1
|
Crosby CE, Redding LE, Ortved KF. Current treatment and prevention of orthopaedic infections in the horse. EQUINE VET EDUC 2023. [DOI: 10.1111/eve.13770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Corinne E. Crosby
- Department of Clinical Studies University of Pennsylvania, New Bolton Center Kennett Square Pennsylvania USA
| | - Laurel E. Redding
- Department of Clinical Studies University of Pennsylvania, New Bolton Center Kennett Square Pennsylvania USA
| | - Kyla F. Ortved
- Department of Clinical Studies University of Pennsylvania, New Bolton Center Kennett Square Pennsylvania USA
| |
Collapse
|
2
|
Ho YL, Jamaluddin MF, Krishinan S, Salleh A, Khamis AY, Abdul Kareem BA. Pediatric empyema thoracis: roles and outcomes of surgery in advanced disease. Asian Cardiovasc Thorac Ann 2020; 28:152-157. [PMID: 32122151 DOI: 10.1177/0218492320910932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aim Empyema thoracis has become increasingly common in the pediatric population. Antibiotics and thoracostomy have been the cornerstones of management of stage 1 empyema, whereas management of stage 2 and 3 empyema remains controversial. Surgical intervention is perceived to be associated with high morbidity and protracted recovery. We aimed to review the role and outcome of surgical decortication, and provide data for comparison with other treatment modalities. Methods The medical records and clinical outcomes of 30 children (median age 5.2 years) with stage 2 or 3 empyema, who underwent surgical decortication from September 2017 to September 2019, were reviewed. Results Most children were referred for decortication by day 8.8 ± 4 of admission, and the median time from referral to surgery was 2.2 ± 2 days. All patients had tube thoracostomy, and 5 (17%) underwent fibrinolysis prior to surgery. Twenty-one (70%) patients required pediatric intensive care unit admission preoperatively. Postoperatively, most patients were extubated on day 2.5 (range 1–4 days), with chest tubes removed on day 3.8 (range 1–7 days). Most were discharge by day 6.2 (range 4–10 days). Postoperative air leak occurred in one (3%) patient. There was no mortality or reoperation. Conclusion Surgical decortication remains an excellent modality for managing stage 2 and 3 pediatric empyema. The procedure has a low morbidity and provides rapid resolution of symptoms with good clinical outcomes if performed promptly. Delayed referral may result in a more protracted clinical course.
Collapse
Affiliation(s)
- Yan Le Ho
- Department of Cardiothoracic Surgery, Hospital Pulau Pinang, George Town, Penang, Malaysia
| | - Mohd Fauzi Jamaluddin
- Department of Cardiothoracic Surgery, Hospital Pulau Pinang, George Town, Penang, Malaysia
| | - Sotheenathan Krishinan
- Department of Cardiothoracic Surgery, Hospital Pulau Pinang, George Town, Penang, Malaysia
| | - Ahmadi Salleh
- Department of Cardiothoracic Surgery, Hospital Pulau Pinang, George Town, Penang, Malaysia
| | - Abu Yamin Khamis
- Department of Cardiothoracic Surgery, Hospital Pulau Pinang, George Town, Penang, Malaysia
| | - Basheer A Abdul Kareem
- Department of Cardiothoracic Surgery, Hospital Pulau Pinang, George Town, Penang, Malaysia
| |
Collapse
|
3
|
Hafen GM, Grenzbach AC, Moeller A, Rochat MK. Lack of concordance in parapneumonic effusion management in children in central Europe. Pediatr Pulmonol 2016; 51:411-7. [PMID: 26291694 DOI: 10.1002/ppul.23263] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 05/14/2015] [Accepted: 06/05/2015] [Indexed: 11/08/2022]
Abstract
Treatment of parapneumonic effusion in children remains controversial in the literature and in clinical practice. The aim of this study was to determine whether mutual consensus exists in the diagnosis and treatment of parapneumonic effusion in Central European countries. A questionnaire was sent to all directors of pediatric respiratory units in four adjacent Central European countries (Austria, France, Germany, Switzerland). The response rate was 61.8%. Responses reflected acceptable agreement regarding initial diagnostic procedures, as most centers performed chest X-ray and biological exams, followed by ultrasound, thoracocentesis, or computed tomography. However, antibiotic regimens were very heterogeneous, and the survey revealed complete lack of agreement on the indications and effusion volume threshold for invasive procedures, such as fibrinolytic instillation and thoracoscopy. In conclusion, apart from initial diagnostic procedures, this study showed a lack of mutual consensus among the four countries regarding the management of pediatric parapneumonic effusion. Multicenter prospective trials are clearly needed to acquire more evidence on the management of childhood parapneumonic effusion, enabling the development of evidence-based algorithms that could help to avoid unnecessary examinations with potential long-term side effects, such as radiation exposure at a young age.
