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EMPYEMA-1 - Empyema thoracic Empyema Dr Rajesh Kumar MD(PGI...

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Unformatted text preview: Empyema thoracic Empyema Dr Rajesh Kumar MD (PGI), DM (Neonatology) PGI, Chandigarh, India Rani Children Hospital, Ranchi There are no universally accepted guidelines for management of empyema thoracic management Definition Definition presence of pus or microorganism in the presence pleural fluid. Microorganisms may be seen on smear examination or on culture. smear In the absence of microorganism, – The pH of pleural fluid is less than 7.0 – Lactic dehydrogenase (LDH) is more than 1000 Lactic IU/L IU/L – glucose is less than 40 mg/dl – lactate is more than 5 mol/L or 45 mg/ml Organisms Organisms Staphylococcus aureus, Streptococcus pneumoniae Staphylococcus and Streptococcus pyogenes Streptococcus Pneumococcal pneumonia presents with effusion in Pneumococcal 40% patients, empyema occurs only in 5% 40% Anaerobes and enterobacter are common in mixed Anaerobes infections. Anaerobes are more common after 6 years of age. For anaerobes, aspiration pneumonia is the most common cause followed by lung abscess, sub diaphrag-matic abscess and spreading infection from adjacent sites, e.g. periodontal, retropharyne.g. geal, peritonsillar and neck abscesses. geal, Tuberculous 230 children, 32 % pleural fluid culture 230 positive, 11% additional blood culure positive positive 60 % S Aureus ( 78 % MRSA) First PRSP in 1995, First MRSA 1998 Early (<48 hours) VATS decreased the Early hospital stay hospital Stages of Empyema Stages Exudative stage (1-3 days ) Fibrino purulent stage (4 to 14 days) Organizing stage (after 14 days) Exudative stage (1-3 days) Exudative Immediate response with outpouring of the Immediate fluid. Low cellular content Low It is simple parapneumonic effusion with It normal pH and glucose levels. – – – – – pH more than 7.30 glucose more than 60 mg/dl pleural fluid/serum glucose ratio more than 0.5 LDH less than 1000 IU/L LDH Gram stain and culture is negative for microorganism. organism. Fibrino purulent stage (4 to 14 days) Fibrino Large number of poly-morphonuclear leukocytes and Large fibrin accumulates fibrin Fluid pH and glucose level fall while LDH rises. Fluid Acumulation of neutro-phils and fibrin, effusion Acumulation becomes purulent and viscous leading to development of empyema. development There is progressive tendency towards loculations There and formation of a limiting membranes. and Pleural fluid analysis – Purulent fluid or pH less than 7.10, glucose less than 40 Purulent mg/dl and LDH more than 1000 IU/L. Gram stain and culture reports show microorganism. Organizing stage (after 14 days) Organizing Fibro-blasts grow into exudates on both the Fibro-blasts visceral and parietal pleural surfaces visceral Development of an inelastic membrane "the Development peel". Thickened pleural peel may prevent the entry Thickened of anti-microbial drugs in the pleural space and in some cases can lead to drug resistance. Most common in S. aureus infection. Most Thickened pleural peel can restrict lung Thickened movement and it is commonly termed as trapped lung trapped CXR CXR Large pleural effusion can be diagnosed Large in posteroanterior view in Lateral decubitus view with affected Lateral side inferior facilitates recognition of smaller volumes of fluid. X-ray in different positions helps to -ray recognize the extent of parenchymal infection and may reveal loculated fluid infection USG USG Very useful tool for diagnosis, guidance of thoracocentesis, or pleural catheter placement. centesis, Sonography can distinugish solid from liquid pleural Sonography abnormalities with 92% accuracy compared to 68% accuracy with chest X-ray. When both are combined, -ray. accuracy rises to 98% accuracy USG shows limiting membranes suggesting the USG presence of loculated collections even when they are invisible by CT scan. invisible Thoracocentesis and Pleural Fluid Analysis If effusion is free flowing and greater than one If centimeter from inside of the chest wall to the pleural fluid line on the lateral decubitus view, immediate diagnostic thoracocentesis should be done. If loculated, thoracocentesis should be done If under ultrasound guidance. The site for thoracocentesis is 1 cm below upper level of dullness dullness Thoracocentesis and Pleural Fluid Analysis Thoracocentesis Two third of the cases of anaerobic infection have malodorous Two empyema empyema Protein level and specific gravity is rarely helpful in Protein differentiating stages of empyema differentiating In some cases with frank pus, organisms are neither seen on In Gram stain nor grown in culture. Such cases must raise a suspicion of chylous effusion suspicion cell fragments will sediment where a chylous effusion will cell remain opaque after centrifugation remain Tuberculous empyema can be confirmed by stains for acid fast Tuberculous bacilli in fewer than 25% cases but pleural biopsy and culture can diagnose more than 90% cases can ADA more than 70 U/L supports the diagnosis of tuberculous ADA pleural empyema pleural PCR Goal of treatment Goal 1. 