Posttraumatic Empyema

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Review Article

European Journal of Trauma

Posttraumatic Empyema J. Jason Hoth, Phillip T. Burch, J. David Richardson1

Abstract Background: Posttraumatic empyema remains a significant clinical problem occurring in 2–10% of victims with thoracic trauma. Many of the factors responsible for the development of posttraumatic empyema are preventable and iatrogenic in nature. As such, it is a source of morbidity and mortality and an additional expense for the institutions who care for these patients. Pathogenesis: The primary feature associated with posttraumatic empyema is a retained hemothorax following chest trauma. Blood trapped within the pleural space impairs its own absorption and acts as an ideal culture medium for bacterial proliferation. Contamination of a retained hemothorax is derived from several sources, including tube thoracostomy, pneumonia, or from the mechanism of injury itself. The combination of tube thoracostomy and retained blood within the pleural space is implicated in most cases of posttraumatic empyema. Diagnosis: The diagnosis of posttraumatic empyema involves the use of clinical parameters and imaging studies. Chest computed tomography, the most useful imaging modality, has a high degree of sensitivity and specificity but must also be correlated with clinical findings of leukocytosis, fever, and often respiratory dysfunction. Treatment: Effective treatment of posttraumatic empyema centers on effective decortication and complete reexpansion of the involved lung. This can be achieved physically either at the time of thoracotomy or thoracoscopy or chemically through the use of fibrinolytic agents. Thoracotomy with decortication is the most successful form of therapy, and the rate of morbidity associated with this procedure is improving. Thoracoscopy with decortication is technically more difficult to perform and more successful when performed early.

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Key Words Chest tubes · Thoracic surgery · Empyema · Hemothorax Eur J Trauma 2002;28:323–32 DOI 10.1007/s00068-002-1264-2

Introduction Empyema thoracis is defined as a bacterial infection within the normally sterile pleural space [1]. Typically, empyema is the result of a parapneumonic process whereby a reactive pleural effusion develops secondary to the pneumonic process and subsequently becomes infected. However, in the trauma setting, this is not necessarily the case. Many of the predisposing factors leading to empyema can be controlled [2]. After both blunt and penetrating chest trauma, the normal relationships of the pleural space are disrupted and blood is sequestered within the potential space. When blood collects within the pleural space, it becomes infected and either forms an empyema, a fibrothorax, or resolves without sequelae [3]. There are several potential sources of contamination of a traumatic hemothorax, including tube thoracostomy, pneumonia, or the mechanism itself. The management of a retained hemothorax has been influenced considerably in the past century, largely as a result of the United States military experiences in World War II, the Korean War, and the Vietnam War [2, 4]. Even though our understanding of the etiology of posttraumatic empyema has progressed considerably, there is no consensus regarding the most prudent technique to identify and treat these patients. Posttraumatic empyema remains a problem occurring in 2–10% of all cases of thoracic trauma and continues to be a source of

Department of Surgery, University of Louisville School of Medicine, and University of Louisville Trauma Program in Surgery, University of Louisville Hospital, Louisville, KY, USA.

Received: October 23, 2002; revision accepted: November 12, 2002

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increased mortality and morbidity and a financial burden to the institutions caring for these patients [5, 6]. In this review, we examine the history, pathogenesis, risk factors, prevention, bacteriology, diagnosis, and treatment options for posttraumatic empyema. Historical Perspective Over 2,000 years ago, Hippocrates was the first to accurately describe the drainage of a pleural empyema by using a piece of tent to act as a drain. He recommended drainage and rib resection and believed that prognosis was related to the color of the effluent. “If pure and white pus flow from the wound, the patients recover; but if mixed with blood, slimy and fetid, they die” [7]. He recognized that drainage should be delayed for approximately 2–3 weeks after signs of infection appear. Open drainage as recommended by Hippocrates through a variety of approaches remained the mainstay of treatment until alternative techniques surfaced in the later portions of the 19th century. In 1892 Sir William Osler described his experiences with four cases of postinfectious empyema successfully treated with serial thoracentesis [8]. While serial thoracentesis was therapeutic in some cases, open drainage was still often required. As knowledge of disease and its natural history progressed, the problem of a thickened pleural peel and pulmonary entrapment was recognized. In 1892 Delorme [9] proposed a method of treatment for empyema that involved thoracotomy and decortication to remove the pulmonary peel and restore normal pulmonary mechanics. This was first successfully performed 1 year later by Fowler [10], a remarkable achievement given the fact that this was done without the use of general anesthesia, mechanical ventilation, antibiotics, and blood products. In the following years, the timing of decortication and open drainage was questionable since early intervention often resulted in open pneumothorax, a fatal complication in most instances [11]. During World War I, our understanding of empyema began to progress significantly, primarily because an influenza epidemic occurred at the time and resulted in many cases of superinfecting pneumonias. This afforded the United States military an opportunity to study both postinfectious and posttraumatic empyema, since the two were still considered a single entity. Resulting from the military’s large experience with empyema during World War I, an “Empyema Commission” led by Drs. Graham and Bell was formed. The Commission made