Collapse
Affiliation(s)
- Gaudenz M Hafen
- Department of Pediatrics, Respiratory Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - Andrea-Claudia Grenzbach
- Department of Pediatric Pulmonology, Clinic for Pediatric and Adolescent Medicine, University of Luebeck, Luebeck, Germany
| | - Alexander Moeller
- Division of Respiratory Medicine, University Children's Hospital Zurich, Zurich, Switzerland
| | - Mascha K Rochat
- Department of Pediatrics, Lausanne University Hospital, Lausanne, Switzerland
| |
Collapse
|
4
|
Taylor JL, Liu M, Hoff DS. Retrospective analysis of large-dose intrapleural alteplase for complicated pediatric parapneumonic effusion and empyema. J Pediatr Pharmacol Ther 2015; 20:128-37. [PMID: 25964730 DOI: 10.5863/1551-6776-20.2.128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Medical treatment of complicated parapneumonic effusion or empyema in pediatric patients includes antibiotics and pleural space drainage. Intrapleural fibrinolysis may facilitate pleural drainage; however, there is a lack of consensus regarding the optimal dosing regimen. The primary purpose of this study was to evaluate the efficacy and safety of a large-dose intrapleural alteplase regimen in pediatric patients. Secondarily, this investigation sought to differentiate the clinical characteristics of responders and non-responders to intrapleural alteplase therapy. METHODS All patients with parapneumonic effusions treated with intrapleural alteplase between June 2003 and December 2011 were reviewed retrospectively. Efficacy was assessed by comparing chest tube output, in mL/hr and mL/kg/hr, for 24 hours before and after the first dose of alteplase. Additional efficacy outcomes included duration of in situ chest tubes, a need for surgical intervention for pleural effusion, and length of hospital stay. Safety was assessed by frequency and severity of adverse events. Non-responders and responders were compared based on demographic and disease characteristics. Responders were defined as patients who did not require surgical intervention after intrapleural alteplase therapy. RESULTS Seventy-three patients, aged 0.5 to 22.5 years, received intrapleural alteplase to facilitate pleural drainage. Median alteplase dose was 7 mg (range, 3 to 10 mg; median 0.38 mg/kg). Chest tube output increased from 10.7 to 24.2 mL/hr (p = 0.006), and median length of hospital stay was 9 days. Eighty-four percent of patients were responders. The most common adverse events were pain (20.5%) and oxygen desaturation greater than 10% from baseline (16.4%). High-flow nasal cannula was the most common intervention for oxygen desaturation to 80% to 90%. Nine patients (12%) required a blood transfusion during the study. CONCLUSION Large-dose intrapleural alteplase is effective in facilitating pleural drainage in pediatric patients with complicated parapneumonic effusion or empyema. Common adverse effects include pain and oxygen desaturation. The potential for bleeding warrants clinical monitoring.
