was 72% (58–83%), with respiratory illness (20%, 16–32%) and cardiac illness (19%, 15–27%) most commonly reported. 125 papers (192 298 patients) reported outcome data. The median (IQR) length of stay was 19 days (13–27 days) and median in-hospital or 30-day mortality was 4% (IQR 1–11%). In regions with high-income economies (n=100, 74%) patients were older (mean 56.5 versus 42.5 years, p<0.0001), but there were no significant differences in prevalence of pre-existing comorbidity nor in length of hospital stay or mortality.

Conclusion

Patients with pleural infection have high levels of comorbidity and long hospital stays. Most reported data are from high-income economy settings. Data from lower-income regions is needed to better understand regional trends and enable optimal resource provision going forward.

In pleural infection, patients from higher-income countries tend to be older with more comorbidities and are more likely to be referred for fibrinolytic treatment in comparison to patients from lower-income countrieshttp://bit.ly/2K2M5HL

Thoracic damage control surgery

The damage control surgery came up with the philosophy of applying essential maneuvers to control bleeding and abdominal contamination in trauma patients who are within the limits of their physiological reserves. This concept was extended to thoracic injuries, where relatively simple maneuvers can shorten operative time of in extremis patients. This article aims to revise the various damage control techniques in thoracic organs that must be known to the surgeon engaged in emergency care. RESUMO A cirurgia de controle de danos surgiu com a filosofia de se aplicar manobras essenciais para controle de sangramento e contaminação abdominal, em doentes traumatizados, nos limites de suas reservas fisiológicas. Este conceito se estendeu para as lesões torácicas, onde manobras relativamente simples, podem abreviar o tempo operatório de doentes in extremis. Este artigo tem como objetivo, revisar as diversas técnicas de controle de dano em órgãos torácicos, que devem ser de conhecimento do cirurgião que atua na emergência.

Suction evacuation of hemothorax: A prospective study

BACKGROUND

Although tube thoracostomy is a common procedure after thoracic trauma, incomplete evacuation of fluid places the patient at risk for retained hemothorax. As little as 300 to 500 cm of blood may result in the need for an additional thoracostomy tube or, in more severe cases, lung entrapment and empyema. We hypothesized that suction evacuation of the thoracic cavity before tube placement would decrease the incidence of late complications.

METHODS

Patients requiring tube thoracostomy within 96 hours of admission were prospectively identified and underwent suction evacuation of the pleural space (SEPS) before tube placement. These patients were compared to historical controls without suction evacuation. Demographics, admission vital signs, laboratory values, details of chest tube placement, and outcomes were collected on all patients. Multivariable logistic regression was used to compare outcomes between groups.

RESULTS

A total of 199 patients were identified, consisting of 100 retrospective controls and 99 SEPS patients. There were no differences in age, sex, admission injury severity score or chest abbreviated injury score, admission laboratory values or vital signs, or hospital length of stay. Mean (SD) volume of hemothorax in SEPS patients was 220 (297) cm; with only 48% having a volume greater than 100 cm at the time of tube placement. Three patients developed empyema, and 19 demonstrated retained blood; there was no difference between SEPS and control patients. Suction evacuation of the pleural space was significantly protective against recurrent pneumothorax after chest tube removal (odds ratio, 0.332; 95% confidence interval, 0.148-0.745).

CONCLUSION

Preemptive suction evacuation of the thoracic cavity did not have a significant impact on subsequent development of retained hemothorax or empyema. Suction evacuation of the pleural space significantly decreased incidence of recurrent pneumothorax after thoracostomy removal. Although the mechanism is unclear, such a benefit may make this simple procedure worthwhile. A larger sample size is required for validation and to determine if preemptive thoracic evacuation has a clinical benefit.

LEVEL OF EVIDENCE

Therapeutic/care management study, level IV.

Nonoperative Damage Control: The Use of Extracorporeal Membrane Oxygenation in Traumatic Bronchial Avulsion as a Bridge to Definitive Operation

The conventional treatment for an avulsed bronchus is emergent thoracotomy and repair or lobectomy. The principles of damage control thoracic operations include initial hemorrhage control with delayed definite repair after physiologic resuscitation. We report a multiply injured patient with avulsion of the left lower lobe bronchus. Profound acidosis, hypercarbia, and hypoxia precluded an emergent operation, and venovenous extracorporeal membrane oxygenation (V-V ECMO) was used for organ support during physiologic resuscitation. After the achievement of physiologic repletion, a thoracotomy and lobectomy were performed while the patient was supported by V-V ECMO.

Efficiency Analysis of Direct Video-Assisted Thoracoscopic Surgery in Elderly Patients with Blunt Traumatic Hemothorax without an Initial Thoracostomy

Hemothorax is common in elderly patients following blunt chest trauma. Traditionally, tube thoracostomy is the first choice for managing this complication. The goal of this study was to determine the benefits of this approach in elderly patients with and without an initial tube thoracostomy. Seventy-eight patients aged >65 years with blunt chest trauma and stable vital signs were included. All of them had more than 300 mL of hemothorax, indicating that a tube thoracostomy was necessary. The basic demographic data and clinical outcomes of patients with hemothorax who underwent direct video-assisted thoracoscopic surgery without a tube thoracostomy were compared with those who received an initial tube thoracostomy. Patients who did not receive a thoracostomy had lower posttrauma infection rates (28.6% versus 56.3%, P = 0.061) and a significantly shorter length of stay in the intensive care unit (3.13 versus 8.27, P = 0.029) and in the hospital (15.93 versus 23.17, P = 0.01) compared with those who received a thoracostomy. The clinical outcomes in the patients who received direct VATS were more favorable compared with those of the patients who did not receive direct VATS.

Video-assisted thoracoscopic surgery for retained hemothorax in blunt chest trauma

Purpose of review

In the last decade, video-assisted thoracoscopic surgery (VATS) has become a popular method in diagnosis and treatment of acute chest injuries. Except for patients with unstable vital signs who require larger surgical incisions to check bleeding, this endoscopic surgery could be employed in the majority of thoracic injury patients with stable vital signs.

Recent findings

In the past, VATS was used to evacuate traumatic-retained hemothorax. Recent study has revealed further that lung repair during VATS could decrease complications after trauma. Management of fractured ribs could also be assisted by VATS. Early VATS intervention within 7 days after injury can decrease the rate of posttraumatic infection and length of hospital stay. In studies of the pathophysiology of animal models, N-acetylcysteine and methylene blue were used in animals with blunt chest trauma and found to improve clinical outcomes.

Summary

Retained hemothorax derived from blunt chest trauma should be managed carefully and rapidly. Early VATS intervention is a well tolerated and reliable procedure that can be applied to manage this complication cost effectively.

Complications of chest tubes: a focused clinical synopsis

PURPOSE OF REVIEW

Chest tube placement, or tube thoracostomy, is an invasive procedure designed to evacuate air and/or fluid from the thorax, whether emergent or elective. In the placement of these devices particular attention and effort must be made to understand safe and reliable anatomic techniques and device maintenance so as to avoid serious injury to the patient. This review focuses on complications of chest tube placement, with the emphasis on patient safety and error prevention.

RECENT FINDINGS

There is a paucity of high-quality recent literature on tube thoracostomy complications. With the advent of value-driven healthcare, increasing emphasis is being placed on appropriate procedural indications, procedural safety, and patient satisfaction. Good clinical outcomes are critical to achieve and maintain in this context.

SUMMARY

Given the high volume of tube thoracostomies globally, greater awareness of potential complications and preventive strategies is needed. The authors attempt to bridge this important gap.