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several recommendations regarding the surgical treatment of empyema [11]. First, early open drainage of empyema was discouraged, since open pneumothorax was less likely to occur after a waiting period of several weeks. Second, a method of closed tube drainage was adopted in favor of early open drainage. Subsequently, as a result of these changes, there was a decrease in mortality rates, from 60% to < 15%. During World War II, posttraumatic empyema was recognized as a complication of penetrating chest trauma [2]. Drs. Parker and Sampson noted the association between a retained hemothorax and subsequent development of empyema [12, 13]. They termed this process “posttraumatic empyema” and postulated that the cause was an undrained hemothorax that later became infected. As such, observation of hemothorax was replaced with more aggressive measures to evacuate a retained hemothorax after injury. These measures included repeated aspiration, closed tube drainage, and early thoracotomy. The incidence of posttraumatic empyema during World Wars I and II was approximately 20%; however, this rate decreased to nearly 9% during the Korean and Vietnam Wars [14–16]. This reduction was, in part, the result of an increased understanding of the physiology of shock, mechanical ventilation, blood transfusion, and use of antimicrobial agents. However, the primary contributing factor for this reduction was the emphasis of the United States military on the complete evacuation of traumatic hemothorax. Tube thoracostomy was introduced during the Korean War, but early thoracotomy was still advocated if tube thoracostomy proved unsuccessful. With further experience using the measures employed during the Korean and Vietnam Wars, the incidence of posttraumatic empyema continued to decline. During the Six-Day War in Israel in 1967 and the Yom Kippur War in 1973, the incidence fell to approximately 3% [17]. The United States military experience over the past 100 years collectively revealed that early evacuation of blood within the pleural space leads to improved outcomes in terms of infectious complications such as empyema. Early thoracotomy and thoracoscopy (a recent addition) for evacuation of a hemothorax, when necessary, has become an accepted practice in the management of chest trauma. Equally important was the advent of endotracheal intubation and positive-pressure ventilation, parental antibiotics, improvements in the understanding of shock, blood transfusions, and

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closed tube thoracostomy. Despite these measures, posttraumatic empyema remains a significant clinical problem, complicating the management of blunt or penetrating chest trauma in 2–10% of the general population [5, 6]. Definitions and Pathogenesis Empyema thoracis is simply an infection of the pleural space and has been classified by Mandal et al [18] as either primary or secondary. Primary empyema refers to infection of a pleural effusion caused by pleuropulmonary inflammation and comprises approximately 50% of the cases of empyema. The most common example of this mechanism is an empyema complicating pneumonia and is referred to as “postinfectious empyema”. Secondary empyema thoracis includes postoperative complications after thoracic surgery (25%), sequelae of thoracic trauma (15%), and extension of suppurative processes involving the neck or abdomen (10%) [18]. The difficulty in defining posttraumatic empyema lies in determining what exactly constitutes an infection of the pleural space. Pus is rarely aspirated from the chest, laboratory studies are not useful, and cultures are often sterile in contradistinction to postinfectious empyema. Often, the diagnosis of posttraumatic empyema is made based on a constellation of findings, including patient characteristics (white blood cell count, temperature, pulmonary status), radiographic findings, intraoperative findings, and microbiological data. The definition of empyema in the posttraumatic setting differs from institution to institution, and the diagnosis cannot be based on a single test. Furthermore, empyema is classically thought to have an orderly progression through three evolutionary stages: (1) an exudative stage occurring within the first few days of infection, (2) a fibrinopurulent stage (1–2 weeks), and (3) an organizing stage (after 2 weeks) when a thickened pleural peel develops [19]. These stages are thought to be useful in directing therapy of empyema and offer some utility when treating postinfectious empyema. However, with posttraumatic empyema, these stages are meaningless and have no role in diagnosis or management. Rapid progression to the organized stage in the case of posttraumatic empyema is predominant and occurs within days of admission. Once blunt or penetrating chest injury occurs, blood enters the pleural space, and when incompletely evacuated, it organizes into a clot. The deposition of fibrin

