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

Indications for TT 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. Retrospective chart review (U of Louisville) 379 trauma pts, 599 tubes

Factors Influencing Complications: Louisville study Empyema Undrained PTX or effusion Improper tube placement (+/- iatrogenic injury) Post-tube PTX Other Measures: 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: Age and sex of patients Mechanism of injury (23% for blunt vs 18% for penetrating) ISS Significantly increased complication rate related to: ICU admission (29% vs 11%, p<.0001) Mechanical ventilation (29% vs 15%, p<.002) Presence of hypotension (SBP<90) on admission (31% vs 17%, p<.003)

Factors influencing Complications: Mechanism/Severity of Injury

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

Factors Influencing Complications: University Hospital study Overall complication rate 25% (29% per tube) 5 (12.8%) improper placement, no iatrogenic injury 4 (10.3%) improper placement w/ iatrogenic injury (lung x 2, diaphragm, subclavian artery) 4 (10.3%) undrained hemothorax/PTX 12 (30.8%) post-removal PTX 7 (18%) post-removal fluid collection 3 (2.3%) empyema 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: Blunt trauma vs. penetrating wounds Indication for TT: hemothorax vs PTX Presence of pulmonary contusion, abdominal injury, or need for immediate abdominal surgery Significantly increased risk of complication related to: Polytrauma (RR 2.7, p<0.05) Need for assisted ventilation (RR 2.7, p<.003) 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: Iatrogenic infection during TT Direct infection from penetrating injury Secondary infection from associated intra-abdominal injuries w/ diaphragmatic disruption or hematogenous or lymphatic spread to pleural space Secondary infection of undrained hemothoraces 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. 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. 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 Class I: prospective, randomized, double-blinded, controlled trials Class II: prospective, randomized, non-blinded trial 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) Level I: insufficient data to support level I recommendation as standard of care Level II: insufficient data to suggest prophylactic antibiotics reduce incidence of empyema 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!