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The timing of surgical treatment of empyema remains controversial. Traditionally, thoracotomy is performed either within three weeks of diagnosis or delayed until presumed pleurodesis occurs. Often, these patients are moribund and the duration of illness impossible to determine. We report our surgical results in seven patients with a deteriorating clinical course and multiple loculations which persisted after tube thoracostomy and would not have responded to multiple thoracostomies. Five patients required decortication. One required lobectomy for an abscess which developed on the contralateral side six weeks after discharge. There were no deaths or recurrences of empyema. Average times from surgery to tube removal and to discharge were six to 12 days, respectively. We conclude that one can safely and cost-effectively treat these patients surgically even when the duration of illness and presence of pleurodesis are unknown, and that the postoperative course will be uncomplicated.

Using a canine model, the authors evaluated the effects of twenty-four hours of intraaortic balloon counterpulsation (IABCP) on the morphology of the thoracoabdominal aorta and its spontaneous and arachidonate stimulated pro duction of prostacyclin (PGI2). The treated group was counter-pulsed at a 1:1 ratio with a 40 cc balloon. The control group had the balloon inserted and left deflated across the thoracoabdominal aorta. There were no differences between the IABCP or sham groups in prostanoid production either in the thoracic or abdominal aorta. Baseline PGI2 production in the control versus treated group of thoracic aortas was 1880 ± 1140 pg/cm2/ min vs 1992 ± 1125. The stimulated response in the control group, 9180 ± 1198, was statistically different from baseline (P < .001). The stimulated in crease in the IABCP group, 6269 ± 5240, relative to baseline was also signifi cant (P < .01). There were no significant differences, either between or within groups in the abdominal aortas. Poststimulation values (30 min) were signifi cantly below baseline in each group in each section of the aorta (P < .05). Light microscopy showed a statistically significant difference in endothelial preserva tion between the control and the balloon group, 66 ± 25% vs 19 ± 17% (P < 0.05) . The authors conclude that IABCP results in severe endothelial destruction but that spontaneous and stimulated PGI2 production is unimpaired. It remains to be determined whether the aorta may sustain long-term damage due to the repair process after IABCP.

We studied the effects of intraaortic balloon counterpulsation (IABCP) on prostacyclin (PGI 2 ) and thromboxane (TXB 2 ) levels in dogs during 24 hours of 1:1 IABCP or a sham procedure in which the balloon was positioned but left deflated. The arterial PGI 2 levels in the IABCP group increased from control values of 95 ± 20 pg/ml to 268 ± 95 pg/ml at 1 hour, 429 ± 95 pg/ml at 4 hours, and 1,884 ± 532 pg/ml at 24 hours. The arterial PGI 2 levels were consistently higher in the IABCP group. Although the TXB 2 measurements revealed no significant differences between groups, the IABCP group consistently had a higher level than the sham group. The platelet count in the control group decreased to 45% of baseline levels versus 55% for the IABCP group. We conclude that prolonged IABCP results in either net production of PGI 2 or decreased degradation. The correlation between TXB 2 and platelet counts is unclear and remains to be defined.

Postpneumonic empyema (EMP) may develop in substance abuse patients, requiring prolonged hospitalization. An algorithm that provides quality care and a rational basis for timely surgical intervention would be advantageous. We report our five-year experience with EMP in substance abuse patients and present such a treatment plan. Sixty-one substance abuse patients were treated for EMP. Posteroanterior, lateral, and decubitus x-ray studies were obtained before treatment to assess fluid movement. Chest tubes were placed to drain frank pus and to obtain material for positive smears. X-ray studies and computed tomography were done 24 hours later to assess parenchymal pathology and to detect any multiple loculations. Thirty-three substance abuse patients recovered following initial tube thoracostomy and 7 after a second chest tube was introduced. Twenty-one had multiple loculations and underwent thoracotomy. Twenty of the 21 required extensive debridement or decortication, or both; 2 required lobectomy and 1 pneumonectomy. Chest tubes were removed on an average of 6 +/- 1.5 days. Average postoperative stay was 10.7 +/- 2 days. There were 2 early deaths and 1 late death and no recurrent EMP. Bacteriology findings were nonspecific and often polymicrobial. We conclude that early thoracotomy can be lifesaving in the presence of a benign clinical course.