Life-threatening hemothorax in a child following intrapleural administration of urokinase

Intrapleural Fibrinolytic Therapy for Residual Coagulated Hemothorax After Lung Surgery

BACKGROUND

Many studies have described the use of intrapleural fibrinolytics for the treatment of complex pleural processes and traumatic hemothorax, but data are scarce regarding their use for hemothorax after lung surgery.

OBJECTIVE

To evaluate the utility of intrapleural fibrinolytic therapy with urokinase for residual coagulated hemothorax (blood clot accumulation in the pleural cavity) after lung surgery.

METHODS

From July 2009 to November 2013, 46 patients (33 males; mean age, 56.9 ± 10.7 years) were treated with intrapleural urokinase (250,000 IU per dose) for residual hemothorax after lung surgery. Complete response was defined as clinical improvement with complete drainage of the retained collection shown by chest X-ray, and partial response as substantial resolution with minimal residual opacity (<25 % of the thorax). Follow-up was at least 30 days.

RESULTS

The procedure was successful in 42 patients (91.3 %), with complete response observed in 35/46 patients (76.1 %) and partial response in 7/46 (15.2 %). These 42 patients did not require re-intervention for fluid accumulation in the pleural cavity. Treatment failed in 4 patients (8.7 %): one developed bronchopleural fistula that later resolved spontaneously and three (6.5 %) required thoracoscopic drainage for pleural cavity fluid accumulation and lung collapse. No patient required thoracotomy for total decortication. Intrapleural urokinase administration was not associated with serious adverse events, including bleeding complications or allergic reactions.

CONCLUSIONS

Intrapleural fibrinolytic agents should be considered a useful therapeutic option for the treatment of postoperative residual hemothorax. This method appears to be safe and effective in >90 % of patients with postoperative hemothorax.

Intrapleural urokinase therapy in a neonate with pleural empyema

Pleural empyema is rare in neonates, and treatment with systemic antibiotics and tube drainage may fail because of the thick viscous fluid, bacterial products with fibrin deposition, and multiple loculations. Intrapleural fibrinolytic therapy with urokinase is an effective and non-invasive treatment option that avoids surgical intervention, although its use in neonates has not been studied extensively. In this report, we describe the case of a 13-day-old male neonate with Escherichia coli sepsis and pneumonia, which rapidly progressed to parapneumonic effusion and pleural empyema. After inadequate response to i.v. antibiotics and chest tube drainage, the patient was successfully treated with intrapleural urokinase.

Timely thoracoscopic decortication promotes the recovery of paediatric parapneumonic empyema

INTRODUCTION

Parapneumonic empyema is one of the most commonly encountered yet difficult to manage paediatric thoracic conditions. Conservative treatment with chest tube drainage and fibrinolytic agents had been proposed but operative decortication remains the gold standard for refractory cases. Thoracoscopic decortication has been advocated in recent years due to its superiority in terms of post-operative pain, cosmesis and other long-term results. However, few studies investigated the effect of timing on peri-operative outcomes. This study aims to explore the benefits of early decortication.

METHODS

Retrospective study of all patients who underwent thoracoscopic decortication between 1999 and 2013 at a tertiary referral centre was performed. Data were extracted from respective medical records. Patients' demographics, peri-operative outcomes, length of hospitalization and post-operative complications were analysed.

RESULTS

A total of 28 patients were identified, 12 males and 16 females. Average age of patients was 4.5 years (range 12 months-14 years). Right-sided empyema was involved in 14 of the patients. Patients who underwent operation within 2 weeks from symptom onset (n = 16) showed significant shorter post-operative hospital stay (mean 9.5 vs 20.4 days, p = 0.003) and total hospitalization duration (mean 19.3 vs 38.8 days, p < 0.001). Correlation study demonstrated a strong relation between delay in operation and prolonged hospitalization (r = 0.63, p = 0.001). The peri-operative and post-operative outcomes were similar. No major post-operative complication was encountered except one patient who required a second decortication for residual empyema.

CONCLUSION

Thoracoscopic decortication is a safe and feasible procedure for parapneumonic empyema. Timely surgery is recommended as it promotes early recovery and shorter hospitalization.

