What is the management approach for a patient with a slim chance of survival who is not stable enough to undergo an open decortication?

Management of Unstable Patients Unable to Tolerate Open Decortication

For patients too unstable to survive open decortication, defer definitive surgical treatment and implement damage control principles with minimal intervention focused on source control and physiologic stabilization, reserving definitive decortication until the patient can tolerate the procedure. 1

Initial Assessment of Instability

A patient should be considered unstable and unsuitable for definitive decortication if any of the following criteria are present: 1

• pH < 7.2
• Core temperature < 35°C
• Base excess < -8
• Laboratory or clinical evidence of coagulopathy
• Signs of sepsis or septic shock requiring inotropic support
• Hemodynamic instability despite resuscitation

Additional high-risk factors predicting mortality after decortication include disseminated cancer, age ≥65 years, ventilator dependence, active hemodialysis, preoperative SIRS/sepsis, CHF, and COPD. 2 Patients requiring surgery from the ICU have significantly elevated mortality risk. 3

Damage Control Approach

Immediate Resuscitation Phase

Damage control should be started as soon as possible in rapid sequence after resuscitation begins, not after complete optimization. 1 The resuscitation phase should utilize goal-directed methods attempting to achieve: 1

• Central venous pressure 8-12 mmHg
• Mean arterial pressure ≥65 mmHg
• Central venous oxygen saturation ≥70%

Critical timing consideration: Time from admission to source control initiation is a critical determinant of survival—survival drops to 0% when surgery is delayed beyond 6 hours in patients with septic shock. 1

Surgical Strategy for Unstable Patients

If the patient remains unstable, definitive treatment must be delayed. 1 The surgical approach should focus solely on source control while deferring anatomical reconstruction: 1

• Perform only procedures the patient can physiologically tolerate (technically easy, rapidly performed, life-saving interventions)
• Avoid prolonged operative times that worsen the "lethal triad" of acidosis, hypothermia, and coagulopathy 1
• Consider chest tube drainage alone as temporizing measure rather than open decortication 1
• Defer stoma creation if open abdomen is required 1

Alternative Temporizing Measures

For empyema/parapneumonic effusions when open decortication is prohibitive: 1

• Chest tube placement with fibrinolytic agents can provide adequate drainage without the morbidity of open surgery
• Video-assisted thoracoscopic surgery (VATS) is less invasive than open decortication if the patient can tolerate minimal intervention 1, 3
• Simple chest tube drainage for moderate effusions without attempting decortication 1

The mortality rate for open decortication is 6.6% overall, but approaches 100% in patients operated from the ICU setting. 3 Thoracoscopic approaches have lower morbidity when feasible. 3, 4

Intraoperative Decision-Making

Close communication between surgeon and anesthesiologist is essential to continuously assess resuscitation effectiveness and determine if the patient can tolerate continuation of the procedure. 1 If physiologic parameters deteriorate intraoperatively:

• Abort the definitive procedure immediately
• Achieve minimal source control only (drainage, not decortication)
• Plan for staged reconstruction after physiologic recovery 1

Antimicrobial Therapy

Broad-spectrum antibiotic therapy targeting gram-negative bacilli and anaerobes must be initiated immediately in unstable patients with empyema or infected pleural space. 1 In critically ill patients with sepsis, early use of broader-spectrum antimicrobials is indicated. 1

Critical Pitfalls to Avoid

• Never delay source control beyond 6 hours in septic patients, but recognize that "source control" may mean simple drainage rather than complete decortication 1
• Do not attempt complete decortication in unstable patients—the procedure cannot be tolerated and mortality approaches 100% 3, 2
• Avoid non-therapeutic operations that provide no source control benefit 1
• Do not pursue "optimal" resuscitation endpoints before intervention—pursue "adequate" resuscitation with rapid transition to minimal intervention 1

Staged Approach

Once the patient is stabilized (typically requiring days to weeks of ICU support), definitive decortication can be reconsidered. 1 Patients with Decortication Prognostic Scores ≥4 have 27.1% mortality even under optimal conditions, necessitating careful risk-benefit discussion. 2