Critical Care Medicine-Pulmonary Disorders>>>>>Pleural Disorders
Question 2#

A 45-year-old male was admitted to the ICU after sustaining a gunshot wound to the chest. The resulting hemothorax was initially managed with a chest tube. On hospital day 4 he developed a fever, and leukocytosis and broad spectrum antibiotics were started. A CT of the chest revealed a multiloculated effusion that was concerning for empyema.

The next best step in management is:

A. Place a second chest tube
B. Continue systemic antibiotics and monitor for resolution
C. Flush the chest tube with 100 mL normal saline
D. Consult thoracic surgery for washout and debridement

Correct Answer is D

Comment:

Correct Answer: D

Retained hemothorax is a risk factor for subsequent development of empyema. The AATS consensus guidelines for empyema management class IIa recommendation is that VATS, chest washout should be the first line approach in all patients with stage II acute empyema (loculated effusions or positive culture/gram stain from pleural fluid). Unfortunately, when the hemothorax or empyema is loculated, another chest tube and antibiotics are not curative.

Reference:

1. Shen KR, Bribriesco A, Crabtree T, et al. The American Association for Thoracic Surgery Consensus Guidelines for the Management of Empyema. J Thorac Cardiovasc Surg. 2017;153:e129-e146.