Posttraumatic empyema

Risk factors for posttraumatic empyema in diaphragmatic injuries

Background

Penetrating diaphragmatic injuries are associated with a high incidence of posttraumatic empyema. We analyzed the contribution of trauma severity, specific organ injury, contamination severity, and surgical management to the risk of posttraumatic empyema in patients who underwent surgical repair of diaphragmatic injuries at a level 1 trauma center.

Methods

This is a retrospective review of the patients who survived more than 48 h. Univariate OR calculations were performed to identify potential risk factors. Multiple logistic regression was used to calculate adjusted ORs and identify independent risk factors.

Results

We included 192 patients treated from 2011 to 2020. There were 169 (88.0) males. The mean interquartile range, (IQR) of age, was 27 (22–35) years. Gunshot injuries occurred in 155 subjects (80.7%). Mean (IQR) NISS and ATI were 29 (18–44) and 17 (10–27), respectively. Thoracic AIS was > 3 in 38 patients (19.8%). Hollow viscus was injured in 105 cases (54.7%): stomach in 65 (33.9%), colon in 52 (27.1%), small bowel in 42 (21.9%), and duodenum in 10 (5.2%). Visible contamination was found in 76 patients (39.6%). Potential thoracic contamination was managed with a chest tube in 128 cases (66.7%), with transdiaphragmatic pleural lavage in 42 (21.9%), and with video-assisted thoracoscopy surgery or thoracotomy in 22 (11.5%). Empyema occurred in 11 patients (5.7%). Multiple logistic regression identified thoracic AIS > 3 (OR 6.4, 95% CI 1.77–23. 43), and visible contamination (OR 5.13, 95% IC 1.26–20.90) as independent risk factors. The individual organ injured, or the method used to manage the thoracic contamination did not affect the risk of posttraumatic empyema.

Conclusion

The severity of the thoracic injury and the presence of visible abdominal contamination were identified as independent risk factors for empyema after penetrating diaphragmatic trauma.

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

INTRODUCTION

Empyema remains a potentially serious condition with multiple etiologies including post-pneumonic, post-resection, and post-traumatic. There are few studies describing the latter. We reviewed our experience at a high volume trauma centre in injured patients with empyema, examining pre-operative status, surgical procedures, pathogens and outcome.

METHODS

Retrospective trauma registry review, from 9/01 to 4/10. Empyema was defined as culture positive pleural fluid or purulence at operation. Data collected included demographics, injury mechanism, thoracic injuries, organ dysfunction, pathogens isolated, surgical procedures, outcomes and follow up.

RESULTS

One hundred twenty-five consecutive patients with empyema were identified. Average injury severity score and age were 27.3 and 37.2 years respectively; 89.6% were male, 63.2% sustained blunt chest trauma. Time from injury to diagnosis averaged 12.1 days. All underwent decortication; 80% by thoracotomy, the remainder thoracoscopically. At operation over half were mechanically ventilated and 13.6% required vasoactive infusions. Monomicrobial cultures with Gram positive cocci predominating were obtained in 44%, 48% had polymicrobial cultures and 18.4% had a ruptured lung abscess. There were five deaths (4%); two occurring after a ruptured lung abscess. Recurrent empyema occurred in 6.4%, all successfully treated by re-operation or catheter drainage. Intensive care and hospital stays were 18.1 and 30.6 days respectively. All survivors achieved resolution of empyema.

CONCLUSIONS

Trauma patients with empyema represent a subset of severely injured critically ill patients with diverse pathogens and polymicrobial flora. Appropriate surgical management and specific antibiotic therapy yields excellent results with acceptable risk. A ruptured lung abscess may be the aetiology of the post-traumatic empyema in a subset of patients and may represent an increased operative risk.

The risk factors and management of posttraumatic empyema in trauma patients

BACKGROUND

Posttraumatic empyema increases patient morbidity, mortality and length of hospital stay, and the cost of treatment. The aim of this study was to identify the risk factors for posttraumatic empyema and to review our treatment outcomes in patients with this condition.

METHODS

A total of 2261 patients who were admitted with thoracic traumas and underwent tube thoracostomy between January 1989 and January 2006 were investigated retrospectively. Posttraumatic empyema developed in 71 patients. Logistic regression was used to assess the association between potential risk factors for posttraumatic empyema. All values were expressed as the mean+/-S.D.

