Tube Thoracostomy: Tube Thoracostomy: Complications and Complications and the Role of the Role of Prophylactic Prophylactic Antibiotics Antibiotics By Ashley Laird By Ashley Laird
Tube Thoracostomy: Complications and the Role of Prophylactic
Antibiotics
By Ashley Laird
Indications for TT
PTX (spontaneous, iatrogenic,
traumatic)HemothoraxChylothoraxDecreased breath sounds in unstable
patient after blunt or penetrating traumaMultiple rib fractures,
sucking chest wound, subcutaneous air in intubated trauma
patientComplicated pleural effusion, empyema, lung
abscessThoracotomy, decorticationPleural lavage for active
rewarming for hypothermia
Complications
Undrained PTX, hemothorax, or effusion despite TT clotted
hemothorax, empyema, fibrothoraxImproper placement +/- iatrogenic
injuries (lung, diaphragm, subclavian, right atrium)Recurrent PTX
after tube removalIntrapleural collections following tube
removalThoracic empyema
Factors Influencing Complications: Louisville study
Prior studies report TT complication rates of 3-36%Etoch SW,
Bar-Natan MF, Miller FB, Richardson JD. Tube Thoracostomy: Factors
related to complications. Arch Surg. 1995;
130:521-525.Retrospective chart review (U of Louisville)379 trauma
pts, 599 tubes
Factors Influencing Complications: Louisville study
Complications:EmpyemaUndrained PTX or effusionImproper tube
placement (+/- iatrogenic injury)Post-tube PTXOtherMeasures: Rate
of complications in association w/ TT setting, operator, patient
characteristics, MOI, and severity of injury
Factors Influencing Complications: Louisville study
Overall rate of complications: 21% per patient (16% per tube)8.2%
of complications required thoracotomy
Factors Influencing Complications: Setting
48% of tubes placed in ED, 23% in OR, 12% in ICU, 7% on floor, and
9% at OSH prior to transferSignificantly higher complication rate
when TT performed in outside hospital prior to transfer (33%,
p
Factors influencing Complications: Operator
59% of tubes placed by surgeons, 26% by ED physicians, 8% by
physicians prior to transferHighest complication rate for tubes
placed by physicians in outside hospitals, mostly nonsurgeon
physicians (38%)Complication rates for TTs in study hospital: 13%
for ED physicians, 6% for surgeons (p
Factors influencing Complications: Mechanism/Severity of
Injury
No difference in complication rate related to:Age and sex of
patientsMechanism of injury (23% for blunt vs 18% for
penetrating)ISSSignificantly increased complication rate related
to:ICU admission (29% vs 11%, p
Factors influencing Complications: Mechanism/Severity of
Injury
Factors Influencing Complications: University Hospital study
Deneuville M. Morbidity of percutaneous tube thoracostomy in trauma
patients. Eur J CT Surg. 2002; 22:673-678.Prospective observational
study (University Hospital, Guadeloupe)128 trauma pts, 134
tubesNon-thoracic operators vs. thoracic surgeons
Factors Influencing Complications: University Hospital study
Overall complication rate 25% (29% per tube)5 (12.8%) improper
placement, no iatrogenic injury4 (10.3%) improper placement w/
iatrogenic injury (lung x 2, diaphragm, subclavian artery)4 (10.3%)
undrained hemothorax/PTX12 (30.8%) post-removal PTX7 (18%)
post-removal fluid collection3 (2.3%) empyema4 (10.3%) combined18
(46.2%) of complications required surgery (thoracotomy or
VATS)
Factors Influencing Complications: University Hospital study
No difference in complication rate related to: Blunt trauma vs.
