Prevention of Empyema in Patients with Residual Hemothorax and Chest Tube

Understanding the Risk

Patients with residual hemothorax have a significant risk of developing empyema, with post-traumatic empyema rates varying from 2-25%, and Staphylococcus aureus responsible for 35-75% of these infections, according to the World Journal of Emergency Surgery guidelines 2
Retained hemothorax is a well-established risk factor for developing both pneumonia and empyema, as stated by the World Journal of Emergency Surgery 2

The British Thoracic Society guidelines recommend checking for tube patency by flushing with 20-50ml normal saline to ensure patency, and performing imaging (chest X-ray or CT scan) to check tube position and identify undrained locules 1, 3
Contrast-enhanced CT is the most useful imaging modality for patients failing chest tube drainage, as recommended by the Thorax guidelines 1
If poor drainage persists despite a patent tube, imaging should be performed to check tube position and distortion, and identify undrained locules that may require additional drainage 1, 3

Placement of a second chest tube is the most effective intervention to prevent progression to empyema, as stated by the Thorax guidelines 3
Tube thoracostomy effectively evacuates the content of the thoracic cavity, reducing the incidence of subsequent empyema, according to the World Journal of Emergency Surgery guidelines 2
Intrapleural fibrinolytic therapy (streptokinase 250,000 IU twice daily for 3 days or urokinase 100,000 IU once daily for 3 days) may be considered as an additional intervention 1, 3

The British Thoracic Society guidelines do not recommend routine antibiotic prophylaxis as the primary intervention for residual hemothorax 1, 3
Antibiotic prophylaxis has shown benefit primarily in penetrating thoracic injuries, not in blunt trauma, as stated by the World Journal of Emergency Surgery guidelines 2

Relying solely on antibiotics without addressing the mechanical problem of residual fluid is a common pitfall, as warned by the Thorax and World Journal of Emergency Surgery guidelines 1, 2
Clamping a bubbling chest tube should never be done as it may lead to tension pneumothorax, as cautioned by the Thorax guidelines 4, 5