report empyema
TRANSCRIPT
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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 & Lab Studies
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 & Lab Studies
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!!!