Collapse
Affiliation(s)
- Jessica L Taylor
- Department of Pharmacy, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Meixia Liu
- Department of Healthcare Economics, Medica, Hopkins, Minnesota
| | - David S Hoff
- Department of Pharmacy, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| |
Collapse
|
5
|
Generali JA, Cada DJ. Alteplase: pleural effusion (parapneumonic) and empyema in children. Hosp Pharm 2014; 48:912-21. [PMID: 24474831 DOI: 10.1310/hpj4811-912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This Hospital Pharmacy feature is extracted from Off-Label Drug Facts, a publication available from Wolters Kluwer Health. Off-Label Drug Facts is a practitioner-oriented resource for information about specific drug uses that are unapproved by the US Food and Drug Administration. This new guide to the literature enables the health care professional or clinician to quickly identify published studies on off-label uses and determine if a specific use is rational in a patient care scenario. References direct the reader to the full literature for more comprehensive information before patient care decisions are made. Direct questions or comments regarding Off-Label Drug Uses to jgeneral@ku.edu.
Collapse
Affiliation(s)
- Joyce A Generali
- Editor-in-Chief, Hospital Pharmacy, and Clinical Professor, Emeritus, Department of Pharmacy Practice, University of Kansas, School of Pharmacy, Kansas City/Lawrence, Kansas, e-mail:
| | - Dennis J Cada
- Founder and Contributing Editor, The Formulary, and Editor, Off-Label Drug Facts, e-mail:
| |
Collapse
|
6
|
Israel EN, Blackmer AB. Tissue Plasminogen Activator for the Treatment of Parapneumonic Effusions in Pediatric Patients. Pharmacotherapy 2014; 34:521-32. [DOI: 10.1002/phar.1392] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Emily N. Israel
- Department of Pharmacy Services; University of Michigan Health System; Ann Arbor Michigan
- Department of Clinical, Social, and Administrative Sciences; University of Michigan College of Pharmacy; Ann Arbor Michigan
| | - Allison B. Blackmer
- Department of Pharmacy Services; University of Michigan Health System; Ann Arbor Michigan
- Department of Clinical, Social, and Administrative Sciences; University of Michigan College of Pharmacy; Ann Arbor Michigan
| |
Collapse
|
7
|
Hendaus MA, Abushahin A. Intrapleural hemorrhage due to alteplase use in a 6-year-old boy with pleural effusion. Int J Gen Med 2013; 6:233-6. [PMID: 23626471 PMCID: PMC3632500 DOI: 10.2147/ijgm.s43783] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Intrapleural fibrinolytics have been used successfully worldwide for the management of complicated pleural effusions and empyema. Bleeding complications are usually mentioned as rare side effects, but there is no clear information in the literature addressing the alarming outcome that might result following the use of alteplase as a fibrinolytic in the management of complicated parapneumonic effusions. We present a rare, if not unique, case of intrapleural hemorrhage requiring transfusion after alteplase use as a fibrinolytic in a 6-year-old male with complicated parapneumonic effusion. Methods A search of the PubMed database was carried out, using a combination of the following terms: alteplase, fibrinolytic, intrapleural hemorrhage, and side effects. Results The majority of studies found in the search concentrated on the efficacy of intrapleural fibrinolytics in the management of pleural effusion, but very few of the reports addressed the bleeding complications which may be caused by the treatment. Conclusion Although intrapleural and systemic hemorrhage are rare side effects of intrapleural fibrinolytic use, the health care provider must be watchful for these potentially life-threatening complications. Further studies are needed to understand not only the efficacy of fibrinolytics but also their safety, especially in children.
