Thoracostomy Drainage Research Articles

Interpleural Analgesia After Thoracotomy

We examined the effects of the following variables on interpleural analgesia after thoracotomy: addition of epinephrine to local anesthetic, thoracostomy drainage, two-catheter placement, and location of catheter tips. Twenty patients were randomized to have one catheter (paravertebral tip location) or two catheters (paravertebral and lateral thoracic wall tip locations). Interpleural catheters were sutured to the parietal pleura by the surgeon at time of wound closure. Patients were then randomly assigned to receive 20 mL of 0.5% bupivacaine with 1:200,000 epinephrine through the single catheter or 10 mL of 0.5% bupivacaine with or without 1:200,000 epinephrine through each of the two catheters while supine. Bupivacaine concentrations in whole blood and in thoracostomy drainage fluid were assayed by gas chromatography. Actual content of bupivacaine in the drainage fluid was calculated. Degree of analgesia was assessed by verbal numerical pain scores over the first 4 h and opioid demand thereafter. Addition of epinephrine to bupivacaine did not influence the degree of analgesia. Approximately 30%-40% of any administered dose of bupivacaine was lost via the thoracostomy tube over a 4-h period. There was no correlation between the true initial dose (100 mg minus thoracostomy drainage) and Cmax. Use of two catheters resulted in significantly less opioid requirements after an initial 8-h period. Failure to achieve adequate interpleural analgesia in postthoracotomy patients may be related to loss of anesthetic via thoracostomy drainage, presence of extravasated blood and tissue fluid in the pleural space, and possibly sequestration and channeling of flow of local anesthetic by restricted motion of an operated lung.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic Value of Nonfluoroscopic Percutaneous Lung Needle Aspiration in Patients with Pneumonia

In forty-one patients (mean [+/- SD] age 51 +/- 19 years; range, 11 to 88 years; seven female and 34 male) with clinical signs and symptoms of pneumonia, we performed a nonfluoroscopic percutaneous lung needle (22 gauges) aspiration (PLNA) to investigate the diagnostic yield of this technique. All the patients were receiving antibiotics at the time of the study, and PLNA was performed either because of a lack of response to empiric antibiotic treatment or because of the severity of the pneumonia or the underlying condition of the patient. Eight patients were mechanically ventilated (MV) due to acute respiratory failure. The PLNA was performed at bedside and without fluoroscopic guidance. Twenty-two microorganisms were identified by means of stains and/or cultures of PLNA samples. Sensitivity of PLNA was 43 percent (18/41). We detected three false-positive cultures probably due to contamination from the skin area punctured. In the eight MV patients studied, the sensitivity of PLNA was 37.5 percent, and the microbiologic findings turned out to be crucial for the outcome of the patients. Pneumothorax developed in three patients (7 percent) after PLNA. None of these three patients developed a pleural infection but two of them required thoracostomy drainage. None of the MV patients presented complications. Our results showed that nonfluoroscopic PLNA is a technique with moderately good sensitivity and with a low rate of false-positive cultures (8 percent) to diagnose pulmonary infections in patients with unresponsiveness to empiric antibiotic treatment or with severe pneumonia. Further evaluation of its diagnostic value and complications in MV patients is needed, although our preliminary results suggest that PLNA can be an alternative technique to other methods for diagnosing pulmonary infections in patients receiving artificial ventilatory support.

Thin-walled cavities, cysts, and pneumothorax in Pneumocystis carinii pneumonia: further observations with histopathologic correlation.

Thin-walled pulmonary cystic lesions were found in five immunocompromised patients, four with acquired immunodeficiency syndrome (AIDS). Four patients had Pneumocystis carinii pneumonia (PCP), and one had pulmonary lesions and disseminated P carinii infection. Two patients demonstrated P carinii within necrotizing, thin-walled, smaller intraparenchymal cavities lined by organisms, exudate, and chronic inflammation. Larger, typically apical and subpleural cysts, lined by fibrosis and/or alveolar parenchyma with little inflammation, were also found during acute episodes. The larger subpleural cysts can arise via rupture of intraparenchymal necrotizing cavities into the subpleural area. Pneumothorax in the four patients with AIDS could not be cured by close thoracostomy drainage; all required pleurodesis. The cysts persisted in cases that were followed up. All cysts were more obvious and numerous with computed tomography (CT), especially with 1.5-mm collimation. CT may be indicated in immunocompromised patients with unexplained pneumothorax or when tube thoracostomy has failed and surgery is being considered, as it can positively influence the operative approach.

