Decortication and Empyema Drainage
Updated On: July 23, 2026
Anesthetic Approaches
Stage of the empyema - a free-flowing exudative effusion drains with a tube, a loculated fibrinopurulent collection needs thoracoscopic debridement, and an organized peel needs open decortication. Settle which of the three you are anesthetizing before you plan the airway, the lines or the analgesia.
Septic on arrival - most arrive bacteremic with a pneumonia underneath. Resuscitate against current sepsis guidance before induction rather than chasing the pressure afterwards, and expect induction to unmask the volume deficit the vasoconstriction was hiding.
Antibiotics and cultures - this operation is the source control, so pleural and blood cultures are taken before the cavity is washed out and cover is given in the operating room on culture and sensitivity data. Do not let the dose slide to the ward round.
Raw-surface bleeding - stripping an inflamed peel off lung and chest wall leaves a bleeding surface across the whole hemithorax, and it oozes steadily rather than spurting. Two large-bore lines, an arterial line and blood in the room before the peel is started.
Lung isolation against pus - the tube exists to keep pus out of the good lung. Place a double lumen tube, confirm the bronchial cuff seals and reconfirm position bronchoscopically after the turn, and suction the diseased lumen often.
Trapped lung on one lung - the operative side is consolidated and the dependent lung may carry the same pneumonia, so hypoxic pulmonary vasoconstriction is blunted and reserve is thin. Desaturation arrives earlier and recovers slower than in a clean thoracic case.
Bronchopleural fistula - a fistula steals tidal volume, so positive pressure escapes instead of reaching alveoli. Put the bronchial lumen on the side away from the fistula, and consider an inhalational or awake intubation if the leak is large.
The chest drain at induction - a functioning drain stays in and unclamped until the lung is isolated. Positive pressure into a fistula with no drain makes a tension pneumothorax, which is why the drain comes out on the surgeon's timing and not at the start.
Gradual re-expansion - a lung held collapsed for weeks can flood if it is snapped open. Reinflate in steps to around 30 cmH2O at the end to recruit atelectatic lung and show up air leaks, and keep the fluid balance tight rather than generous.
Transfusion planning - crossmatch rather than screen, and replace measured loss as it happens. Chronic sepsis leaves most of these patients anemic before they start, so set the trigger against current transfusion guidance rather than a remembered number.
Chronic wasting - weeks of infection and repeated antibiotic courses leave many malnourished, anemic and deconditioned, and some are immunosuppressed. Low albumin, a poor cough and thin muscle mass all argue for a plan that ends sitting up and extubated.
Epidural in a septic patient - a thoracic epidural earns its place for an open decortication, but it is not sited in a patient who is bacteremic or septic, or who has skin infection or deformity over the insertion point. Decide that before induction, not after.
Emergence and the drain - plan to extubate in the operating room, and exchange the double lumen tube for a single lumen first if ventilation will continue. The drain travels unclamped, because a functioning drain is what stands between a persistent leak and a tension pneumothorax.
High Blood Loss (general considerations): Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.
Lateral position (general considerations): If an ETT has been placed, make sure ETT is secure with extra tape. Unhook anesthesia circuit while turning lateral and be especially careful to keep patient's head neutral and aligned with body to avoid neck injury. Once lateral, use pillows/blankets/foam headrest to keep the patient's head in neutral position. The most common nerve injury for orthopedic lateral procedures are neurapraxias of the brachial plexus. These are motor and/or sensory loss for 6-8 weeks due to pressure on the contralateral (dependent) axilla. To prevent this, place an axillary roll under the patient (caudad to the axilla, on the rib cage, and NOT in the axilla). Check routinely to make sure the axillary roll does not migrate into the axilla. If the non-dependent arm is placed on a board, check padding and reposition regularly to avoid radial nerve compression. If a bean bag is employed, check the hard edges to ensure that unnecessary pressure isn't being put on soft tissues. Pad all dependent bony prominences such as the fibular head (to prevent peroneal nerve injury), and place pillows between the knees and ankles (to prevent saphenous nerve injury). If anterior hip supports are in place, ensure they are properly padded or neuropraxias and/or occlusions of large blood vessels may result.
Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also, consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.
High post-operative pain (general considerations): Plan ahead to treat pain in the postoperative period. If not contraindicated, consider hydromorphone or other long-acting analgesics along with adjuncts such as Ofirmev and/or toradol. Where possible, give during the operative period to limit pain in the postoperative period. Where applicable, consider peripheral nerve blocks and/or epidural interventions.
Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.
High Blood Loss RISK (general considerations): Though most of these cases don't result in a high blood loss, there is a high blood loss RISK. Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra IV push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.
An empyema is pus in the pleural space, usually spreading outward from a pneumonia but also seen after trauma, thoracic surgery or an esophageal leak. It passes through three phases. An exudative effusion is thin and free flowing. Over days it becomes fibrinopurulent, with thick fibrin strands dividing the space into loculations. Finally it organizes: the fibrin matures into a thick rind that adheres to visceral and parietal pleura, splints the lung and holds it collapsed. That trapped lung cannot expand, so the hemithorax contributes little gas exchange while the patient carries an ongoing septic focus that antibiotics reach poorly, because the collection has no blood supply of its own.
Staging - imaging and pleural fluid sampling place the collection in the exudative, fibrinopurulent or organized phase, and that decides whether a tube, a thoracoscope or a thoracotomy is used.
Positioning - lateral decubitus with the infected side up.
Thoracoscopic drainage - for a fibrinopurulent collection, three ports, the first placed into the largest pocket of pus or an existing drain site; loculations are broken down and the fine peel lifted off the lung.
Irrigation - large volumes of irrigation are used to wash pus and fibrin out of the whole cavity.
Decortication - an organized peel needs an open thoracotomy; the rind is stripped off the visceral and parietal pleura, and the lung is reinflated repeatedly to find the correct plane.
Open drainage - in a patient too unwell for thoracotomy a short segment of rib is excised and a large-bore tube placed into the cavity; an Eloesser flap or Clagett window turns that into a permanent skin-lined opening.
Closure - one or two large-bore chest drains are placed, and the wound is left open when an open-drainage procedure has been done.
The trap is treating the booking as one operation. A tube thoracostomy or a rib-resection drainage is a short case with minimal loss in a sick patient, while an open decortication for an organized peel is a long, bloody thoracotomy in the same sick patient. Ask the surgeon which one is planned and what the fallback is, because a thoracoscopic debridement that will not free the lung converts to an open decortication mid-case, and the conversion is the moment the blood loss starts.