Use of fibrinolytics in abdominal and pleural collections

Fluid collections that are incompletely drained despite adequate catheter position, size, and number represent a minority of abscesses but a source of great frustration for patients, surgeons, and interventional radiologists. Drainage of such complex collections is known to be more effective with the adjunctive use of intracavitary fibrinolytic agents instilled via the drainage catheter. In this review article, we discuss the role of fibrinolytics specifically tissue plasminogen activator as explored by interventional radiologists in enhancing effective drainage of these complex abdominal and pelvic collections as well as complex pleural collections.

Current evidence for the management of paediatric parapneumonic effusions

BACKGROUND

Parapneumonic effusions (PPE) and empyema, secondary to bacterial pneumonia, are relatively uncommon but their prevalence is increasing lately. Even if their prognosis is generally good, they may still cause significant morbidity. The traditional treatment of PPE has been intravenous antibiotics and, when necessary, chest tube drainage. Open thoracotomy with decortication has usually been applied in case of failure of the traditional approach. Lately, the use of fibrinolysis and/or video-assisted thoracoscopic surgery (VATS) are utilized in the management of PPE; however, there is still little consensus on the most effective primary treatment.

SCOPE

In this article our goal was to summarize, based on up-to-date evidence, all the management options for PPE available to physicians and weigh the benefits and risks of the most popular ones, in an effort to figure out which one is superior as a first-line approach in children.

FINDINGS

A literature search of randomized and retrospective studies that pinpoint methods of evaluation and treatment of PPE was carried out in Medline and Scopus databases. Chest X-ray, ultrasound as well as microbiology and biochemical characteristics of the pleural fluid will facilitate decision-making. Small uncomplicated effusions resolve with antibiotics alone, larger ones require small-bore chest tube drainage and in case of complicated loculated PPE, fibrinolysis or VATS should be considered. Both methods promote faster drainage, reduce hospital stay and obviate the need for further interventions when used as first-line approach. However, primary treatment with VATS is not advised by the majority of studies as a first choice intervention, unless medical treatment has failed.

CONCLUSION

The main steps in treatment are diagnostic thoracocentesis and imaging, small percutaneous drainage, and considering fibrinolysis in complicated PPE. In case of failure, VATS should be the surgical method to be applied.

Efficacy of video-assisted thoracoscopic surgery in managing childhood empyema: a large single-centre study

BACKGROUND/PURPOSE

A randomised controlled trial evaluating the role of video-assisted thoracoscopic surgery (VATS) in childhood empyema reported a failure rate of 16.6%. Our aim is to determine the outcome of VATS in a large series of children managed by 3 paediatric surgeons experienced in endoscopic surgery.

METHOD

A retrospective study of all children with empyema admitted under the care of the 3 surgeons between February 2004 and February 2008 was undertaken. Recorded details included demographic data, mode of presentation, preoperative investigations, operative details, antibiotic usage, microbiological data, postoperative course, follow-up data and complications.

RESULTS

114 children (69 boys, 45 girls) had VATS for empyema. Their median age was 5 (0.2-15) years. The pleural cavity was drained for a median of 4 (2-13) days. Median postoperative hospital stay was 7 (4-36) days. Median follow-up was 8 (1-24) months. There were 8 (7%) treatment failures: 5 conversions to thoracotomy and 3 recurrent empyemas. There were 7 complications (6%): air leak (n = 6) and lung injury (n = 1). 104 (91%) children had full resolution of symptoms. There were no deaths.

CONCLUSION

Video-assisted thoracoscopic surgery has a better outcome in childhood empyema than reported in a recent randomised trial and it has an important role in the management of this condition.

Adjunctive intrapleural tissue plasminogen activator administered via chest tubes placed with imaging guidance: effectiveness and risk for hemorrhage

PURPOSE

To retrospectively determine the effectiveness of and risk for hemorrhage with intrapleural adjunctive tissue plasminogen activator (tPA) administered via chest tubes placed with imaging guidance.

MATERIALS AND METHODS

This HIPAA-compliant study was approved by the institutional review board of Massachusetts General Hospital, with informed consent waived. A retrospective review of 66 patients (age range, 1-95 years; mean age, 55 years; 44 male, 22 female) who received intrapleural tPA between 2000 and 2006 was performed. Overall effectiveness of tPA was defined as successful drainage without need for additional decortication or video-assisted thoracoscopic surgery. Primary and secondary effectiveness were defined as effectiveness after one and two cycles of tPA, respectively. Imaging findings and complications were recorded. Hemorrhagic complications were noted, and the Fisher exact test was used to show whether concurrent systemic anticoagulation increased bleeding risk.

