Tube Thoracostomy: Complications and the Role of Prophylactic Antibiotics

Tube Thoracostomy: Complications and the Role of Prophylactic Antibiotics
By Ashley Laird

Indications for Tube Thoracostomy
* PTX (spontaneous, iatrogenic, traumatic)
* Hemothorax
* Chylothorax
* Decreased breath sounds in unstable patient after blunt or penetrating trauma
* Multiple rib fractures, sucking chest wound, subcutaneous air in intubated trauma patient
* Complicated pleural effusion, empyema, lung abscess
* Thoracotomy, decortication
* Pleural lavage for active rewarming for hypothermia

Complications
* Undrained PTX, hemothorax, or effusion despite TT clotted hemothorax, empyema, fibrothorax
* Improper placement +/- iatrogenic injuries (lung, diaphragm, subclavian, right atrium)
* Recurrent PTX after tube removal
* Intrapleural collections following tube removal
* Thoracic empyema

Factors Influencing Complications: Louisville study
* Prior studies report TT complication rates of 3-36%
* Etoch SW, Bar-Natan MF, Miller FB, Richardson JD. Tube Thoracostomy: Factors related to complications. Arch Surg. 1995; 130:521-525.
o Retrospective chart review (U of Louisville)
o 379 trauma pts, 599 tubes

Factors Influencing Complications: Louisville study
* Complications:
o Empyema
o Undrained PTX or effusion
o Improper tube placement (+/- iatrogenic injury)
o Post-tube PTX
o Other
* Measures:
o Rate of complications in association w/ TT setting, operator, patient characteristics, MOI, and severity of injury

Factors Influencing Complications: Louisville study
* Overall rate of complications: 21% per patient (16% per tube)
* 8.2% of complications required thoracotomy

Factors Influencing Complications: Setting
* 48% of tubes placed in ED, 23% in OR, 12% in ICU, 7% on floor, and 9% at OSH prior to transfer
* Significantly higher complication rate when TT performed in outside hospital prior to transfer (33%, p<.0001)
* No significant difference in complication rates between TT in ED (9%) vs. TT in other areas of study hospital (7%)

Factors influencing Complications: Operator
* 59% of tubes placed by surgeons, 26% by ED physicians, 8% by physicians prior to transfer
* Highest complication rate for tubes placed by physicians in outside hospitals, mostly nonsurgeon physicians (38%)
* Complication rates for TT’s in study hospital: 13% for ED physicians, 6% for surgeons (p<.0001)
* For TT’s in ED: 13% complication rate for ED physicians vs 5% complication rate for surgeons (p<.01)

Factors influencing Complications: Mechanism/Severity of Injury

* No difference in complication rate related to:
o Age and sex of patients
o Mechanism of injury (23% for blunt vs 18% for penetrating)
o ISS
* Significantly increased complication rate related to:
o ICU admission (29% vs 11%, p<.0001)
o Mechanical ventilation (29% vs 15%, p<.002)
o Presence of hypotension (SBP<90) on admission (31% vs 17%, p<.003)

Factors Influencing Complications: University Hospital study
* Deneuville M. Morbidity of percutaneous tube thoracostomy in trauma patients. Eur J CT Surg. 2002; 22:673-678.
o Prospective observational study (University Hospital, Guadeloupe)
o 128 trauma pts, 134 tubes
o ‘Non-thoracic’ operators vs. thoracic surgeons

Factors Influencing Complications: University Hospital study
* Overall complication rate 25% (29% per tube)
o 5 (12.8%) improper placement, no iatrogenic injury
o 4 (10.3%) improper placement w/ iatrogenic injury (lung x 2, diaphragm, subclavian artery)
o 4 (10.3%) undrained hemothorax/PTX
o 12 (30.8%) post-removal PTX
o 7 (18%) post-removal fluid collection
o 3 (2.3%) empyema
o 4 (10.3%) combined
* 18 (46.2%) of complications required surgery (thoracotomy or VATS)

