CURRENT Essentials of Critical Care.pdf

88 Current Essentials of Critical Care■■■Pleural Effusions in the ICUEssentials of Diagnosis• Accumulation of fluid within pleural space• Symptoms range from none to dyspnea, pleuritic chest pain, respiratoryfailure• Radiographic findings may be subtle in ICU patients as radiographsfrequently taken with patient in semirecumbent or recliningposition; 500 mL of fluid may appear as haziness overlower lung fields in these positions• Primary pleural disease rarely reason for admission to ICU;pleura can be secondarily affected as part of spectrum of criticalillness• Clinical relevance of small effusions ( 100 mL) found onlyby ultrasound or CT scan in this patient population remains unclear• Performing thoracentesis generally safe in critically ill patients• Risk factors for development of pleural effusion in ICU includeimmobility, sedation, paralytic agents• Common etiologies: congestive heart failure (bilateral transudatesor “pseudoexudate”), atelectasis (unilateral transudate),uncomplicated parapneumonic effusion (unilateral exudate)Differential Diagnosis• Parenchymal consolidation or atelectasis• Pleural thickening• Lung or pleural-based mass• Elevated hemidiaphragmTreatment• Diagnostic thoracentesis if pleural effusion and fever, lack ofclinical response to antibiotic therapy, atypical presentation forunderlying disease• Majority resolve with therapy aimed at underlying disease• Antibiotic therapy alone for uncomplicated parapneumonic effusions;chest tube thoracostomy for empyemas• Chest tube drainage for complicated parapneumonic effusions,large hemothoraces, symptomatic malignant effusions■ PearlConsider thoracentesis in critically ill patients with pleural effusionsas the finding of an unsuspected infectious etiology will have a dramaticimpact on therapy and outcome.ReferenceFartoukh M et al: Clinically documented pleural effusions in medical ICU patients.Chest 2002;121:178. [PMID:11796448]