The controversial role of decortication in the management of pediatric empyema

Open surgical procedures for pleural empyema remain controversial in children. The pediatric literature generally recommends a prolonged trial of antibiotics and closed tube thoracostomy drainage. We report a favorable experience with a selective approach to open drainage in 22 children, many of whom had an empyema already organizing at admission. Open drainage was considered in children whose conditions failed to improve after 3 to 5 days of therapy with antibiotics and closed drainage. The method of drainage was selected according to the pathologic phase of the empyema: five children with fibrinopurulent empyema were successfully managed by limited decortication, and 17 with organizing empyema received decortication. Clinical improvement was usually dramatic; most of the children became afebrile by postoperative day 3 and were discharged by postoperative day 10. There were no deaths. Three children (14%) had complications of postoperative air leak or infection. Streptococcus pneumoniae (5) and Hemophilus influenzae (3) were the most common single pathogens. The presence of anaerobic bacteria in 8 of 22 children (36%) was associated with rapid organization of the empyema and the need for decortication. Decortication procedures have a low risk and are effective in children with empyema. They should be considered as definitive therapy, rather than as a last resort.

Spontaneous pneumothorax in children—a review of 95 cases

We reviewed the records of 95 consecutive patients with spontaneous pneumothorax. The children, 75 boys and 20 girls, ranged in age from newborn to 12 years. The average duration of symptoms, cough, chest pain and breathlessness, was 5 days. Pyogenic lung infection (74.8%) and pulmonary tuberculosis (21%) were the commonest underlying causes of pneumothorax. All children underwent tube thoracostomy drainage along with supportive treatment. Five died owing to sever infection present at the time of admission. Except for the five (5.21%) who died, all children (94.79%) had full relief of pneumothorax. We conclude that pyogenic pulmonary infection and pulmonary tuberculosis are still the commonest causes of pneumothorax in the tropics. Tube thoracostomy drainage is very successful and thoracotomy in selected patients is safe.

Management of Empyema thoracis in children—a study of 65 cases

Sixty-five cases of pleural empyema (50 boys and 15 girls) were seen between January 1983 and June 1986. Fifty-three of these 65 children were below 10 years of age. Pulmonary infection was the commonest underlying cause. Cough with or without expectoration (98%) and fever (95%) were the commonest symptoms followed by breathlessness (85%) and chest pain (83%). Staphylococcus aureus was isolated from pus and blood in 61% and 18% of cases, respectively, while pseudomonas was grown in 8% and 3%. Most of the children (88%) were treated with antibiotics and tube thoracostomy drainage. Decortication was needed in 12% of cases. There were four deaths in this study. The overall success rate was 94%.

Empyema thoracis: a ten-year experience.

Over a ten-year period, 50 patients with thoracic empyema have been treated at the Metropolitan Nashville General Hospital, where a systematic, stepwise approach to the management of empyema has been followed. The initial step was thoracentesis; if this failed to resolve the empyema, dependent thoracostomy tube drainage was used. Closed thoracostomy drainage was converted to open drainage when closed drainage failed to obliterate the empyema cavity. When all other measures failed, thoracotomy with pleural decortication was done. Of the 27 patients who had empyema as a consequence of pneumonia, most (14) were successfully treated with open empyema tube drainage, though five required decortication. Eight of the ten posttraumatic empyemas resolved with open drainage, but pleural decortication was necessary in the remaining two cases. Nine patients had postoperative empyemas; six were managed with open drainage, and three resolved with closed thoracostomy drainage. Of the four remaining empyemas, two resolved with closed drainage and two required open drainage. Treatment was successful in 85% of cases, with six deaths (15%). This experience with empyema shows that early, staged surgical management is successful in most cases. In our experience, the causative organism had no bearing on outcome. Resolution of the condition was possible only after adequate drainage and obliteration of the empyema space was accomplished.

Reevaluation of early evacuation of clotted hemothorax

During an 18 1 2 year period, we encountered 14,300 patients with blunt or penetrating thoracic or thoracicoabdominal trauma. In 155 patients, residual clotted hemothorax or empyema developed later. Thirty-nine patients underwent early evacuation of clotted hemothorax with no mortality and an average hospital stay of only 10 days. When progression to empyema occurred, the mortality rate increased to 9.4 percent and the average hospital stay to 37.9 days. The most common related event in the development of empyema was concurrent injury to intraabdominal organs and the inevitable bacterial contamination of the thorax. In a small number of patients, tube thoracostomy drainage is inadequate and results in residual clotted hemothorax. Despite recent pleas for conservative, expectant management, it is our experience that early evacuation of clotted hemothorax is not only cost-effective, it is also associated with lower morbidity, lower mortality, and reduces the chance of development of empyema.