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along the pleural surface impairs its absorption, and the resulting clot is an ideal medium for bacterial proliferation [20, 21]. Contamination of the hemothorax may occur at the time of thoracic procedures (tube thoracostomy), from a respiratory source (pneumonia), from an intraabdominal source (as with penetrating thoracoabdominal injuries involving the gastrointestinal tract), or resulting from the mechanism of injury itself (penetrating injuries) [1]. The most likely source of contamination is tube thoracostomy. It is important to realize that simple inoculation of the pleural space with bacteria is not solely responsible for the development of posttraumatic empyema. Other factors may be responsible. It is well known that patients with severe injury develop a state of relative immunosuppression [22]. The exact mechanisms whereby this occurs are beyond the scope of this discussion, but monocyte and neutrophil dysfunction and production of anti-inflammatory cytokines all contribute to a predisposition toward infectious complications in this patient population. When these factors are considered, it is not surprising that complete evacuation of a hemothorax and rapid resuscitation with arrest of hemorrhage have added a considerable priority in the care of injured patients and have reduced the incidence of posttraumatic empyema [23, 24]. Risk Factors Several risk factors for the development of posttraumatic empyema have been identified (Table 1). Penetrating trauma has long been associated with posttraumatic empyema, with a reported incidence of 25% after injury [24–26]. Posttraumatic empyema occurs more frequently after gunshot wounds than after stab wounds [2, 24, 25], since gunshot wounds inherently transfer more kinetic energy to the tissue and result in a worse Table 1. Risk factors for posttraumatic empyema. ER: emergency room; ICU: intensive care unit; OR: operating room. Incomplete evacuation of hemothorax Penetrating injury (gunshot wound > stab wound) Tube thoracostomy • Increasing number • Prolonged duration of drainage • Setting of placement (i.e., ER, ICU, OR) • Personnel performing procedure Shock Thoracoabdominal injury Pulmonary contusion

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injury in terms of local tissue destruction. The resulting combination of necrotic tissue, blood, and bacteria that is swept into the thorax after gunshot wounds creates an ideal environment for empyema. However, posttraumatic empyema after blunt injury is becoming recognized more frequently. These patients are frequently denizens of the intensive care unit and require mechanical ventilation for prolonged periods of time prior to the diagnosis. Simply placing a chest tube is a known risk factor for developing posttraumatic empyema, with an incidence of 2–16% [6, 27, 28]. This risk is compounded by several factors, including the experience of the medical personnel who are placing the tube, the setting in which the procedure is performed, the number of tubes placed, and the duration of tube drainage [5, 25, 29, 30]. Tube thoracostomy is performed after injury to evacuate a hemothorax and fully reexpand the lung. Often, this procedure is performed in an “urgent” fashion in which sterile technique and administration of prophylactic antibiotics are omitted. Retrospectively, in many of these situations, the “urgent” nature of tube placement was more elective and proper precautions for the sterile technique could have been taken. The risk is increased when tubes are placed in the emergency department, likely due to the aforementioned reasons. Personnel with various levels of experience often perform the procedure, leading to breaches in sterile technique and improper placement with incomplete evacuation of blood in the pleural space [29, 30]. Improper placement results in the subsequent placement of additional tubes and additional attempts at “repositioning” the tube, often with no regard for sterile technique. Additionally, the risk increases in direct proportion to the number of tubes placed and the duration of tube drainage [5]. Thoracoabdominal injuries that occur along with gastrointestinal injuries represent a group of patients at increased risk of empyema as well as patients with prehospital hypotension and severe chest injury, as identified by the Abbreviated Chest Injury Score [27, 28]. In particular, patients with pulmonary contusion have been singled out as being at increased risk for posttraumatic empyema [5]. Whether this is related to the injury itself, or the fact that a pulmonary contusion is simply a marker of severe chest injury, has not been delineated. Prophylactic Antibiotics and Tube Thoracostomy Ideally, prophylactic antibiotics are administered prior to the planned intervention so that optimal tissue levels

