From the Guidelines
For a trace left-sided pleural effusion in a surgical ICU patient awaiting neurosurgery for spine, a careful history and physical examination should be performed to elucidate the likely cause, and thoracic ultrasound (TUS) should be used as the initial diagnostic tool to assess the size and character of the effusion. According to the British Thoracic Society guideline for pleural disease 1, TUS is now an essential diagnostic tool and should be performed on every patient at their initial presentation. The patient's drug history should also be recorded, as certain medications can cause exudative pleural effusions, with tyrosine kinase inhibitors being the most common implicated drugs 1.
If the patient is asymptomatic with stable vital signs and adequate oxygenation, observation with serial chest imaging (daily chest X-rays) may be appropriate. However, if the patient shows respiratory distress, hypoxemia, or the effusion is enlarging, consider diagnostic thoracentesis to determine the etiology, as recommended by the guideline 1. Therapeutic drainage is indicated for moderate to large effusions causing symptoms.
While awaiting neurosurgery, maintaining the patient in a semi-upright position (30-45 degrees) when possible can help improve respiratory mechanics. Ensuring adequate pain control, encouraging deep breathing exercises, and considering incentive spirometry can also help prevent atelectasis. The underlying cause of the effusion should be addressed, with common causes in surgical ICU patients including hypoalbuminemia, volume overload, or post-surgical inflammation. Diuretics like furosemide 20-40mg IV may help if volume overload is suspected, as pleural effusions often develop in critically ill patients due to altered hydrostatic and oncotic pressures, inflammation, or decreased lymphatic drainage, particularly in patients with limited mobility awaiting surgery.
Some key points to consider in the management of the patient include:
- Careful history and physical examination to elucidate the likely cause of the pleural effusion
- Use of thoracic ultrasound (TUS) as the initial diagnostic tool
- Recording of the patient's drug history to identify potential causes of exudative pleural effusions
- Observation with serial chest imaging for asymptomatic patients with stable vital signs and adequate oxygenation
- Diagnostic thoracentesis for patients with respiratory distress, hypoxemia, or enlarging effusions
- Therapeutic drainage for moderate to large effusions causing symptoms
- Maintenance of the patient in a semi-upright position to improve respiratory mechanics
- Ensuring adequate pain control and preventing atelectasis through deep breathing exercises and incentive spirometry.
From the Research
Diagnosis and Management of Pleural Effusion
- A trace left-sided pleural effusion in a surgical ICU patient waiting for neurosurgery for spine requires careful evaluation and management 2, 3.
- The first step is to determine the cause of the pleural effusion, which can be due to various underlying diseases, such as congestive heart failure, cancer, pneumonia, or pulmonary embolism 2.
- A pleural fluid puncture (pleural tap) can help differentiate between a transudate and an exudate, which is essential for further diagnostic work-up 2.
Treatment Options
- Treatment of the underlying disease is crucial, and specific treatment of pleural effusion may include pleurodesis, thoracoscopy, video-assisted thoracoscopy, or placement of a permanently indwelling pleural catheter 2, 3.
- In patients undergoing significant pleural manipulation during spinal deformity surgery, postoperative furosemide therapy may decrease the incidence of clinically symptomatic pleural effusion requiring thoracocentesis 4.
- Mechanically ventilated patients with pleural effusions should be managed with higher levels of positive-end expiratory pressure and semirecumbent positioning, and bedside ultrasound can be used to diagnose and guide thoracentesis 5.
Considerations for Left-Sided Pleural Effusion
- A left-sided pleural effusion is an infrequent clinical occurrence and may require careful evaluation to determine the underlying cause 6.
- Chylothorax is a rare complication that can occur after coronary artery bypass grafting and should be considered in the differential diagnosis of left-sided pleural effusions 6.