penetrating woundsIndication for TT: hemothorax vs PTXPresence of
pulmonary contusion, abdominal injury, or need for immediate
abdominal surgerySignificantly increased risk of complication
related to:Polytrauma (RR 2.7, p
Thoracic Empyema
Causes of post-traumatic empyema: Iatrogenic infection during
TTDirect infection from penetrating injurySecondary infection from
associated intra-abdominal injuries w/ diaphragmatic disruption or
hematogenous or lymphatic spread to pleural spaceSecondary
infection of undrained hemothoracesParapneumonic empyema resulting
from posttraumatic pneumonia, contusion, or ARDS
Thoracic Empyema
Empyema occurred in 1.8% (Louisville study) and 2.3% (University
Hospital study) of patients undergoing TT No difference in rate of
empyema related to setting or operatorNo difference in rate of
empyema related to administration of antibiotics within 24 hours of
initial TT in Louisville study (2% vs 2%)
Prophylactic Antibiotics in TT: EAST Guidelines
Does prophylactic antibiotic use in injured patients requiring TT
reduce the incidence of empyema and/or pneumonia?Paucity of
literature, especially well-designed multi-institutional
double-blinded trials that control for setting, operator, mechanism
of injury, timing of antibiotic administration, choice and dose of
antibiotic, and duration of prophylaxis
Prophylactic Antibiotics in TT: EAST Guidelines
Luchette FA, Barrie PS, Oswanski MF, Spain DA, Mullins CD, Palumbo
F, Pasquale MD. Practice Management Guidelines for Prophylactic
Antibiotic Use in Tube Thoracostomy for Traumatic Hemopneumothorax:
the EAST Practice Management Guidelines Work Group. J Trauma. 2000;
48(4):753-7.MEDLINE search (1977-1997) for references using query
words: antibiotic prophylaxis, chest tubes, human, drainage, tube
thoracostomy, infection, empyema, and bacterial
infection-prevention and control.11 articles reviewed: 9
prospective series, 2 meta-analyses
Prophylactic Antibiotics in TT: EAST Guidelines
Articles classified by Agency for Health Care Policy and Research
(AHCPR) methodologyClass I: prospective, randomized,
double-blinded, controlled trialsClass II: prospective, randomized,
non-blinded trialClass III: retrospective series of patients or
meta-analysisFour class I articles, five class II, and two class
III meta-analyses
Prophylactic Antibiotics in TT: Conclusions and
Recommendations
Incidence of empyema in placebo groups ranged from 0-18%, compared
to 0-2.6% in antibiotic groupsTwo class I studies saw a reduced
incidence of empyema w/ antibiotic Rx (Cant, 1993; Grover, 1977)Two
class II studies saw no benefit w/ antibiotics (Mandal, 1985;
Demetriades, 1991)Other studies didnt control for MOI Insufficient
evidence to support prophylactic antibiotics as a standard of care
for reducing incidence of empyema or PNA in patients requiring
TT
Prophylactic Antibiotics in TT: Conclusions and
Recommendations
Extreme variability in choice of antibiotic, dosing, and duration
of therapy among studiesOne class I study reported no empyema in
patients receiving cefazolin for 24hrs compared to 5% incidence in
placebo group (Cant et al, 1993)Administration of antibiotics for
>24hrs did not significantly reduce risk of empyema compared
with shorter duration (Demetriades, 1991)
Prophylactic Antibiotics in TT: Conclusions and
Recommendations
Incidence of pneumonia in placebo groups ranged from 2.5-35.1%,
compared to 0-12% in antibiotic groupsIn most reports, significant
reduction in pneumonitis seen in patients receiving prolonged
antibiotics (but also see increased cost and length of hospital
stay) Presumptive, rather than prophylactic therapy, in setting of
acute trauma
Prophylactic Antibiotics in TT: Conclusions and
Recommendations
Recommendations (for isolated chest trauma)Level I: insufficient
data to support level I recommendation as standard of careLevel II:
insufficient data to suggest prophylactic antibiotics reduce
incidence of empyemaLevel III: sufficient class I and II data to
recommended prophylactic antibiotic use in patients receiving TT
after chest trauma. A first generation cephalosporin should be used
for no longer than 24hrs. There may be a reduction in incidence of
PNA, but not empyema.
Recommendations
Additional training of all trauma physiciansEarly thoracotomy or
VATS in settings of persistent fluid collection or multiple chest
tube placements as means to prevent against development of
empyemaFirst generation cephalosporin for no more than 24
hoursFurther research!
