Thoracic Packing Failure due to Occult Diaphragmatic Injury after Empyema Surgery

Intrathoracic gauze packing is an established damage control technique for life-threatening thoracic hemorrhage in trauma settings. However, its role in nontraumatic coagulopathic bleeding remains unclear, and the mechanisms underlying packing failure have not been well characterized. We report a case in which intrathoracic packing failed due to an unrecognized diaphragmatic injury, highlighting an important limitation of this strategy.

An 82-year-old man with chronic kidney disease, diabetes mellitus, and hypoalbuminemia underwent emergency video-assisted thoracoscopic decortication for organized empyema. During surgery, he developed severe intraoperative coagulopathic bleeding in the setting of sepsis. Although the thoracic cavity was temporarily closed, persistent hemorrhage necessitated re-exploration, and intrathoracic gauze packing was undertaken as a damage control strategy. Postoperative imaging suggested adequate filling of the pleural cavity; however, hemodynamic instability persisted. Exploratory laparotomy revealed a previously unrecognized laceration of the left diaphragm, through which the intrathoracic packing gauze had prolapsed into the abdominal cavity. The diaphragmatic injury was repaired, hemostasis was achieved, and the patient subsequently recovered with intensive care support.

Intrathoracic gauze packing may serve as a valuable temporizing measure for severe coagulopathic intrathoracic bleeding, even in nontraumatic settings, provided that diaphragmatic integrity is preserved. When adequate tamponade cannot be achieved, an occult diaphragmatic injury should be actively suspected. Because such injuries are often difficult to diagnose radiologically in the absence of herniation, early surgical exploration may be warranted. Awareness of this potential mechanism of packing failure may facilitate timely intervention and improve outcomes in critically unstable patients.