Collapse
|
8
|
Shawyer AC, Amaral JGPV, Langer JC. The role of tissue plasminogen activator in the management of complex intra-abdominal abscesses in children. J Pediatr Surg 2012; 47:1380-4. [PMID: 22813800 DOI: 10.1016/j.jpedsurg.2011.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 12/06/2011] [Accepted: 12/08/2011] [Indexed: 01/02/2023]
Abstract
OBJECTIVE The objective of this study is to assess the safety of fibrinolytic therapy using tissue plasminogen activator (tPA) in children with complex intra-abdominal abscesses. SUMMARY BACKGROUND DATA Intra-abdominal abscesses are common in children. Antibiotics and percutaneous drainage are the mainstays of treatment, but drainage may be less effective when the fluid is thick or septated. Fibrinolytic therapy using tPA is effective in a rat model of intra-abdominal abscesses, has recently been reported for the treatment of intra-abdominal abscesses in adults, and is commonly used in the treatment of empyema in children. METHODS This is a retrospective review of all patients over a 10-year period who had intra-abdominal collections managed with tPA abscess drainage. RESULTS Sixty-four children had a total of 66 drains placed and 92 doses of tPA. Appendicitis was the cause of the abscesses in 52 of 64 children. Mean length of stay pre-tPA was 11.7 ± 7.63 days, mean time from drain insertion to tPA was 4.3 ± 3.78 days, and mean time from tPA to discharge was 8.6 ± 8.85 days. Thirty patients underwent an operation before tPA administration. No patients experienced bleeding complications, anastomotic or appendiceal stump leak, or wound dehiscence after the administration of tPA, and no patients had abnormalities in coagulation studies related to tPA administration. One child died of sepsis. CONCLUSIONS Tissue plasminogen activator is safe for the management of thick or septated intra-abdominal abscesses in children. A prospective controlled study will be needed to evaluate the efficacy of this technique.
Collapse
Affiliation(s)
- Anna C Shawyer
- Division of Pediatric Surgery, Department of Surgery, Hospital for Sick Children, Toronto, Ontario, Canada M5G 1X8
| | | | | |
Collapse
|
9
|
Paraskakis E, Vergadi E, Chatzimichael A, Bouros D. Current evidence for the management of paediatric parapneumonic effusions. Curr Med Res Opin 2012; 28:1179-92. [PMID: 22502916 DOI: 10.1185/03007995.2012.684674] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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.
Collapse
Affiliation(s)
- Emmanouil Paraskakis
- Department of Paediatrics, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece.
| | | | | | | |
Collapse
|
10
|
Rahman NM, Maskell NA, West A, Teoh R, Arnold A, Mackinlay C, Peckham D, Davies CWH, Ali N, Kinnear W, Bentley A, Kahan BC, Wrightson JM, Davies HE, Hooper CE, Lee YCG, Hedley EL, Crosthwaite N, Choo L, Helm EJ, Gleeson FV, Nunn AJ, Davies RJO. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med 2011; 365:518-26. [PMID: 21830966 DOI: 10.1056/nejmoa1012740] [Citation(s) in RCA: 465] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND More than 30% of patients with pleural infection either die or require surgery. Drainage of infected fluid is key to successful treatment, but intrapleural fibrinolytic therapy did not improve outcomes in an earlier, large, randomized trial. METHODS We conducted a blinded, 2-by-2 factorial trial in which 210 patients with pleural infection were randomly assigned to receive one of four study treatments for 3 days: double placebo, intrapleural tissue plasminogen activator (t-PA) and DNase, t-PA and placebo, or DNase and placebo. The primary outcome was the change in pleural opacity, measured as the percentage of the hemithorax occupied by effusion, on chest radiography on day 7 as compared with day 1. Secondary outcomes included referral for surgery, duration of hospital stay, and adverse events. RESULTS The mean (±SD) change in pleural opacity was greater in the t-PA-DNase group than in the placebo group (-29.5±23.3% vs. -17.2±19.6%; difference, -7.9%; 95% confidence interval [CI], -13.4 to -2.4; P=0.005); the change observed with t-PA alone and with DNase alone (-17.2±24.3 and -14.7±16.4%, respectively) was not significantly different from that observed with placebo. The frequency of surgical referral at 3 months was lower in the t-PA-DNase group than in the placebo group (2 of 48 patients [4%] vs. 8 of 51 patients [16%]; odds ratio for surgical referral, 0.17; 95% CI, 0.03 to 0.87; P=0.03) but was greater in the DNase group (18 of 46 patients [39%]) than in the placebo group (odds ratio, 3.56; 95% CI, 1.30 to 9.75; P=0.01). Combined t-PA-DNase therapy was associated with a reduction in the hospital stay, as compared with placebo (difference, -6.7 days; 95% CI, -12.0 to -1.9; P=0.006); the hospital stay with either agent alone was not significantly different from that with placebo. The frequency of adverse events did not differ significantly among the groups. CONCLUSIONS Intrapleural t-PA-DNase therapy improved fluid drainage in patients with pleural infection and reduced the frequency of surgical referral and the duration of the hospital stay. Treatment with DNase alone or t-PA alone was ineffective. (Funded by an unrestricted educational grant to the University of Oxford from Roche UK and by others; Current Controlled Trials number, ISRCTN57454527.).