RESULTS

Eight hundred and thirty-six (37%) of the patients had penetrating type trauma, while 1425 (63%) had blunt type trauma. The rate of posttraumatic empyema development was 3.1% for all patients. Pulmonary contusion was seen in 221 (9.8%) patients and fractures of more than two ribs were seen in 191 (8.4%) patients. Tube thoracostomy placement was performed in the emergency room in 1728 (76.4%) patients, in the hospital ward in 197 (8.7%), in the intensive care unit in 182 (8.0%), and in the operating room in 154 (6.8%). The duration of tube thoracostomy was 6.11+/-2.99 (1-21) days. Retained haemothorax was seen in 175 (7.7%) patients. The mean lengths of hospital and intensive care unit stay were 6.42+/-3.45 and 2.36+/-2.66 days, respectively. The analysis showed that duration of tube thoracostomy (OR, 2.49, p<0.001), length of intensive care unit stay (OR, 4.21, p<0.001), and presence of contusion (OR, 3.06, p<0.001), retained haemothorax (OR, 5.55, p<0.001), and exploratory laparotomy (OR, 2.46, p<0.001) were independent predictors of posttraumatic empyema. The relative risk of posttraumatic empyema was higher than 1 for each of the following risk factors: penetrating trauma (OR, 1.59, p=0.055), associated injuries (OR, 1.12, p=0.628) and fractures of more than two ribs (OR, 1.60, p=0.197).

CONCLUSION

Prolonged duration of tube thoracostomy and length of intensive care unit stay, and the presence of contusion, laparotomy and retained haemothorax are independent predictors of posttraumatic empyema. Use of prophylactic antibiotics may be recommended in patients with these risk factors.

Video-assisted thoracic surgery--the past, present status and the future

Video-assisted thoracic surgery (VATS) has developed very rapidly in these two decades, and has replaced conventional open thoracotomy as a standard procedure for some simple thoracic operations as well as an option or a complementary procedure for some other more complex operations. In this paper we will review its development history, the present status and the future perspectives.

Empyema and Restrictive Pleural Processes after Blunt Trauma: An Under-Recognized Cause of Respiratory Failure

Respiratory failure is a common complication among patients sustaining major blunt trauma. This is usually due to the underlying pulmonary injury, pneumonia, or adult respiratory distress syndrome. However, we have frequently found these patients to actually have a pleural process as the cause of their respiratory failure. Our objective was to assess the frequency of empyema and restrictive pleural processes after blunt trauma and their contribution to respiratory failure. We retrospectively reviewed all blunt trauma patients over a 5-year period who required a thoracotomy and decortication for empyema. Twenty-eight patients with blunt trauma required a thoracotomy and decortication for empyema. The most common finding was infected, loculated hemothorax/effusion in 23 patients, whereas 5 had an associated pneumonia. Chest radiographs were nondiscriminating, whereas CT scans in 25 patients showed previously unrecognized fluid collections, air-fluid levels, or gas bubbles. Neither thoracentesis nor placement of additional chest tubes was helpful. Positive cultures were uncommon. Ventilator dependence was present preoperatively in 13 patients who were on the ventilator an average of 13 days preoperatively and only 5.8 days postoperatively. Several patients believed to have adult respiratory distress syndrome were weaned within 72 hours of operation. All patients were ultimately cured. Empyema is an under-recognized complication of blunt trauma and may contribute to respiratory failure and ventilator dependence. Although difficult to diagnose, empyema should be considered in blunt trauma patients with respiratory failure and an abnormal chest radiograph. CT aids in the diagnosis, and the results of surgical treatment are excellent.

