Tube Thoracostomy: Complications and the Role of Prophylactic Antibiotics By Ashley Laird
Indications for TT <ul><li>PTX (spontaneous, iatrogenic, traumatic) </li></ul><ul><li>Hemothorax </li></ul><ul><li>Chyloth...
Complications <ul><li>Undrained PTX, hemothorax, or effusion despite TT    clotted hemothorax, empyema, fibrothorax </li>...
Factors Influencing Complications: Louisville study <ul><li>Prior studies report TT complication rates of 3-36% </li></ul>...
Factors Influencing Complications: Louisville study <ul><li>Complications: </li></ul><ul><ul><li>Empyema </li></ul></ul><u...
Factors Influencing Complications: Louisville study <ul><li>Overall rate of complications: 21% per patient (16% per tube) ...
Factors Influencing Complications: Setting <ul><li>48% of tubes placed in ED, 23% in OR, 12% in ICU, 7% on floor, and 9% a...
Factors influencing Complications: Operator <ul><li>59% of tubes placed by surgeons, 26% by ED physicians, 8% by physician...
Factors influencing Complications: Mechanism/Severity of Injury <ul><li>No difference in complication rate related to: </l...
Factors influencing Complications: Mechanism/Severity of Injury
Factors Influencing Complications: University Hospital study <ul><li>Deneuville M. Morbidity of percutaneous tube thoracos...
Factors Influencing Complications: University Hospital study <ul><li>Overall complication rate 25% (29% per tube) </li></u...
Factors Influencing Complications: University Hospital study <ul><li>No difference in complication rate related to:  </li>...
Thoracic Empyema <ul><li>Causes of post-traumatic empyema:  </li></ul><ul><ul><li>Iatrogenic infection during TT </li></ul...
Thoracic Empyema <ul><li>Empyema occurred in 1.8% (Louisville study) and 2.3% (University Hospital study) of patients unde...
‘ Prophylactic’ Antibiotics in TT: EAST Guidelines <ul><li>Does ‘prophylactic’ antibiotic use in injured patients requirin...
‘ Prophylactic’ Antibiotics in TT: EAST Guidelines <ul><li>Luchette FA, Barrie PS, Oswanski MF, Spain DA, Mullins CD, Palu...
‘ Prophylactic’ Antibiotics in TT: EAST Guidelines <ul><li>Articles classified by Agency for Health Care Policy and Resear...
‘ Prophylactic’ Antibiotics in TT: Conclusions and Recommendations <ul><li>Incidence of empyema in placebo groups ranged f...
‘ Prophylactic’ Antibiotics in TT: Conclusions and Recommendations <ul><li>Extreme variability in choice of antibiotic, do...
‘ Prophylactic’ Antibiotics in TT: Conclusions and Recommendations <ul><li>Incidence of pneumonia in placebo groups ranged...
‘ Prophylactic’ Antibiotics in TT: Conclusions and Recommendations <ul><li>Recommendations (for isolated chest trauma) </l...
Recommendations <ul><li>Additional training of all trauma physicians </li></ul><ul><li>Early thoracotomy or VATS in settin...
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Tube Thoracostomy.ppt

  1. 1. Tube Thoracostomy: Complications and the Role of Prophylactic Antibiotics By Ashley Laird
  2. 2. Indications for TT <ul><li>PTX (spontaneous, iatrogenic, traumatic) </li></ul><ul><li>Hemothorax </li></ul><ul><li>Chylothorax </li></ul><ul><li>Decreased breath sounds in unstable patient after blunt or penetrating trauma </li></ul><ul><li>Multiple rib fractures, sucking chest wound, subcutaneous air in intubated trauma patient </li></ul><ul><li>Complicated pleural effusion, empyema, lung abscess </li></ul><ul><li>Thoracotomy, decortication </li></ul><ul><li>Pleural lavage for active rewarming for hypothermia </li></ul>
  3. 3. Complications <ul><li>Undrained PTX, hemothorax, or effusion despite TT  clotted hemothorax, empyema, fibrothorax </li></ul><ul><li>Improper placement +/- iatrogenic injuries (lung, diaphragm, subclavian, right atrium) </li></ul><ul><li>Recurrent PTX after tube removal </li></ul><ul><li>Intrapleural collections following tube removal </li></ul><ul><li>Thoracic empyema </li></ul>
  4. 4. Factors Influencing Complications: Louisville study <ul><li>Prior studies report TT complication rates of 3-36% </li></ul><ul><li>Etoch SW, Bar-Natan MF, Miller FB, Richardson JD. Tube Thoracostomy: Factors related to complications. Arch Surg. 1995; 130:521-525. </li></ul><ul><ul><li>Retrospective chart review (U of Louisville) </li></ul></ul><ul><ul><li>379 trauma pts, 599 tubes </li></ul></ul>