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may be obtained prior to contamination [31]. Administration of prophylactic antibiotics has been shown to reduce the incidence of infectious complications after abdominal surgery [32]. As such, several authors have attempted to address the role of prophylactic antibiotics in patients with isolated chest trauma requiring tube thoracostomy [33–38]. The primary problem with these studies is that, although they are well constructed, the numbers of patients enrolled are low. This is further complicated by low overall incidence of posttraumatic empyema, the lack of uniform definition of what constitutes an empyema, the use of different antibiotics, and varying durations of antibiotic therapy. However, the results of these trials indicate that the use of prophylactic antibiotics in this patient population reduces infectious complications (specifically empyema), length of hospital stay, cost of care, and need for thoracotomy. Enough evidence exists that in a recent report from the Eastern Association for the Surgery of Trauma, sufficient class I and class II data were recognized to recommend the use of prophylactic antibiotics in patients receiving tube thoracostomy after chest trauma [39]. The appropriate antimicrobial agent selected should be based on providing coverage of the most likely pathogen, Staphylococcus aureus. In this case, a firstgeneration cephalosporin is adequate. The issue regarding length of prophylactic coverage was addressed in a randomized prospective study conducted by Demetriades et al [40]. Patients requiring tube thoracostomy were administered a single dose of ampicillin at the time of tube placement and then randomized to receive no further antibiotic therapy or oral ampicillin until the tube was removed. The rate of thoracic infection was 3.1% in the single-dose group versus 3.2% in the multiple-dose group. Antibiotic prophylaxis is the only proven method for prevention of posttraumatic empyema. Other forms of prophylaxis emphasize the prevention of pneumonia following injury with the thought that the occurrence of posttraumatic empyema would be reduced. Kinetic therapy or rotational beds are an example of such prophylaxis. Kinetic therapy has been shown to reduce the incidence of atelectasis and lower respiratory tract infections in trauma patients [41, 42]. Although this is theoretically appealing, the effectiveness of this therapy in reducing the incidence of posttraumatic empyema remains unproven. Overall, prophylactic antibiotic coverage for patients who suffer isolated chest trauma requiring tube

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thoracostomy is justified based on the results of reported trials [33–39]. An appropriate choice is a first-generation cephalosporin, and a single dose at the time of chest tube placement would be the most prudent course of therapy. Bacteriology The organism most often cultured from a posttraumatic empyema is Staphylococcus aureus, with an incidence ranging from 35% to 75% [5, 18, 43–46]. This is not surprising given the mechanisms thought to be responsible for posttraumatic empyema. Staphylococcus aureus is entirely different from the prevalent organism isolated from postinfectious empyema, which is Streptococcus pneumoniae [1]. In fact, the entire microbiological spectrum of posttraumatic empyema has little resemblance to its postinfectious counterpart. A significant percentage of posttraumatic empyemas (up to 35%) fail to have any growth on culture. This contributes to the argument regarding what exactly defines posttraumatic empyema and implies the inclusion of several cases of evacuation of a hemothorax rather than decortication for empyema [1]. Anaerobes and other gram-negative organisms (Klebsiella sp., Pseudomonas sp.), once rarely encountered, are increasing in frequency. These organisms are usually isolated from patients who suffered thoracoabdominal injuries with gastrointestinal involvement or have a blunt mechanism of injury [2, 6]. Diagnosis Standard supine chest radiographs are the initial diagnostic study for assessing patients with suspected significant thoracic injuries. Plain chest radiographs readily demonstrate rib fractures, pneumothoraces, and moderate-to-large pleural fluid collections. Dependent on the timing of the study in relation to the injury, pulmonary contusion may also be apparent. However, when plain radiography is used to evaluate patients for the presence of an empyema, findings are often nonspecific. Loculated fluid characteristic of empyema may be difficult to distinguish from parenchymal processes such as a contusion or abscess. Furthermore, supine portable chest films may fail to demonstrate smaller fluid collections, and it is often impractical to place the patient in the lateral decubitus position to make the effusion more apparent [47, 48]. Standard chest radiographs are an excellent screening tool, but are suboptimal for definitively diagnosing posttraumatic empyema.