Profile of Chest Trauma in a Referral Hospital: A Five-Year Experience

From April 1993 to March 1998, 90 patients with chest injuries were retrospectively assessed for the incidence, presentation, and outcome of thoracic trauma. The majority (55.6%) were less than 40 years of age and 83 (92%) were male. The mode and extent of injury, specific intrathoracic organ injuries, associated injuries, flail chest, ventilatory requirements, management, morbidity, and mortality were analyzed. Blunt injuries were seen in 56 (62.2%) and penetrating injuries in 34 (37.7%). Multiple rib fractures with hemopneumothorax was the most frequent presentation with orthopedic and head injuries being most commonly associated. Patients with tachypnea, cyanosis, lung contusion, partial pressure of aterial oxygen less than 60 mm Hg, and those with more than 6 rib fractures most often required ventilation but the majority (54.4%) were treated with a chest drain only. Emergency or delayed thoracotomy was required in 24.4%. The mortality rate was 6.7%, mainly due to respiratory insufficiency. Subcutaneous emphysema requiring releasing incisions accounted for most of the morbidity. Mean hospital stay was 9.5 days. Chest injuries were of major concern in multisystem trauma patients and early planned management is recommended in a mostly vulnerable section of our population in an age of violence and vehicular accidents.

Delayed hemothorax after blunt thoracic trauma: an uncommon entity with significant morbidity

OBJECTIVE

To describe the nature of delayed hemothorax occurring after blunt thoracic trauma and to identify the population at risk for this complication.

METHODS

A retrospective review was conducted of 36 consecutive patients with hemothorax consequent to blunt trauma. Criteria for the definition of delayed hemothorax were established involving normal interval chest radiographs or computed tomographic scans during hospitalization.

RESULTS

Twelve cases of delayed development of hemothorax were identified. Ninety-two percent of cases occurred in patients with multiple or displaced rib fractures. Presentation occurred from 18 hours to 6 days after injury. Eleven of the 12 cases were heralded by a prodrome of new pleuritic chest pain and dyspnea that occurred from 4 to 19 hours before treatment.

CONCLUSION

Delayed hemothorax after blunt trauma is a unique entity occurring in patients with multiple or displaced rib fractures. Vigilance for the recognizable prodrome in the high-risk population should allow early remediation of this complication.

Posttraumatic empyema thoracis: a 24-year experience at a major trauma center

The purpose of this paper is to review the outcome of patients with posttraumatic empyema thoracis. Between April 1972 and March 1996, the Division of Cardiothoracic Surgery at the King-Drew Medical Center managed or was consulted on 5,474 trauma patients (4,584 patients with penetrating injuries and 890 with blunt injuries) who were admitted emergently for thoracic and thoracoabdominal injuries and who underwent tube thoracostomy. Patients were not given routine prophylactic antibiotics merely because they had a chest tube placed. Based on our previous reports on thoracic trauma, our criteria for empiric antibiotic administration included (1) emergent or urgent thoracotomy, (2) soft-tissue destruction of the chest wall by shotgun injuries, (3) lung contusion with hemoptysis, (4) associated abdominal trauma requiring exploratory laparotomy, or (5) associated open long-bone fractures. Eighty-seven of these 5,474 patients developed posttraumatic empyema thoracis, for an incidence of 1.6%. These 87 patients were treated with tube thoracostomy, image-guided catheter drainage, or open thoracotomy with decortication. Seventy-nine of 87 patients (91%) were cured without conversion to open thoracostomy. Four patients required conversion to open thoracostomy, and there were three deaths. Even though a majority of our patients required decortication, successful management of posttraumatic empyema thoracis also was achieved with closed-tube thoracostomy or image-guided catheter drainage based on clinical and radiographic findings with appropriate patient selection. When thoracic empyema did occur in our group, Staphylococcus aureus was the most common microbe isolated, followed by anaerobic bacteria. In correlating microbiologic data with outcomes, S. aureus, especially methicillin-resistant S. aureus, was the most frequent cause of antibiotic failure. Because of the low incidence of posttraumatic empyema thoracis, we do not recommend routine antibiotic prophylaxis for all trauma patients who undergo closed-tube thoracostomy. A review of the role of tube thoracostomy, intrapleural fibrinolytic therapy, image-guided catheter drainage, video-assisted thoracoscopy, and open thoracotomy for the management of thoracic empyema is provided.

