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Management of Pleural Effusion in the Pulmonary Sepsis

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Sepsis

Abstract

Whenever a pulmonary sepsis patient with a pleural effusion is evaluated, the possibility of a parapneumonic effusion should be considered. If there is more than a minimal amount of pleural fluid, the fluid should be sampled with a therapeutic thoracentesis to determine if any poor prognostic factors are present (pus, positive Gram stain, glucose less than 40 mg/dL, pH less than 7.20, positive culture or LDH greater than three times the upper limit of normal for serum). It is important to administer appropriate antibiotics. The antibiotic is selected on the basis of the results of blood, sputum, or pleural fluid cultures. If the fluid cannot be removed with the therapeutic thoracentesis, either tube thoracostomy with the instillation of fibrinolytics or thoracoscopy should be performed. If the lung does not expand with thoracoscopy, thoracotomy with decortication should be performed. Open drainage procedures are reserved for those patients who are too ill to undergo thoracoscopy or thoracotomy. The definitive procedure should be performed within 10 days of the patient’s initial hospitalization.

An estimated 750,000 cases of severe sepsis occur annually in the United States, and the mortality rate is about 30%. Bacterial pneumonia is one of the most important causes of pulmonary sepsis.1 Bacterial pneumonia leads to significant morbidity and mortality despite the availability of potent antimicrobial agents. The annual incidence of bacterial pneumonia in the United States is estimated to be 4 million, with approximately 20% of patients requiring hospitalization.2 Approximately 20% to 40% of hospitalized patients with bacterial pneumonia have an accompanying pleural effusion.3, 4 The morbidity and mortality rates for patients with pneumonia and pleural effusions are higher than those for patients with pneumonia alone. In one study of patients with community-acquired pneumonia (CAP), patients with bilateral pleural effusions had a relative mortality risk 7.0 times higher than patients without a pleural effusion. Patients with a unilateral pleural effusion of moderate or greater size had a relative risk 3.4 times higher than patients without effusion.5 In assessing risks of patients with CAP, the presence of a pleural effusion is given the same weight as a PO2 of less than 60 mmHg.6

Most pleural effusions associated with pneumonia resolve without any specific therapy directed toward the pleural fluid,3 but about 10% require operative intervention for their resolution. Delay in instituting proper therapy for these effusions is responsible for a significant percentage of the increased morbidity and mortality associated with parapneumonic effusions.7

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Authors
  1. Yubiao Guo
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  2. Richard W. Light
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Editors and Affiliations

  1. Universidad del Bosque, Bogotá, Colombia

    Guillermo Ortiz-Ruiz MD (Professor of Pulmonary and Critical Care Medicine) (Professor of Pulmonary and Critical Care Medicine)

  2. Fundacion Clinica Shaio, Bogotá, Colombia

    Marco A. Perafán MD (Professor of Cardiology and Critical Care Medicine) (Professor of Cardiology and Critical Care Medicine)

  3. Department of Surgery, Klinikum Grosshadern, University of Munich, Munich, Germany

    Eugen Faist MD (Professor) (Professor)

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Guo, Y., Light, R.W. (2004). Management of Pleural Effusion in the Pulmonary Sepsis. In: Ortiz-Ruiz, G., Perafán, M.A., Faist, E. (eds) Sepsis. Springer, New York, NY. https://doi.org/10.1007/978-1-4757-3824-7_11

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  • DOI: https://doi.org/10.1007/978-1-4757-3824-7_11

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-0-387-20451-2

  • Online ISBN: 978-1-4757-3824-7

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