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Figure 1. A CT scan demonstrating a posttraumatic empyema complicating the course of a patient involved in a motor vehicle crash.

Evaluation of the chemical properties of fluid obtained by thoracentesis is of proven value in distinguishing empyema from exudates and transudates [49]. The prevalence of tube thoracostomy in patients with thoracic trauma limits the availability of fluid that can be aspirated; however, ultrasound guidance has been shown to increase the yield of thoracentesis [34, 50]. Sonography also effectively detects pleural thickening, pleural fluid, and septations within pleural fluid [50]. Septations are of prognostic significance, indicating that conservative management is likely to fail [51]. Ultrasound can be performed at the bedside, eliminating the transportation of critically ill patients. Ultrasound is also relatively inexpensive compared with computed tomography (CT) and magnetic resonance imaging (MRI). Despite these advantages, the presence of chest tubes may limit probe placement, and pain from the probe on the chest wall overlying rib fractures may be prohibitive. In addition, subcutaneous emphysema and residual pneumothoraces can prevent transmission of sound waves, and therefore technically limit the study. A CT scan is perhaps the most useful study in the evaluation of patients for posttraumatic empyema. It distinguishes between parenchymal and pleural processes well [52]. Pleural enhancement, pleural thickening, and thickening of the soft tissue adjacent to the pleural cavity on contrast-enhanced CT are consistent with the diagnosis of empyema [53, 54]. However, rib fractures or soft tissue injury alone can cause these fea-

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tures since they are all the result of inflammation. When associated with fever, leukocytosis, and respiratory dysfunction, these findings are highly suggestive of an infection in the pleural cavity. The distinctive, welldefined, lenticular shape of a loculated fluid collection is characteristic of empyema. The “split pleura sign”, which is defined by separation of enhanced visceral and parietal pleural layers by a fluid collection, is also specific for empyema [55]. A CT scan also provides detailed anatomic information that may aid in planning therapeutic interventions. MRI does not allow visualization of the pulmonary parenchyma well, but it can provide information regarding the character of the pleural fluid [56]. The expense of MRI and the presence of therapeutic and monitoring devices containing metallic components limit the application of MRI to trauma patients. When the findings of diagnostic studies and constellation of clinical signs and symptoms do not clarify the diagnosis, video-assisted thoracic surgery (VATS) may be used to directly visualize the pleural cavity. If an empyema is present, complete evacuation may often be accomplished via VATS or open thoracotomy at the same operative setting in which the diagnosis is confirmed. Treatment The goal in treating posttraumatic empyema is twofold: (1) to remove the infectious process, and (2) to allow for complete reexpansion of the lung. Central to any effective treatment strategy is the use of decortication. “Decortication refers to the act of stripping or removing the cortex enveloping membrane or fibrinous peel from the lung” [1]. Without an effective decortication, complete reexpansion of the lung cannot be accomplished, and the patient may suffer respiratory embarrassment and recurrent infectious episodes. Decortication may be accomplished physically at the time of thoracotomy or thoracoscopy or chemically with the use of fibrinolytic agents. Thoracoscopy Since its introduction in the early 1990s, VATS had been applied in a number of clinical situations that were traditionally treated by open thoracotomy, including solitary pulmonary nodules, pleural-based masses, spontaneous pneumothoraces, and parapneumonic empyema. The proven effectiveness of VATS in treating these disease processes and its favorable decreased morbidity compared with open thoracotomy have prompted the