Acute Empyema in Children Treated by Open Thoracotomy and Decortication

Acute nontuberculous empyema treated conventionally by thoracentesis, thoracostomy drainage, and antibiotics has an unacceptably high rate of morbidity and mortality. Early open thoracotomy to eliminate the empyema with decortication of the fibrinous peel and reexpansion of the lung has proven safe and effective for 25 years. The goals of treatment of acute nontuberculous empyema are: (1) to save life, (2) to eliminate the empyema, (3) to reexpand the trapped lung, (4) to restore mobility of the chest wall and diaphragm, (5) to return respiratory function to normal, (6) to eliminate complications or chronicity, and (7) to reduce the duration of hospital stay. Our studies confirm the normal values to be expected in patients who have had complete recovery from the acute empyema, and we lay to rest any concern that decortication might, in time, limit pulmonary function. We present the cases of 21 children who had acute and mature empyemas that were treated by open thoracotomy and decortication, with an average follow-up of 18 years, among whom there were no deaths or complications.

Instillation of fibrinolytic enzymes in the treatment of pleural empyema.

Acute pleural empyema which is not amenable to pleural puncture or closed thoracic drainage should be treated operatively by decortication or, in persistent cavities, by open thoracostomy drainage. In the last 2 years we have instilled 500,000 IU of fibrinolysines (streptokinase and streptodornase) per day into the pleural cavity of 27 patients with pleural infections requiring closed intrapleural drainage. By means of this treatment, pus and fibrinous membranes are liquefied and necrotic tissue is discharge. Therapeutic success is indicated by considerably increased fluid drainage about one hour after instillation. This therapy was performed for an average of 5 days. In 12 patients (44%) pleural empyema could be cured. In the other 15 cases decortication, and in 3 of them open thoracostomy drainage, was necessary. In our opinion intrapleural instillation of fibrinolytic enzymes should be added to the well-recognized method of treatment of pleural empyema, although not replace them.

Persistent chylothorax: Treatment by talc pleurodesis

Two patients with persistent chylothorax resistant to therapy by special diet, thoracenteses, and tube thoracostomy drainage were successfully treated by talc pleurodesis. In one patient with advanced lymphosarcoma involving pleura and mediastinal nodes, the chylothorax was managed by open thoracotomy and talc powder. The other patient developed chylothorax following resection of a thoracic aortic aneurysm. She was successfully treated by talc suspension introduced through a thoracostomy tube. Pleurodesis with talc should be considered only when the chylothorax persists after an adequate period of medical treatment and pleural decompression. Intrapleural instillation of talc through a thoracostomy tube should be successful if the chylothorax can be evacuated and the underlying lung fully expanded.

Indications for thoracotomy following penetrating thoracic injury.

The treatment of penetrating thoracic injuries has been reviewed in both civilian and military series. Although most surgeons agree that closed that closed thoracostomy drainage is the initial treatment of choice, the timing of early thoracotomy and perhaps cardiorrhaphy upon patients with penetrating thoracic injuries remains controversial. The purpose of this study was to determine which patients will require immediate thoractomy or cardiorrhaphy following penetrating chest injury. Over a two-year period 190 patients with penetrating thoracic injuries were treated. Of 53 patients who required immediate thoracotomy, 31 suffered cardiac wounds. Seventy-nine patients required laparotomy for associated intra-abdominal injuries. The mortality rate was related to exsanguinating hemorrhage or postoperative intra-abdominal sepsis. Cardiopulmonary complications were rare in the absence of intra-abdominal sepsis and could not be attributed to the thoracic injury or thoracotomy. Indications for immediate cardiorrhaphy or thoracotomy are: 1) location of the entrance wound (70% in upper mediastinum); 2) blood pressure on admission less than 90; 3) initial thoracostomy blood loss greater than 800 cc; 4) radiographic evidence of retained hemothorax; and/or 5) clinical evidence of pericardial tamponade.

Pulmonary surgery in immunosuppressed patients

Six immunosuppressed patients were subjected to thoracic surgical procedures for the treatment of pulmonary complications; 5 were receiving drugs to prevent homograft rejection, and the sixth had congenital sex-linked hypogammaglobulinemia. The indications for intervention were lung perforation (4 examples), bronchiectasis (1 example), and unyielding atelectasis (1 example). Pulmonary resection was carried out in 5 instances and closed chest thoracostomy drainage in the sixth. Two of the patients made a complete recovery. The other 4, including all those who had lung perforation and a bronchopleural fistula, died of overwhelming infections. It has been suggested that earlier operation for an expanding cavitary lesion may be one way of improving the results if it is anticipated that rupture is likely.