2. 3. Control of infection Drainage of pus Expansion of lungs Treatment Options Treatment Non-Operative – – – – Primary non-operative Primary Salvage operative Primary operative Antibiotics Thoracocentesis ICTD Fibrinolysis Operative – VATS – Thoracotomy Emperical antibiotics Emperical Anti Staph antibiotic + Cephalosporin + Anti Aminoglycoside Aminoglycoside Suspectedanaerobic infection Suspectedanaerobic Clindamycin should be added Clindamycin Antibiotics Antibiotics Paren-teral therapy should be continued for Paren-teral 48-72 hours after abatement of fever and then oral therapy can be used to complete the course. Antibiotic should be continued until patient is Antibiotic afebrile, WBC count is normal, radiograph show consider-able clearing show Duration of therapy – – H. influnezae, S. pneumonia: 10-14 days Staph aureus: 3-4 weeks Empyema drainage Empyema Indications for drainage – Frank pus, smear positive fluid, loculated fluid – pH less than 7.10, glucose less than 40 mg/dl and LDH pH more than 1000 IU/L more Repeated thoracocentesis is rarely successful; Smallbore percutaneous catheters can be used if the fluid bore is thin is CT or USG guided drainage if empyema collection is CT small. Chest tube drainage is advised for drainage of Chest tuberculous empyema. Chest tube must be kept inside till drainage is less Chest than 30-50 ml per day and cavity size is less than 50 mll in size( m Predicting Factors for Outcome of Tube Thoracostomy in Complicated Parapneumonic Effusion or Empyema : Chest 1999 Effusion loculation of pleural effusion and pleural fluid loculation WBC count 6,400/µL were independent predicting factors for poor outcome of tube thoracostomy thoracostomy Surgical intervention should be considered early Surgical after failure of first chest tube drainage in good surgical candidates with loculated empyema or pleural fluid with WBC count 6,400/µL to minimize the mortality and morbidity minimize Thrombolytic Therapy Thrombolytic Useful in multiloculated empyema.It hydrolyse fibrin leading to Useful hydrolysis of fibrin coagulum hydrolysis Multiloculation of empyema defined on the basis of USG/CT SK 2,50,000 unit or UK 1,00,000 unit in 100 ml normal saline SK was instilled through chest tube and tube was clamped for 3 hours. Number of instillation in SK and UK were 6 ± 2.16 and 5.92 ± Number 2.05, two patients out of 25 patients failed to respond completely. Transient increase of body temperature was noted in 28% Transient cases of SK while no complication was noted with UK. UK as little as 50,000 unit per instillation was found to be UK successful in 95% cases in one series. Surgical modalities Surgical Videoassisted Thoracoscopic Surgery (VATS): It is quite effective in lysis of adhesions in multiloculated effusions and removal of fibrinous material from pleural cavity. VATS is often not as useful in organizing stage. Thoracoscopic Debridement and Irrigation: It is quite Thoracoscopic effective in cases with multiloculated empyema. Success rate is as high as 69% to 89% Decortication: helpful in organizing stage with thick Decortication: pleural peel, Bronchopleural fistula Bronchopleural ICTD Decortication and fistula closure: after 2-3 Decortication weeks of ICTD weeks Gradual tube withdrawal Thoracoplasty or resectional surgery Response depends on – – – – Size of fistula, Size state of underlying lung and contralateral lung, state presence or absence of systemic illness, presence nutritional rehabilitation Response to therapy Response S. pneumoniae and H. influenzae infection children can H. remain febrile for 7 or more days after adequate antibiotic therapy has been instituted while children having S. aureus infection can remain febrile for 10-14 S. days despite appropriate management days Scoring system for empyema thoracis and help in management: IJJP 2005 and SSE > 4 a is predictors of SSE surgical intervention for fibrinopurulent empyema in the present study. Early elective VATS may be adopted not later than 7 days after failure of appropriate antibiotic therapy and adequate drainage of empyema to decrease the length of stay and minimize morbidity. and Prognosis Prognosis In most of the cases, pulmonary In function is found to be normal function Few cases show complications such as Few scoliosis, mild pleural thickening and mild restrictive defect mild Younger children fared less well Younger ...
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