Video-assisted thoracic surgery in treatment of chest trauma

Although the indications for video-assisted thoracic surgery (VATS) have expanded rapidly, especially in the areas of therapeutic and operative procedures, its role in the definite surgical treatment of chest trauma is not clear. From July 1994 to December 1995, 56 patients with hemothorax or posthemothorax complications resulting from chest trauma received thoracic surgery. Their ages ranged from 17 to 71 years. Mechanisms of injury included penetrating (n = 23) and blunt injury (n = 33). VATS was successfully applied in 50 patients; six patients with cardiovascular injuries (n = 4) or minor chest wall lacerations (n = 2) did not receive VATS. All patients who received VATS survived, with no morbidity. Twelve of the 50 patients treated with VATS would have otherwise had to undergo thoracotomy. Our results indicate that VATS can be safely used in hemodynamically stable patients with no cardiovascular or great vessel injury, sparing many patients the pain and morbidity associated with thoracotomy. Additionally, use of VATS may reduce the likelihood of posthemothorax complications by allowing early direct inspection of the chest wall, because VATS has a lower associated risk and can be performed with a lower index of suspicion than can standard thoracotomy.

The role of thoracoscopy in the management of retained thoracic collections after trauma

BACKGROUND

Retained hemothorax and infected thoracic collections after trauma can be seen in up to 20% of patients initially treated with tube thoracostomy and have traditionally been treated nonoperatively, often with prolonged hospital stays.

METHODS

Twenty-five patients with retained thoracic collections were reviewed. They underwent 26 thoracoscopies to evacuate undrained blood with or without infection.

RESULTS

In 19 patients (76%), the collections were evacuated thoracoscopically. In 4 patients the procedure was converted to an open thoracotomy, and 2 patients required additional procedures to drain these collections. Failure of thoracoscopy correlated with the time between injury and operation and the type of collection, but not with the mechanism of injury. When thoracoscopy was performed in less than 7 days after admission, no cases of empyema were noted at operation.

CONCLUSIONS

Videothoracoscopy is an accurate, safe, and reliable operative therapy to evacuate retained thoracic collections. In 90% of the patients in whom the procedure was completed, good results were obtained, reducing hospital stay and possible complications. Videothoracoscopy should be the initial treatment in trauma patients with retained thoracic collections and should be used earlier and more frequently in these patients.

Mortality in thoracic empyema

With a view of elucidating factors influencing mortality in patients with thoracic empyema, which varies widely (10-50%) in reported case series, a retrospective analysis was made. The series comprised 259 patients treated for thoracic empyema at Bispebjerg Hospital in the period 1965-1980. The mortality was 33% in the total case series, 61% when the underlying pathology was malignant and 25% when it was benign. As malignancy was apparently cured in only 17% of the cases, the investigation was focused on the 200 patients with benign conditions underlying the empyema. The mortality then ranged from nil in spontaneous pneumothorax and thoracic trauma to 50% in lung abscess. Most of the patients with empyema were elderly, but there was no clear difference in mortality between younger and older groups. Concomitant, other disease was present in 80% of the patients who died, but in only 40% of the survivors. Mortality showed no significant difference in relation to primary treatment. Staphylococcus aureus was statistically predominant among the fatal cases. It is concluded that empyema occurring, as in the present study, mainly in elderly and enfeebled patients, is a serious complication with high mortality.

Early decortication for anaerobic empyema in children

Nine children underwent early decortication for empyema. Three had posttraumatic empyema and six had postpneumonic empyema. The decision for decortication was made 3-5 days after diagnosis of empyema, when it was judged that conventional treatment by antibiotics and intercostal catheter drainage was failing. Such failure was manifested by: loculated effusions (9), persistent fever (8), persistent respiratory distress (3), pulmonary air leak (3), and worsening parenchymal disease (1). The decortication procedure consisted of a standard posterolateral thoracotomy, removal of the fibrinous peel from the visceral and parietal pleurae, debridement or resection of necrotic lung tissue, irrigation of the pleural space, and drainage by intercostal catheters. In the 9 children who underwent this procedure, there were no deaths and a single complication, suppurative thrombophlebitis. Recovery was rapid in 6 out of 9 children, who were discharged within 10 days of operation. The remaining 3 out of 9 children had associated injuries or illnesses that necessitated a longer hospital stay. Bacteriologic studies confirmed anaerobic bacteria in the infected pleural contents of 5 out of 9 children. Bacteroides and anaerobic streptococci were the commonest isolates. Anaerobic infection of the pleural space cannot be cured without aggressive surgical drainage, in addition to antibiotics. Our experience suggests that early decortication is an efficacious procedure for selected children with empyema. The presence of anaerobic bacteria in the empyema may constitute an unequivocal indication for early decortication.