Factors Influencing Complications: University Hospital study
* No difference in complication rate related to:
o Blunt trauma vs. penetrating wounds
o Indication for TT: hemothorax vs PTX
o Presence of pulmonary contusion, abdominal injury, or need for immediate abdominal surgery
* Significantly increased risk of complication related to:
o Polytrauma (RR 2.7, p<0.05)
o Need for assisted ventilation (RR 2.7, p<.003)
o TT by non-thoracic surgeons (RR 8.7, p<.0001 for blunt trauma and RR 12.5%, p<.0001 for penetrating trauma)

Thoracic Empyema
* Causes of post-traumatic empyema:
o Iatrogenic infection during TT
o Direct infection from penetrating injury
o Secondary infection from associated intra-abdominal injuries w/ diaphragmatic disruption or hematogenous or lymphatic spread to pleural space
o Secondary infection of undrained hemothoraces
o Parapneumonic empyema resulting from posttraumatic pneumonia, contusion, or ARDS

Thoracic Empyema
* Empyema occurred in 1.8% (Louisville study) and 2.3% (University Hospital study) of patients undergoing TT
* No difference in rate of empyema related to setting or operator
* No difference in rate of empyema related to administration of antibiotics within 24 hours of initial TT in Louisville study (2% vs 2%)


‘Prophylactic’ Antibiotics in TT: EAST Guidelines
* Does ‘prophylactic’ antibiotic use in injured patients requiring TT reduce the incidence of empyema and/or pneumonia?
* 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

‘Prophylactic’ Antibiotics in TT: EAST Guidelines
* 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.
o 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.
o 11 articles reviewed: 9 prospective series, 2 meta-analyses

Prophylactic’ Antibiotics in TT: EAST Guidelines
* Articles classified by Agency for Health Care Policy and Research (AHCPR) methodology
o Class I: prospective, randomized, double-blinded, controlled trials
o Class II: prospective, randomized, non-blinded trial
o Class III: retrospective series of patients or meta-analysis
* Four class I articles, five class II, and two class III meta-analyses

Prophylactic’ Antibiotics in TT: Conclusions and Recommendations
* Incidence of empyema in placebo groups ranged from 0-18%, compared to 0-2.6% in antibiotic groups
* Two class I studies saw a reduced incidence of empyema w/ antibiotic Rx (Cant, 1993; Grover, 1977)
* Two class II studies saw no benefit w/ antibiotics (Mandal, 1985; Demetriades, 1991)
* Other studies didn’t control for MOI
* Insufficient evidence to support prophylactic antibiotics as a standard of care for reducing incidence of empyema or PNA in patients requiring TT

Prophylactic Antibiotics in TT: Conclusions and Recommendations
* Extreme variability in choice of antibiotic, dosing, and duration of therapy among studies
* One class I study reported no empyema in patients receiving cefazolin for 24hrs compared to 5% incidence in placebo group (Cant et al, 1993)
* Administration of antibiotics for >24hrs did not significantly reduce risk of empyema compared with shorter duration (Demetriades, 1991)

Prophylactic’ Antibiotics in TT: Conclusions and Recommendations

* Incidence of pneumonia in placebo groups ranged from 2.5-35.1%, compared to 0-12% in antibiotic groups
* In most reports, significant reduction in pneumonitis seen in patients receiving prolonged antibiotics (but also see increased cost and length of hospital stay)
* Presumptive, rather than prophylactic therapy, in setting of acute trauma

‘Prophylactic’ Antibiotics in TT: Conclusions and Recommendations

* Recommendations (for isolated chest trauma)
o Level I: insufficient data to support level I recommendation as standard of care
o Level II: insufficient data to suggest prophylactic antibiotics reduce incidence of empyema
o 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.


Recommendations
* Additional training of all trauma physicians
* Early thoracotomy or VATS in settings of persistent fluid collection or multiple chest tube placements as means to prevent against development of empyema
* First generation cephalosporin for no more than 24 hours
* Further research!

Tube Thoracostomy: Complications and the Role of Prophylactic Antibiotics.ppt