Report Empyema

8/8/2019 Report Empyema

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Empyema

An accumulation of thick,

purulent fluid within thepleural space, often with

fibrin development & aloculated (walled-off) area

where infection is located


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Causes/Risk Factors:

Presence of bacterial pneumonia orlung abscess

Penetrating chest trauma

Hematogenous infection of thepleural space

Nonbacterial infections

Iatrogenic causes (after thoracic

surgery or thoracentesis)


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Assessments with

PE & NHHSigns & Symptoms:

FeverNight

sweatsPleural pain

CoughDyspnea

AnorexiaWeight loss


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Assessments with

PE & NHHPhysical Exams:

r or absent breathsounds over affected area

dullness on chestpercussionr

fremitus


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Diagnostic & Lab Studies

Computed Tomography(CT) scan reveals largeempyema collection with

atelectic lobe andconsolidation


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CT scan of chest showing empyemanecessitans (long arrow), a chronic

untreated empyema that has eroded

through the thoracic cage and formed a

subcutaneous abscess (short arrow)


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CT scan showing empyema with split pleura

sign (enhancement of the thickened inner

visceral and outer parietal pleura separated by

a collection of pleural fluid)


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Diagnostic Thoracentesis,under ultrasound guidance

extraction of a cloudy orfrankly purulent fluid; little

or no offense odor (aerobicpus); foul smelling

(anaerobic pus)


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Diagnostic Thoracentesis,under ultrasound guidance

fluid analysispH < 7.2Glucose 1000

IU/ml

Total protein >3g/ml

WBC > 15,000cells/mm3


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Diagnostic

Thoracentesis


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Presence ofParapneumonic Effusion

Release of inflammatory

mediators

Pathophysiology


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permeability of thecapilliaries

Attracts WBCs to the site

Escape of albumin & otherprotein from the capillaries


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Pleural fluid

Presence of free-flowing,protein rich pleural fluid

(Stage I)


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Extensive purulentexudate production

Initiation of fibroblastic

activity(Stage II)


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Adherence of the two

pleural membranes(Stage III)

Formation of a peel


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Nursing Diagnosis

Impaired Gas Exchange r/tcompressed lung

Acute Pain r/t infection ofthe pleura

Risk for Activity Intolerancer/t hypoxia secondary to

empyema


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Principles of Management

Help the patient cope withthe condition

Instruct patient in lung-expanding breathing exercises

to restore normal respiratoryfunction


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Pharmacology

Antibiotic, cephalosporin (secondgeneration) for bacterialinfections;

Cefuroxime (Zinacef) forstaphylococcal & streptococcal

organisms; most often selectedinitial antibiotic (Adult: 750-1500mg IV q8h; Pedia:

150mg/kg/d IV divided q8h)


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Pharmacology

Antibiotics, anaerobic infections an aspiration or likely anaerobicinfection is the cause of the

pneumoniaClindamycin (Cleocin) for gram-

positive organisms & anaerobes(Adult: 600-1200mg/d IV/IMdivided q6-8h; Pedia: 25-

40mg/kg/d IV divided q6-8h)


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Pharmacology

Antibiotic, Miscellaneous whenmethicillin-resistant S.aureus issuspected.

Vancomycin (Vancocin, Vancoled) a glycopeptide agent for gram-

positive (Adult: 500mg IV q6h or1g IV q12h- not to exceed infusionrate of 10mg/min; Pedia:

40mg/kg/d IV divided tid/qid)


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Pharmacology

Thrombolytic Agents convertplasminogen to plasmin, leading toclot lysis.

Alteplase (Activase) binds tofibrin in a thrombus & converts

the entrapped plasminogen toplasmin, initiating localfibrinolysis. (administered

intrapleural via chest tube)


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Surgery/Special Procedures

Antibiotic Therapy prescribedin large doses based on the

causative organismThoracentesis for small fluid

volume w/c is not too purulentor thick


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Surgery/Special Procedures

Tube Thoracostomy forloculated or complicated pleuraleffusions

Open Chest Drainage viaThoracotomy, including potential

rib resection for thickenedpleura & removal of the underlyingdiseased pulmonary tissue


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BioEthics

Is open thoracotomy

still a good treatmentoption for the

management ofempyema in children?


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Open thoracotomy remains an

excellent option for managementof stage IIIII empyema inchildren. When openthoracotomy is performed in atimely manner there is low

morbidity and it provides rapidresolution of symptoms with ashort hospital stay.


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However, delayed referrals mayresult in advanced pulmonarysepsis and a protracted clinicalcourse. The late results are

encouraging. Use of thoracoscopyor fibrinolysis should beconsidered on the basis of theirown merit, not on the assumptionof probable adverse outcomes

after thoracotomy.


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THATS ALL,

THANK

YOU!!!

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Report Empyema