Collapse
Affiliation(s)
- Najib M Rahman
- UKCRC Oxford Respiratory Trials Unit, Oxford Centre for Respiratory Medicine, Nuffield Department of Medicine, University of Oxford, Churchill Hospital Site, Headington, Oxford OX3 7LJ, United Kingdom.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Ben-Or S, Feins RH, Veeramachaneni NK, Haithcock BE. Effectiveness and Risks Associated With Intrapleural Alteplase by Means of Tube Thoracostomy. Ann Thorac Surg 2011; 91:860-3; discussion 863-4. [DOI: 10.1016/j.athoracsur.2010.10.082] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Revised: 10/27/2010] [Accepted: 10/29/2010] [Indexed: 11/26/2022]
|
12
|
Lee J, Jeon SJ, Yoo YC, Kim JH, Lee YM, Kwon SJ, Son JW, Choi E, Na MJ. The Effect of Tissue Plasminogen Activator on TGF-β1 Pre-Treated Human Mesothelial Cell Line. Tuberc Respir Dis (Seoul) 2011. [DOI: 10.4046/trd.2011.70.5.405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Junglim Lee
- Department of Microbiology, Konyang University College of Medicine, Daejeon, Korea
- Myunggok Research Institute of Medical Science, Konyang University College of Medicine, Daejeon, Korea
| | - Soo Jin Jeon
- Department of Microbiology, Konyang University College of Medicine, Daejeon, Korea
- Myunggok Research Institute of Medical Science, Konyang University College of Medicine, Daejeon, Korea
| | - Young Choon Yoo
- Department of Microbiology, Konyang University College of Medicine, Daejeon, Korea
- Myunggok Research Institute of Medical Science, Konyang University College of Medicine, Daejeon, Korea
| | - Ji Hye Kim
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Yu Mi Lee
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Sun Jung Kwon
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
- Myunggok Research Institute of Medical Science, Konyang University College of Medicine, Daejeon, Korea
| | - Ji Woong Son
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
- Myunggok Research Institute of Medical Science, Konyang University College of Medicine, Daejeon, Korea
| | - Eugene Choi
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
- Myunggok Research Institute of Medical Science, Konyang University College of Medicine, Daejeon, Korea
| | - Moon Jun Na
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
- Myunggok Research Institute of Medical Science, Konyang University College of Medicine, Daejeon, Korea
| |
Collapse
|
13
|
Wheeler DS, Wong HR, Shanley TP. Pneumonia and Empyema. THE RESPIRATORY TRACT IN PEDIATRIC CRITICAL ILLNESS AND INJURY 2009. [PMCID: PMC7123273 DOI: 10.1007/978-1-84800-925-7_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Derek S. Wheeler
- Medical Center, Div. of Critical Care Medicine, Cincinnati Children's Hospital, Burnet Avenue 3333, Cincinnati, 45229 U.S.A
| | - Hector R. Wong
- Medical Center, Div. of Critical Care Medicine, Cincinnati Children's Hospital, Burnet Avenue 3333, Cincinnati, 45229 U.S.A
| | - Thomas P. Shanley
- C.S. Mott Children's Hospital , Pediatric Critical Care Medicine , University of Michigan, E. Medical Center Drive 1500, Ann Arbor, 48109-0243 U.S.A
| |
Collapse
|
14
|
Froudarakis ME, Kouliatsis G, Steiropoulos P, Anevlavis S, Pataka A, Popidou M, Mikroulis D, Pneumatikos I, Bouros D. Recombinant tissue plasminogen activator in the treatment of pleural infections in adults. Respir Med 2008; 102:1694-700. [PMID: 18824340 DOI: 10.1016/j.rmed.2008.08.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Revised: 08/10/2008] [Accepted: 08/15/2008] [Indexed: 11/18/2022]
Abstract