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application of VATS in the field of trauma. Early evacuation of retained hemothoraces has been shown to effectively reduce the development posttraumatic empyema [4]. VATS has proven to be a safe and reliable means of evacuating retained thoracic collections after trauma [57–59]. The goals of therapy are the same with VATS as with thoracotomy, including drainage of the infectious process and complete reexpansion of the lung. Several studies have demonstrated the effectiveness of VATS in treating postinfectious empyema during the fibrinopurulent stage with success rates between 60% to 100%. VATS is less effective in treating disease that has progressed to the fibrotic or organized stage [24, 60–62]. As discussed earlier, the classification system for postinfectious empyema does not readily apply to posttraumatic empyema, when rapid progression to an organized or fibrotic stage is the rule, and direct comparison between postinfectious and posttraumatic empyema in terms of treatment is difficult. A review of the available literature indicates that successful intervention with VATS for posttraumatic empyema is also dependent on timely intervention and the surgeon’s expertise with the procedure. However, the use of VATS to evacuate a retained hemothorax has been more successful than its use for the treatment of empyema. When VATS is used to evacuate hemothorax within 7 days of injury, conversion to thoracotomy is seldom required. The procedure is successful in terms of reducing the incidence of pleural infectious complications [57]. Thus, it appears that the most efficient use of VATS is prophylaxis, evacuating a hemothorax prior to the development of an empyema. The success of this procedure is dependent on early recognition and intervention. A word of caution regarding the use of VATS to treat posttraumatic empyema involves the thoroughness of decortication. Removal of the visceral peel is technically the most demanding portion of the procedure. At the time of thoracotomy, this often requires partial reexpansion of the lung to develop a cleavage plane, and it remains difficult to remove the entire visceral peel. To do so with VATS is challenging, if not impossible. Partial reexpansion of the lung is not an option with VATS, and visualization of the cleavage plane often proves difficult. Conversion to thoracotomy is advised when an excessively difficult dissection with resulting uncontrollable hemorrhage or inadequate visualization is encountered. An initial attempt at VATS appears warranted in all cases, with conversion to thora-

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cotomy applied liberally. Many times, the visualization afforded by VATS allows us to make a smaller thoracotomy incision when conversion is necessary. Conversion to an open procedure should not be interpreted as failure if the ultimate goals of treatment are achieved. Thoracotomy An infected, retained hemothorax is the genesis of virtually all cases of posttraumatic empyemas. Once infected, the clot rapidly organizes and develops a dense fibrinous coagulum, which is adherent to the surrounding structures and multiloculated. When the process has reached this stage, it is not surprising that other forms of therapy are largely ineffective in accomplishing the goals of treatment, removal of the infectious focus and reexpansion of the lung. Thoracotomy with decortication is required in the vast majority of cases and is curative in over 90% [6, 46, 63]. When performed early, the operation is technically easier, subsequent morbidity and mortality are reduced, and patients have shorter lengths of stay [63–66]. Decortication should be performed with the patient under general anesthesia and with a duallumen endotracheal tube, whenever possible. Collapse of the involved lung allows the surgeon to enter the chest atraumatically, enhances intraoperative exposure, and allows one to use a small thoracotomy incision. Once proper access to the pleural space is obtained, all purulent fluid is drained, and the visceral peel is removed. Removal of the visceral peel permits complete expansion of the underlying lung and is technically easier when removed early in the course of the infectious process. The knife, forceps, or clamps may be used to develop a cleavage plane between the lung and peel. Partial reexpansion of the lung may assist dissection at this point. When the operation is performed late, vigorous stripping will cause injury to the underlying lung and large air leaks, and hazardous bleeding may result. Often, cessation of the operation may be required. In addition, the surgeon should decide whether to excise the pleural peel. This is a controversial topic, since excision of the inflamed parietal peel has been proposed to reduce the incidence of postoperative bacteremia [43]. Whether this actually occurs is debatable, but excision of the parietal peel is justified when it is not overly dangerous and aids with reexpansion of the involved lung. Large air leaks should be treated with suture closure and several large-bore chest tubes placed at the

