Empyema in the acute care surgical patient

Abstract

Parapneumonic effusions are common in the intensive care unit. The fluid can be sterile or infected. It is of critical importance drain infected pleural space fluid in a timely fashion as it is unlikely to resolve on its own. These parapneumonic effusions can evolve from a simple-to-complex process and ultimately become an empyema mandating surgical intervention. Thus, early recognition is critical. Chest tube placement in a pleural cavity concerning for infection that fails to improve radiographically or the patients’ symptoms 24-48 h after placement is concerning for a complicated multi-loculated process, which warrants CT imaging. Treatment of this process requires a secondary intervention, which can include injecting the pleural space with tissue plasminogen activator (tPA) and DNAse for three days, versus early video-assisted thoracoscopic surgery (VATS) decortication. Patients who have frank purulent drainage (empyema) or fail fibrinolytic therapy require surgical intervention, which can be attempted with VATS but may require a thoracotomy.