BACKGROUND Intrapleural recombinant tissue plasminogen activator (r-TPA) has been successfully evaluated in pediatric patients with complicated parapneumonic pleural effusion (CPE) and pleural empyema (PE). Yet, there is no data concerning r-TPA in adults with CPE/PE. The aim of our study was to investigate the efficacy and complications of r-TPA in adult patients with CPE/PE. METHODS Twenty consecutive patients (mean age 50+/-18.9 years) with pleural infection (14 CPE and 6 PE) were included. Chest tube was inserted under guidance of chest ultrasound and/or computed tomography. After failure of pleural fluid drainage, 25mg of r-TPA was administered intrapleurally in a single daily dose. The evaluation was made according to imaging and clinical status. RESULTS The mean volume of fluid increased significantly after r-TPA administration (p<0.0001). White blood cells count (WBC) and C-reactive protein (CRP) were significantly improved after r-TPA instillations (both p<0.0001). Significant clinical and imaging improvement was noted in all but one patient after r-TPA administration (overall p<0.0001). Complications observed were mild: pain in 4 (25%) and local bleeding in 3 (15%) patients. The median number of r-TPA instillations was 3 (range 2-5). CONCLUSION Intrapleural instillation of r-TPA at a dose of 25 mg is a well-tolerated and effective treatment in 95% of our adult patients with CPE/PE.
Collapse
Affiliation(s)
- Marios E Froudarakis
- Department of Pneumonology, Medical School, Democritus University of Thrace, Greece.
| | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Emerson CR, Bercume CM, Antonopoulos MS, Marzella N. The Administration of rt-PA (Activase®) for the Treatment of Empyema in an Adult Patient. J Pharm Pract 2008. [DOI: 10.1177/0897190008329205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The administration of various fibrinolytic agents for the treatment of empyema has been reported in past studies. Most of the current literature has shown favorable outcomes in terms of increased tube drainage, improved chest radiography, and reduction in surgical intervention. However, a randomized controlled trial that compared streptokinase to placebo showed no significant reduction in mortality. To date, there have been no randomized controlled trials evaluating the safety, efficacy, and administration of recombinant tissue plasminogen activator for the treatment of empyema in the adult population. The authors report the use of a 10 mg daily dose of intrapleural recombinant tissue plasminogen activator for 6 days in a 57-year-old, white, male patient with empyema that was unresponsive to antibiotic therapy and chest tube drainage. They conclude that intrapleural administration of recombinant tissue plasminogen activator in conjunction with antibiotic therapy for the treatment of empyema in this patient resulted in increased chest tube drainage and provided complete resolution of all signs and symptoms of his infection.
Collapse
Affiliation(s)
- Christopher R. Emerson
- Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, New York,
| | | | - Marilena S. Antonopoulos
- Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, New York
| | - Nino Marzella
- Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, New York
| |
Collapse
|
16
|
Sahn SA. Diagnosis and management of parapneumonic effusions and empyema. Clin Infect Dis 2007; 45:1480-6. [PMID: 17990232 DOI: 10.1086/522996] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Accepted: 07/26/2007] [Indexed: 01/29/2023] Open
Abstract
Approximately 1 million patients develop parapneumonic effusions (PPEs) annually in the United States. The outcome of these effusions is related to the interval between the onset of clinical symptoms and presentation to the physician, comorbidities, and timely management. Early antibiotic treatment usually prevents the development of a PPE and its progression to a complicated PPE and empyema. Pleural fluid analysis provides diagnostic information and guides therapy. If the PPE is small to moderate in size, free-flowing, and nonpurulent (pH, >7.30), it is highly likely that antibiotic treatment alone will be effective. Prolonged pneumonia symptoms before evaluation, pleural fluid with a pH <7.20, and loculated pleural fluid suggest the need for pleural space drainage. The presence of pus (empyema) aspirated from the pleural space always requires drainage. Fibrinolytics are most likely to be effective during the early fibrinolytic stage and may make surgical drainage unnecessary. If pleural space drainage is ineffective, video-assisted thoracic surgery should be performed without delay.
