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

Complications:

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 TTs in study hospital:
13% for ED physicians, 6% for surgeons
(p<.0001)
For TTs in ED: 13% complication rate for ED
physicians vs 5% complication rate for
surgeons (p<.01)

Factors influencing
Complications:
Mechanism/Severity of
No difference in complication
Injury 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 intraabdominal 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 welldesigned multi-institutional doubleblinded 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 metaanalyses

Prophylactic Antibiotics in
TT: EAST Guidelines

Articles classified by Agency for Health

Care Policy and Research (AHCPR)
methodology
Class I: prospective, randomized, doubleblinded, controlled trials
Class II: prospective, randomized, nonblinded 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 didnt 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!