What is the best method to prevent empyema in a patient with residual hemothorax and a chest tube in place?

Prevention of Empyema in Patients with Residual Hemothorax

Placement of a second chest tube is the most effective intervention to prevent empyema in patients with residual hemothorax and a chest tube already in place. 1

Pathophysiology and Risk Assessment

Residual hemothorax after initial chest tube placement significantly increases the risk of empyema development:

• Patients with residual hemothorax have a 33% risk of developing empyema versus only 2% in those without residual collections 1
• Retained blood in the pleural space serves as an excellent culture medium for bacteria
• The risk increases with injury severity and volume of retained hemothorax 2

Management Algorithm

First-Line Intervention

1. Place a second chest tube under ultrasound or CT guidance
   • Small-bore catheters (10-14F) inserted under imaging guidance are preferred for loculated collections 3, 4
   • This approach allows for complete evacuation of the residual hemothorax
   • Early evacuation of clotted hemothorax reduces hospital stay (average 10 days vs. 37.9 days when empyema develops) 5

Additional Interventions

• For residual hemothorax >300cc, observation alone is unlikely to be successful 2
• For volumes >900cc, more aggressive drainage is required as this independently predicts the need for thoracotomy 2
• If the second chest tube fails to drain adequately:
  • Consider video-assisted thoracoscopic surgery (VATS) for evacuation
  • VATS has high success rates for clearing retained hemothorax 2

Role of Antibiotics

While antibiotics play a supportive role, they should not be the primary intervention:

• Periprocedural antibiotics during chest tube placement reduce empyema risk 2
• First-generation cephalosporins (e.g., cefazolin) can be used prophylactically 6
• For established infections, antibiotic selection should be guided by local resistance patterns:
  • Community-acquired: Cefuroxime + metronidazole or amoxicillin + clavulanic acid 3, 4
  • Hospital-acquired: Piperacillin/tazobactam or broader coverage 3, 4

Monitoring and Follow-up

• Daily assessment of:
  • Vital signs
  • Chest tube output (volume and characteristics)
  • Pain levels
  • Laboratory markers (WBC, CRP) 4
• Repeat imaging to assess resolution of fluid collection
• Ensure tube patency by flushing with 20-50 ml normal saline if drainage is inadequate 4

Common Pitfalls to Avoid

1. Delayed intervention: Early evacuation of residual hemothorax is associated with lower morbidity and mortality 5
2. Inadequate drainage: A single chest tube may not adequately drain loculated collections
3. Relying solely on antibiotics: While important, antibiotics alone cannot effectively treat retained hemothorax
4. Improper tube management: Ensure proper positioning and patency of chest tubes
5. Needle thoracentesis: This approach is inadequate for complete evacuation of residual hemothorax

By implementing prompt placement of a second chest tube under image guidance, the risk of empyema can be significantly reduced, leading to shorter hospital stays and improved patient outcomes.