Collapse
Affiliation(s)
- Steve A Sahn
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Medical University of South Carolina, Charleston, SC 29425, USA.
| |
Collapse
|
17
|
Buyne OR, Bleichrodt RP, van Goor H, Verweij PE, Hendriks T. Tissue-type plasminogen activator prevents formation of intra-abdominal abscesses after surgical treatment of secondary peritonitis in a rat model. Int J Colorectal Dis 2007; 22:819-25. [PMID: 17089129 DOI: 10.1007/s00384-006-0222-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND Optimal therapy of secondary peritonitis frequently results in the formation of residual abscesses, which bear a substantial mortality and morbidity. This study aims to prove that fibrinolytic therapy with recombinant tissue plasminogen activator (rtPA) can reduce abscess formation after surgical treatment of secondary peritonitis in a rat model, without causing unwanted side effects. MATERIALS AND METHODS Male Wistar rats received an intra-abdominal injection with a suspension of sterile feces, 10(5) cfu Escherichia coli and 10(4) cfu Bacteroides fragilis. Surgical debridement was performed 1 h after inoculation. Animals were randomized into four groups (n = 14 each). Three groups received human rtPA at 1 h (rtPA1); 1 h and 6 h (rtPA2); and 1, 6, and 24 h (rtPA3), respectively. Each dose contained 1.25 mg rtPA. Controls received saline only. Animals were killed after 5 days. RESULTS rtPA treatment reduced abscess formation in surviving animals, depending on number of doses given. Animals in group rtPA3 had no abscesses in contrast to 88% of the controls (mean 3.6 +/- 2.7 abscesses per rat; p < 0.05). In the rtPA1 and rtPA2 group, frequency of abscess formation was 58 and 33%, respectively. Mortality, course of body weight, and bacteremia were not affected by rtPA and neither were peritoneal cell counts and levels of TNF-alpha, IL-1beta, IL-6 and IL-10. No bleeding complications were observed. CONCLUSION rtPA reduces intra-abdominal abscess formation after surgical treatment of generalized peritonitis without increasing mortality or affecting the local inflammatory response.
Collapse
Affiliation(s)
- Otmar R Buyne
- Department of Surgery, Radboud University Nijmegen Medical Centre, P.O. Box 91091, 6500, HB Nijmegen, The Netherlands
| | | | | | | | | |
Collapse
|
18
|
Dikensoy O, Zhu Z, Na MJ, Liao H, Donnelly E, Light RW. Intrapleural heparin or heparin combined with human recombinant DNase is not effective in the treatment of empyema in a rabbit model. Respirology 2007; 11:755-60. [PMID: 17052304 DOI: 10.1111/j.1440-1843.2006.00934.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE AND BACKGROUND The aim of this study was to investigate the effectiveness of intrapleural heparin or heparin combined with human recombinant DNase in the treatment of empyema. METHODS Empyema was induced in rabbits with an intrapleural injection of 10(9)Pasteurella multicoda organisms in infusion agar via a surgically placed chest tube. Once empyema was verified, a blinded investigator administered drugs via the chest tube. There were three treatment groups each with six rabbits. One group was given 1000 IU heparin, a second group was given 1000 IU heparin plus 1 mg of human recombinant DNase via chest tube and the control group received saline. The rabbits received treatment every 12 h for a total of six treatments and the volume of each treatment was 3 mL. The animals were sacrificed at day 10 and the amount of empyema and pleural thickening was scored macroscopically on a scale of 0-6. RESULTS The total volume of pleural effusion aspirated was significantly higher in the heparin group (25.8+/-10.7 mL) compared with either saline (8+/-8.9) or heparin plus human recombinant DNase (6.8+/-6.1) groups (P=0.003). The mean empyema and pleural thickening scores did not differ significantly between the groups (P=0.8, P=0.5 respectively). A weak correlation was found between total volume of aspirated pleural fluid and pleural parameters of white blood cell counts and LDH levels (r=0.546 and P=0.02, r=0.631 and P=0.02 respectively). CONCLUSION The intrapleural administration of 1000 IU heparin alone or in combination with 1 mg of human recombinant DNase is no more effective than saline in the treatment of empyema in rabbits. Intrapleural heparin significantly increased the drainage of pleural fluid compared with the combination and saline group.
