Complications
Undertreated infection can lead to the development of septic shock.
Key signs are tachycardia and hypotension (BP <90/60) with associated pyrexia.
This complication is preventable with early administration of antibiotics, fluid resuscitation, and chest drain insertion.
Patients presenting with an empyema should have their vital signs monitored frequently for the early detection of septic shock.
Recognised complications of chest drain insertion include organ damage, haemorrhage, subcutaneous emphysema, and death.[40]
Chest drains should be inserted by competent personnel under ultrasound guidance to reduce the risk of such complications.
This complication occurs uncommonly following intrapleural administration of streptokinase.
Patients should receive an exposure card and alternative fibrinolytics in the future if these are ever indicated.
Streptokinase does not increase the risk of haemorrhage.
This complication is more common when >1.5 L of fluid is drained at one time in patients who have had lung collapse for at least 7 days.
In adults, the drain should be clamped if the patient develops symptoms of cough or chest pain during initial drainage or once 1 to 1.5 L have been drained.
In children, the drain should be clamped for 1 hour once 10 mL/kg of fluid has been drained.
Direct extension of the empyema through the chest wall is known as empyema necessitans and is preventable with prompt treatment of the empyema.
Surgical debridement is indicated in the treatment of this complication.
Unrecognised empyema may extend internally into a bronchus forming a bronchopleural fistula and causing a pyopneumothorax.
The majority of fistulae resolve with continued chest drainage and antibiotics, although surgery is sometimes necessary.[8]
Acutely, if the volume of pleural fluid is large and drainage is difficult due to loculations or pus, restrictive ventilatory dysfunction may develop. Surgery or fibrinolytics should be considered in such cases.
Chronically, the pleura may remain thickened, causing a restrictive pulmonary defect. In such cases, decortication should be considered.
This complication is commonly seen on CXRs in children with empyema but is transient. Once its resolution has been confirmed on CXR, no treatment is required.
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