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Complicated pleural effusion with pleurx

Cadet133

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    If lady has pleurx placed for recurrent malignant effusion and then found to have complicated parapneumonic effusion based on analysis and culture. Would you just use pleurx to drain and put on abx or need to replace pleurx
     

    jdh71

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      If lady has pleurx placed for recurrent malignant effusion and then found to have complicated parapneumonic effusion based on analysis and culture. Would you just use pleurx to drain and put on abx or need to replace pleurx

      This is why I HATE these pleurx catheters. Put on in and you own the ****ing thing. And it's always nights, weekends, and holidays when someone wants to to fix the issue.

      If it's infected - empyema - then the catheter has to come out. I'd probably use a chest tube and maybe even more than one over a time course until I was getting sterile pleural fluid. Remember the antibiotics can't actually treat the empyema (there is no way for them to get into the fluid and be effective), only drainage can treat this. Settle in for the long haul. Get used to seeing this patient.
       

      redpanda

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        If lady has pleurx placed for recurrent malignant effusion and then found to have complicated parapneumonic effusion based on analysis and culture. Would you just use pleurx to drain and put on abx or need to replace pleurx

        Probably a) would've done a separate thoracentesis into the complicated effusion to take out any argument that sample obtained was due to "colonization" of the PleurX, b) if finding infected fluid, place another chest tube and remove the PleurX along with abx and lytics if needed. No more tunneled plastic until sure that things are good and sterile.
         
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        chessknt

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          Ive seen it go both ways, not sure there is a definite right answer but most would probably remove pleurx.

          That being said you need to be damn sure it is actually infected and not a pseudoexudate (eg fevers, lung infiltrate, low pH/glucose). An ultrasound showing septations in a chronic effusion with a fever in an immunocompromised person without damning pleural effusion labs would not be overly compelling for me unless no other source could be found or clinical status worsens.
           

          Hamhock

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            Ive seen it go both ways, not sure there is a definite right answer but most would probably remove pleurx.

            That being said you need to be damn sure it is actually infected and not a pseudoexudate (eg fevers, lung infiltrate, low pH/glucose). An ultrasound showing septations in a chronic effusion with a fever in an immunocompromised person without damning pleural effusion labs would not be overly compelling for me unless no other source could be found or clinical status worsens.

            Note, I am not a pulmonologist...but I 'play' one each month in the ICU sometimes (including floor consults)

            I am not sure there is a right answer here, except for:

            1. Be patient...or, as @jdh71 said, be ready to see this patient often...and then again...and wait for abx...and wait some more

            2. skip ultrasound for early CT

            3. call CTSx early; too often I see these cases and the medical docs are dicking around when the CTSx may provide a more rapid and definitive answer (even if it "only" gets the patient feeling better and onto a hospice course)

            HH
             

            jdh71

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              Note, I am not a pulmonologist...but I 'play' one each month in the ICU sometimes (including floor consults)

              I am not sure there is a right answer here, except for:

              1. Be patient...or, as @jdh71 said, be ready to see this patient often...and then again...and wait for abx...and wait some more

              2. skip ultrasound for early CT

              3. call CTSx early; too often I see these cases and the medical docs are dicking around when the CTSx may provide a more rapid and definitive answer (even if it "only" gets the patient feeling better and onto a hospice course)

              HH

              Most surgeons don't have a lot of interest in these patients dying with VATS or thoracotomy scars. I did some retrospective analysis of culture positive empyema at my institution. This was presented at CHEST this last year as a poster. Bottom line: basically all of our end points are improved with early surgical intervention. This has been made aware to my surgeons, who all shrugged, and said they still don't want to be bothered until we've tried at least three days of tpa/dornase through a chest tube. There is also a very strong overlap in being crotchety and decrepit and empyema. It's the classic "not sick enough" or "too sick" for surgery. FYI: The really bad actors (definitely not resolving with tap/dornase and chest tube) on my analysis were any strep species, staph epi, and candida (though if you have a fungal empyema, you should just consult palliative care and lean very hard for hospice). Interestingly enough MRSA had a reasonable shot of tpa/dornase "fix" and gram negative empyemas seem to do very well with a chest tube and "lytics" (though those microbiologies are much fewer).
               
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