RESULTS

Fifty-seven (86%) of 66 patients underwent complete drainage with tPA without further surgical procedures. Primary effectiveness was seen in 52 (87%) of 60 patients and secondary effectiveness was seen in five (83%) of six. Loculation of fluid was the most common finding in this selected cohort. Number of fluid pockets, pleural heterogeneity, and pleural thickness were not predictors of effectiveness. There were five major pleural hemorrhages in four patients across five tPA cycles. Hemorrhages occurred only in patients receiving therapeutic anticoagulation (four of 12) and in none of the other patients (P < .001). No hemorrhages occurred in the 38 patients receiving prophylactic anticoagulation.

CONCLUSION

Intrapleural tPA is effective in improving drainage of loculated effusions not drained with catheters alone; prophylactic systemic anticoagulation does not increase bleeding risk with intrapleural tPA, but therapeutic anticoagulation is associated with a significantly increased risk of pleural hemorrhage.

Medical management of parapneumonic pleural disease

Considerable heterogeneity exists in the management of parapneumonic pleural disease. A randomized controlled trial (RCT) demonstrated the effectiveness of small-catheter drainage with fibrinolysis, but surgical devotees suggest this may only be applicable to "early" cases. We examined evidence-based medical management in "all-comers." We performed a retrospective database analysis of the management of all children with complex pleural effusion admitted to the John Radcliffe Hospital over the 7-year period 1996-2003. One hundred and ten children were admitted. Ten were excluded as they were part of a multicenter RCT and had received intrapleural saline instead of urokinase. Of the remaining 100, 51 were female and 49 male. Median age on admission was 5.8 years (range, 0.3-16.5). Symptoms preadmission averaged 11 days, with December the most common month for presentation. Ninety-six underwent chest ultrasound, confirming an effusion in all, described as loculated/septated (68) or echogenic (11). In 17 cases, no specific comment was made regarding the nature of the fluid seen on ultrasound. Ninety-five had subsequent chest tube drainage and then received intrapleural fibrinolysis with urokinase. An etiological organism was identified in 21 cases (21%) (Streptococcus pneumoniae in 10, group A Streptococcus in 5, Staphylococcus aureus in 4, Haemophilus influenzae in 1, and coliform in 1). In a further 9 cases (9%), Gram-positive organisms were seen on pleural fluid microscopy, but did not grow on culture. Two (2%) required surgery due to the persistence of symptoms and an inadequate response to medical management. Median duration of admission was 7 days (range, 2-21 days); median duration of stay from intervention was 5 days (range, 2-19 days). At median follow-up of 8 weeks (range, 3-20 weeks), all children were symptom-free, with minimal pleural thickening on chest X-ray. In conclusion, antibiotic therapy with chest drain insertion and intrapleural urokinase is effective in treating complex parapneumonic effusion and is associated with a good long-term outcome.

Use of urokinase in childhood pleural empyema

Urokinase is an enzyme with a fibrinolytic effect that facilitates pleural empyema drainage through a chest tube. The aim of this study was to assess the risk of pneumothorax, the need for pleural debridement surgery, the persistence of fever, and the number of days in hospital in a group of children with parapneumonic pleural empyema treated with urokinase. This was an uncontrolled retrospective study on children suffering from parapneumonic empyema. Data collected on 17 children treated with urokinase were compared with 11 children treated prior to the advent of urokinase (the "historic" group). The urokinase was instilled in the pleural cavity over a period ranging from 2-8 days, amounting to a median total dose per kilogram of body weight of 18,556 IU (range, 7,105-40,299). Surgical treatment of the empyema involved drainage tube placement and/or debridement of the pleural cavity. Three children developed pneumothorax during their hospital stay, and one more case occurred 6 months after the child had recovered from his empyema; there were 3 cases of pneumothorax during the acute phase in the "historic" group (P = 0.54). Five children in the urokinase group were debrided and 12 were only drained, as opposed to 9 and 2, respectively, in the "historic" group (P = 0.02). The overall hospital stay was 17 days for the urokinase group, and 24 for the "historic" group (P = 0.02). No bleeding or other major complications were reported in the group treated with urokinase. In conclusion, urokinase treatment does not carry a risk of pneumothorax, while it does reduce hospital stay and the need for pleural debridement.