  5. 5. Factors Influencing Complications: Louisville study <ul><li>Complications: </li></ul><ul><ul><li>Empyema </li></ul></ul><ul><ul><li>Undrained PTX or effusion </li></ul></ul><ul><ul><li>Improper tube placement (+/- iatrogenic injury) </li></ul></ul><ul><ul><li>Post-tube PTX </li></ul></ul><ul><ul><li>Other </li></ul></ul><ul><li>Measures: </li></ul><ul><ul><li>Rate of complications in association w/ TT setting, operator, patient characteristics, MOI, and severity of injury </li></ul></ul>
  6. 6. Factors Influencing Complications: Louisville study <ul><li>Overall rate of complications: 21% per patient (16% per tube) </li></ul><ul><li>8.2% of complications required thoracotomy </li></ul>
  7. 7. Factors Influencing Complications: Setting <ul><li>48% of tubes placed in ED, 23% in OR, 12% in ICU, 7% on floor, and 9% at OSH prior to transfer </li></ul><ul><li>Significantly higher complication rate when TT performed in outside hospital prior to transfer (33%, p<.0001) </li></ul><ul><li>No significant difference in complication rates between TT in ED (9%) vs. TT in other areas of study hospital (7%) </li></ul>
  8. 8. Factors influencing Complications: Operator <ul><li>59% of tubes placed by surgeons, 26% by ED physicians, 8% by physicians prior to transfer </li></ul><ul><li>Highest complication rate for tubes placed by physicians in outside hospitals, mostly nonsurgeon physicians (38%) </li></ul><ul><li>Complication rates for TT’s in study hospital: 13% for ED physicians, 6% for surgeons (p<.0001) </li></ul><ul><li>For TT’s in ED: 13% complication rate for ED physicians vs 5% complication rate for surgeons (p<.01) </li></ul>
  9. 9. Factors influencing Complications: Mechanism/Severity of Injury <ul><li>No difference in complication rate related to: </li></ul><ul><ul><li>Age and sex of patients </li></ul></ul><ul><ul><li>Mechanism of injury (23% for blunt vs 18% for penetrating) </li></ul></ul><ul><ul><li>ISS </li></ul></ul><ul><li>Significantly increased complication rate related to: </li></ul><ul><ul><li>ICU admission (29% vs 11%, p<.0001) </li></ul></ul><ul><ul><li>Mechanical ventilation (29% vs 15%, p<.002) </li></ul></ul><ul><ul><li>Presence of hypotension (SBP<90) on admission (31% vs 17%, p<.003) </li></ul></ul>
  10. 10. Factors influencing Complications: Mechanism/Severity of Injury
  11. 11. Factors Influencing Complications: University Hospital study <ul><li>Deneuville M. Morbidity of percutaneous tube thoracostomy in trauma patients. Eur J CT Surg. 2002; 22:673-678. </li></ul><ul><ul><li>Prospective observational study (University Hospital, Guadeloupe) </li></ul></ul><ul><ul><li>128 trauma pts, 134 tubes </li></ul></ul><ul><ul><li>‘ Non-thoracic’ operators vs. thoracic surgeons </li></ul></ul>
  12. 12. Factors Influencing Complications: University Hospital study <ul><li>Overall complication rate 25% (29% per tube) </li></ul><ul><ul><li>5 (12.8%) improper placement, no iatrogenic injury </li></ul></ul><ul><ul><li>4 (10.3%) improper placement w/ iatrogenic injury (lung x 2, diaphragm, subclavian artery) </li></ul></ul><ul><ul><li>4 (10.3%) undrained hemothorax/PTX </li></ul></ul><ul><ul><li>12 (30.8%) post-removal PTX </li></ul></ul><ul><ul><li>7 (18%) post-removal fluid collection </li></ul></ul><ul><ul><li>3 (2.3%) empyema </li></ul></ul><ul><ul><li>4 (10.3%) combined </li></ul></ul><ul><li>18 (46.2%) of complications required surgery (thoracotomy or VATS) </li></ul>
  13. 13. Factors Influencing Complications: University Hospital study <ul><li>No difference in complication rate related to: </li></ul><ul><ul><li>Blunt trauma vs. penetrating wounds </li></ul></ul><ul><ul><li>Indication for TT: hemothorax vs PTX </li></ul></ul><ul><ul><li>Presence of pulmonary contusion, abdominal injury, or need for immediate abdominal surgery </li></ul></ul><ul><li>Significantly increased risk of complication related to: </li></ul><ul><ul><li>Polytrauma (RR 2.7, p<0.05) </li></ul></ul><ul><ul><li>Need for assisted ventilation (RR 2.7, p<.003) </li></ul></ul><ul><ul><li>TT by non-thoracic surgeons (RR 8.7, p<.0001 for blunt trauma and RR 12.5%, p<.0001 for penetrating trauma) </li></ul></ul>
