Elsevier

Injury

Volume 39, Issue 1, January 2008, Pages 44-49
Injury

The risk factors and management of posttraumatic empyema in trauma patients

https://doi.org/10.1016/j.injury.2007.06.001Get rights and content

Summary

Background

Posttraumatic empyema increases patient morbidity, mortality and length of hospital stay, and the cost of treatment. The aim of this study was to identify the risk factors for posttraumatic empyema and to review our treatment outcomes in patients with this condition.

Methods

A total of 2261 patients who were admitted with thoracic traumas and underwent tube thoracostomy between January 1989 and January 2006 were investigated retrospectively. Posttraumatic empyema developed in 71 patients. Logistic regression was used to assess the association between potential risk factors for posttraumatic empyema. All values were expressed as the mean ± S.D.

Results

Eight hundred and thirty-six (37%) of the patients had penetrating type trauma, while 1425 (63%) had blunt type trauma. The rate of posttraumatic empyema development was 3.1% for all patients. Pulmonary contusion was seen in 221 (9.8%) patients and fractures of more than two ribs were seen in 191 (8.4%) patients. Tube thoracostomy placement was performed in the emergency room in 1728 (76.4%) patients, in the hospital ward in 197 (8.7%), in the intensive care unit in 182 (8.0%), and in the operating room in 154 (6.8%). The duration of tube thoracostomy was 6.11 ± 2.99 (1–21) days. Retained haemothorax was seen in 175 (7.7%) patients. The mean lengths of hospital and intensive care unit stay were 6.42 ± 3.45 and 2.36 ± 2.66 days, respectively. The analysis showed that duration of tube thoracostomy (OR, 2.49, p < 0.001), length of intensive care unit stay (OR, 4.21, p < 0.001), and presence of contusion (OR, 3.06, p < 0.001), retained haemothorax (OR, 5.55, p < 0.001), and exploratory laparotomy (OR, 2.46, p < 0.001) were independent predictors of posttraumatic empyema. The relative risk of posttraumatic empyema was higher than 1 for each of the following risk factors: penetrating trauma (OR, 1.59, p = 0.055), associated injuries (OR, 1.12, p = 0.628) and fractures of more than two ribs (OR, 1.60, p = 0.197).

Conclusion

Prolonged duration of tube thoracostomy and length of intensive care unit stay, and the presence of contusion, laparotomy and retained haemothorax are independent predictors of posttraumatic empyema. Use of prophylactic antibiotics may be recommended in patients with these risk factors.

Introduction

Posttraumatic empyema (PTE) is a significant problem in both blunt and penetrating chest injuries. The incidence of PTE in patients who have sustained injuries to the chest has been reported to range from 2% to 25%.1, 5, 7, 9 Potential causes for PTE include iatrogenic infection of the pleural space during chest tube placement, direct infection resulting from penetrating injuries of the thoracic cavity, secondary infection of the pleural cavity from associated intra-abdominal organ injuries with diaphragmatic disruption, secondary infection of undrained or inadequately drained haemothoraces, haematogenous or lymphatic spread of subdiaphragmatic infection to the pleural space, and parapneumonic empyema resulting from posttraumatic pneumonia, pulmonary contusion, or acute respiratory distress syndrome.16

PTE causes an increase in the duration of hospitalisation, in morbidity and mortality rates, and in the cost of treatment. Therefore, a good knowledge of the risk factors for the development of PTE is necessary and measures should be taken to prevent it. The role of prophylactic antibiotics is controversial. In addition, risk factors that may independently predict PTE in patients with tube thoracostomy have not been elucidated fully. The aim of this study was to identify the risk factors for PTE and to review our treatment outcomes in patients with this condition.

Section snippets

Patients and methods

Between January 1989 and January 2006, 2261 patients who underwent tube thoracostomy for thoracic trauma were treated in our Thoracic Surgery clinics. The hospital records of these patients were reviewed retrospectively. Clinical data including age, sex, type of injury, associated injuries, duration of tube thoracostomy, setting of tube thoracostomy placement, length of hospital and intensive care unit stay, lung and chest wall injuries, presence of retained haemothorax and exploratory

Results

The mean age of all patients was 37.2 ± 20.6 (5–78) years, and 1560 (69%) of the patients were males. The rate of PTE development was 4.0% (n = 34) in patients with penetrating thoracic trauma, and 2.6% (n = 37) in those with blunt thoracic trauma. This rate was 3.1% (n = 71) for all patients. Firearm wounds existed in 20 of the 34 (58.8%) patients with penetrating thoracic trauma who developed PTE, while the remaining 14 (41.2%) were wounded with sharp or piercing objects.

The most common associated

Discussion

The use of prophylactic antibiotics for the prevention of PTE after tube thoracostomy remains a controversial issue in the trauma literature. While a number of studies3, 4, 11, 15, 18, 22, 25 show favourable effects of prophylactic antibiotics in preventing PTE, several reports12, 14, 17, 20 have shown no benefit. The EAST Practice Management Guidelines Work Group concluded that there were insufficient data available to recommend routine use of prophylactic antibiotics in the management of tube

Conclusion

We determined that prolonged duration of tube thoracostomy and length of intensive care unit stay, and presence of contusion, laparatomy and retained haemothorax were independent predictors of PTE. Use of prophylactic antibiotics may be recommended only in patients with these risk factors. Because of the low incidence of posttraumatic empyema thoracis, we do not recommend routine antibiotic prophylaxis for all trauma patients who undergo tube thoracostomy. Fibrinolytic therapy and thoracoscopy

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