Collapse
Affiliation(s)
- Oner Dikensoy
- Pulmonary Division, St. Thomas Hospital and Vanderbilt University, Nashville, TN, USA.
| | | | | | | | | | | |
Collapse
|
19
|
Zhu Z, Hawthorne ML, Guo Y, Drake W, Bilaceroglu S, Misra HL, Light RW. Tissue Plasminogen Activator Combined With Human Recombinant Deoxyribonuclease Is Effective Therapy for Empyema in a Rabbit Model. Chest 2006; 129:1577-83. [PMID: 16778278 DOI: 10.1378/chest.129.6.1577] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES There have been no controlled studies to test the efficacy of tissue plasminogen activator (tPA) or recombinant human deoxyribonuclease (rhDNase) in the treatment of empyema. In vitro studies show that streptokinase without rhDNase does not liquefy empyemic material from rabbits. However, the combination of streptokinase and streptodornase and rhDNase have been shown to liquefy pus in vitro. The aim of this study was to determine if tPA or rhDNase, or a combination of the two, is more effective than saline solution in the treatment of empyema in rabbits. MATERIALS AND METHODS Empyema was induced in rabbits using 10(9) Pasteurella multicoda organisms in infusion agar injected via a surgically placed chest tube. Once empyema was verified, a blinded investigator administered one of four treatments via the chest tube: 3 mL of saline solution; 4 mg of alteplase (recombinant tPA); 1 mg of rhDNase; or 4 mg of alteplase and 1 mg of rhDNase. The rabbits received a treatment every 12 h following the initial for a total of six treatments. The animals were killed at day 10, and the degree of empyema and pleural peel was scored macroscopically on a scale of 0 to 4. RESULTS The combination group had a significantly lower mean empyema score (1.83 +/- 0.75) than did the saline solution group (3.86 +/- 0.38, p = 0.001), rhDNase group (3.17 +/- 0.75, p = 0.012), and alteplase group (3.71 +/- 0.49, p = 0.02) [+/- SD]. The total volume of pleural fluid was markedly higher in the alteplase and rhDNase combination group (142 +/- 79.1 mL) or the alteplase group (231 +/- 78.0 mL) compared to either the rhDNase group (0.8 +/- 1.6 mL) or the saline solution group (5.8 +/- 14.0 mL). CONCLUSION The combination of alteplase and rhDNase is more effective in the treatment of rabbit empyema than either agent alone. The intrapleural injection of alteplase alone or in combination with rhDNase leads to the production of large amounts of pleural fluid.
Collapse
Affiliation(s)
- Zhiwen Zhu
- Vanderbilt University Medical Center, T-1218 Medical Center North, Nashville, TN 37232, USA
| | | | | | | | | | | | | |
Collapse
|
20
|
Abstract
Septic arthritis (SA) is a common orthopedic condition encountered in horses that are presented to equine veterinarians. Successful out-come is dependent on prompt and thorough evaluation and treatment. This article briefly reviews the pathophysiology, outlines diagnostics, describes treatment options and prognostics, and discusses current research in diagnosis and treatment of SA.
Collapse
Affiliation(s)
- Alison J Morton
- Department of Large Animal Sciences, University of Florida College of Veterinary Medicine, Box 100136, Gainesville, FL 32610, USA.
| |
Collapse
|