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completion of the procedure to ensure adequate drainage. Lung resection may be necessary when overly diseased segments are encountered. Therefore, surgeons performing this procedure should be comfortable with formal lung resection. The chest tubes should be kept on suction until all air leaks have ceased and there is complete apposition of the lung to the chest wall. Postoperative complications are few and include bronchopleural fistula (4%), empyema recurrence (5–8%), and wound infection (4–10%) [1]. Bronchopleural fistula is a particularly vexing problem and more apt to occur in patients requiring pulmonary resection after injury. Initial closed drainage may be attempted with conversion to an Eloesser flap once the mediastinum is fixed. This should be followed by closure of the bronchial stump using a vascularized muscle flap (intercostal or diaphragm) at a later time. Fibrinolytics After the discovery of streptokinase in 1944, the first clinical application occurred in 1949 when Tillett & Sherry [67] used intrapleural instillation of this agent for acute fibrinous pleurisy, bacterial empyema, and hemothorax. Urokinase, a less antigenic fibrinolytic agent than streptokinase, became available in the 1980s, and application of urokinase to treat loculated pleural fluid collections was first reported in 1989 by Moulton et al [68]. The use of fibrinolytic agents to treat empyema is appealing. Fibrinolytic agents activate plasmin through the cleavage of plasminogen and initiate the degradation of fibrin. Degradation of fibrin will reduce the viscosity of the fluid within the empyema cavity and dissolve loculations. Theoretically, coupled with chest tube drainage, this will eventually allow for resolution of the infectious process and dissolve the peel, allowing complete lung expansion. Intrapleural administration of these agents has no systemic absorption and does not cause coagulation defects [69]. Common systemic side effects associated with intrapleural administration of streptokinase include fever up to 40 °C and pleural pain [70]. The fever represents a delayed-type hypersensitivity reaction, probably from the presence of contaminating streptococcal proteins [71]. This type of contamination was common in the 1970s and 1980s and led to the use of urokinase, but with more purified preparations available, contamination is currently uncommon. Other reactions common to all fibrinolytic agents include arthralgias, nausea, malaise, headaches, and anaphylaxis in 3.3% of patients. Only one case report of massive

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intrapleural hemorrhage after fibrinolytic therapy is present in the literature [72]. The streptokinase or urokinase at a dose of 250,000 IE in 100 ml of normal saline may be instilled intrapleurally with the chest tubes clamped for 1–2 h and then placed back on suction. This may be repeated on a daily basis for several days until drainage is minimal and reexpansion is evident. The reported success rates of intrapleural fibrinolytic agents vary from 70% to 90%; however, most of this information comes from series that pertain to postinfectious empyema [71, 73]. In some of these series, patients with retained hemothoraces or posttraumatic empyema have been reported to undergo fibrinolytic therapy with reasonable rates of success [71, 73]. Success is influenced by proper patient selection and intervention when the infectious process is relatively acute [46–73]. Operative treatment is required if fibrinolytic therapy fails to effectively treat posttraumatic empyema. Successful use of fibrinolytics increases with physician experience but also requires patience from the physician, since the process is tedious, taking several days to complete or declare a failure. The patient’s hospital stay is therefore lengthened, and the delay may make decortication more difficult. Most importantly though, the major limitation regarding the use of fibrinolytic agents is that both urokinase and streptokinase are no longer produced in the United States and the use of tissue plasminogen activator has not been reported in the literature. Conclusion Posttraumatic empyema remains a prevalent problem in the care of patients who sustain chest trauma. Despite many innovations in the care of these trauma victims (thoracoscopy, thoracostomy, parental antibiotics), the incidence has remained relatively unchanged for the past 50 years. Posttraumatic empyema continues to be a source of increased morbidity and mortality. Central to the development of posttraumatic empyema is the retained hemothorax. The use of thoracoscopy has greatly aided in the evacuation of blood from the chest. An aggressive search for retained hemothoraces in chest trauma victims is warranted to avoid later infectious morbidity. When posttraumatic empyema is diagnosed, decortication using thoracotomy is an effective and safe method of treatment. Fibrinolytic therapy is tedious, often resulting in prolonged hospital stays, and standard

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pharmacologic agents are not readily available at this time. We recommend treating most posttraumatic empyema patients with thoracoscopy, but one should not hesitate to convert to thoracotomy when the dissection is difficult or decortication is believed to be inadequate. References 1. 2. 3.

4. 5. 6. 7. 8. 9. 10.

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19. 20. 21. 22. 23.

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Address for Correspondence J. David Richardson, MD Department of Surgery University of Louisville School of Medicine Louisville, KY 40292 USA Phone (+1/502) 852-5442, Fax -8915 e-mail: [email protected]

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