  14. 14. Thoracic Empyema <ul><li>Causes of post-traumatic empyema: </li></ul><ul><ul><li>Iatrogenic infection during TT </li></ul></ul><ul><ul><li>Direct infection from penetrating injury </li></ul></ul><ul><ul><li>Secondary infection from associated intra-abdominal injuries w/ diaphragmatic disruption or hematogenous or lymphatic spread to pleural space </li></ul></ul><ul><ul><li>Secondary infection of undrained hemothoraces </li></ul></ul><ul><ul><li>Parapneumonic empyema resulting from posttraumatic pneumonia, contusion, or ARDS </li></ul></ul>
  15. 15. Thoracic Empyema <ul><li>Empyema occurred in 1.8% (Louisville study) and 2.3% (University Hospital study) of patients undergoing TT </li></ul><ul><li>No difference in rate of empyema related to setting or operator </li></ul><ul><li>No difference in rate of empyema related to administration of antibiotics within 24 hours of initial TT in Louisville study (2% vs 2%) </li></ul>
  16. 16. ‘ Prophylactic’ Antibiotics in TT: EAST Guidelines <ul><li>Does ‘prophylactic’ antibiotic use in injured patients requiring TT reduce the incidence of empyema and/or pneumonia? </li></ul><ul><li>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 </li></ul>
  17. 17. ‘ Prophylactic’ Antibiotics in TT: EAST Guidelines <ul><li>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. </li></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>11 articles reviewed: 9 prospective series, 2 meta-analyses </li></ul></ul>
  18. 18. ‘ Prophylactic’ Antibiotics in TT: EAST Guidelines <ul><li>Articles classified by Agency for Health Care Policy and Research (AHCPR) methodology </li></ul><ul><ul><li>Class I: prospective, randomized, double-blinded, controlled trials </li></ul></ul><ul><ul><li>Class II: prospective, randomized, non-blinded trial </li></ul></ul><ul><ul><li>Class III: retrospective series of patients or meta-analysis </li></ul></ul><ul><li>Four class I articles, five class II, and two class III meta-analyses </li></ul>
  19. 19. ‘ Prophylactic’ Antibiotics in TT: Conclusions and Recommendations <ul><li>Incidence of empyema in placebo groups ranged from 0-18%, compared to 0-2.6% in antibiotic groups </li></ul><ul><li>Two class I studies saw a reduced incidence of empyema w/ antibiotic Rx (Cant, 1993; Grover, 1977) </li></ul><ul><li>Two class II studies saw no benefit w/ antibiotics (Mandal, 1985; Demetriades, 1991) </li></ul><ul><li>Other studies didn’t control for MOI </li></ul><ul><li> Insufficient evidence to support prophylactic antibiotics as a standard of care for reducing incidence of empyema or PNA in patients requiring TT </li></ul>
  20. 20. ‘ Prophylactic’ Antibiotics in TT: Conclusions and Recommendations <ul><li>Extreme variability in choice of antibiotic, dosing, and duration of therapy among studies </li></ul><ul><li>One class I study reported no empyema in patients receiving cefazolin for 24hrs compared to 5% incidence in placebo group (Cant et al, 1993) </li></ul><ul><li>Administration of antibiotics for >24hrs did not significantly reduce risk of empyema compared with shorter duration (Demetriades, 1991) </li></ul>
  21. 21. ‘ Prophylactic’ Antibiotics in TT: Conclusions and Recommendations <ul><li>Incidence of pneumonia in placebo groups ranged from 2.5-35.1%, compared to 0-12% in antibiotic groups </li></ul><ul><li>In most reports, significant reduction in pneumonitis seen in patients receiving prolonged antibiotics (but also see increased cost and length of hospital stay) </li></ul><ul><li>Presumptive, rather than prophylactic therapy, in setting of acute trauma </li></ul>
  22. 22. ‘ Prophylactic’ Antibiotics in TT: Conclusions and Recommendations <ul><li>Recommendations (for isolated chest trauma) </li></ul><ul><ul><li>Level I: insufficient data to support level I recommendation as standard of care </li></ul></ul><ul><ul><li>Level II: insufficient data to suggest prophylactic antibiotics reduce incidence of empyema </li></ul></ul><ul><ul><li>Level 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. </li></ul></ul>
  23. 23. Recommendations <ul><li>Additional training of all trauma physicians </li></ul><ul><li>Early thoracotomy or VATS in settings of persistent fluid collection or multiple chest tube placements as means to prevent against development of empyema </li></ul><ul><li>First generation cephalosporin for no more than 24 hours </li></ul><ul><li>Further research! </li></ul>

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