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The cost of treatments for retained traumatic hemothorax: A decision analysis. Injury 2022; 53:2930-2938. [PMID: 35871855 DOI: 10.1016/j.injury.2022.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/15/2022] [Accepted: 07/12/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Early video-assisted thorascopic surgery (VATS) is the recommended intervention for retained hemothorax in trauma patients. Alternative options, such as lytic therapy, to avoid surgery remain controversial. The purpose of this decision analysis was to assess expected costs associated with treatment strategies. METHODS A decision tree analysis estimated the expected costs of three initial treatment strategies: 1) VATS, 2) intrapleural tissue plasminogen activator (TPA) lytic therapy, and 3) intrapleural non-TPA lytic therapy. Probability parameters were estimated from published literature. Costs were based on National Inpatient Sample data and published estimates. Our model compared overall expected costs of admission for each strategy. Sensitivity analyses were conducted to explore the impact of parameter uncertainty on the optimal strategy. RESULTS In the base case analysis, using TPA as the initial approach had the lowest total cost (U.S. $37,007) compared to VATS ($38,588). TPA remained the optimal initial approach regardless of the probability of complications after VATS. TPA was an optimal initial approach if TPA success rate was >83% regardless of the failure rate with VATS. VATS was the optimal initial strategy if its total cost of admission was <$33,900. CONCLUSION Lower treatment costs with lytic therapy does not imply significantly lower total cost of trauma admission. However, an initial approach with TPA lytic therapy may be preferred for retained traumatic hemothorax to lower the total cost of admission given its high probability of avoiding the operating room with its resultant increased costs. Future studies should identify differences in quality of life after recovery from competing interventions.
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Janowak CF, Becker BR, Philpott CD, Makley AT, Mueller EW, Droege CA, Droege ME. Retrospective Evaluation of Intrapleural Tissue Plasminogen Activator With or Without Dornase Alfa for the Treatment of Traumatic Retained Hemothorax: A 6-Year Experience. Ann Pharmacother 2022; 56:10600280221077383. [PMID: 35184602 DOI: 10.1177/10600280221077383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Intrapleural fibrinolytic instillation is second-line treatment for retained hemothorax. Dornase alfa (DNase) has demonstrated efficacy in parapneumonic effusion, but the lack of deoxyribonucleoproteins limits direct extrapolation to traumatic retained hemothorax treatment. OBJECTIVE This study evaluated the effectiveness of intrapleural tissue plasminogen activator (tPA) with and without DNase in the treatment of retained traumatic hemothorax. METHODS This retrospective cohort study included patients aged 16 years and older admitted to a level 1 trauma center from January 2013 through July 2019 with retained hemothorax and one or more intrapleural tPA instillations. Exclusion criteria were tPA for other indications or concomitant empyema. The primary endpoint was treatment failure defined as the need for operative intervention. RESULTS Fifty patients were included (tPA alone: 28; tPA with DNase: 22). Baseline characteristics were similar between groups, including time to diagnosis (6.5 [interquartile range (IQR), 4-15.5] days vs 6 [IQR, 6.3-10.8] days, P = 0.52). Median tPA dose per treatment (6 [IQR, 6-6.4] mg vs 10 [IQR, 8.4-10] mg, P < 0.001) and cumulative tPA (18 [IQR, 6.5-24] mg vs 30 [IQR, 29.5-40], P < 0.001) dose were significantly lower in the tPA alone group. Treatment failure was similar between groups. Chest tube output, retained hemothorax reduction, and bleeding incidences were similar between groups. Multivariate logistic regression demonstrated no significant risk factors for treatment failure. CONCLUSIONS AND RELEVANCE Dornase alfa added to tPA may not reduce the need for operation to treat retained hemothorax. Further studies should be directed at optimal tPA dose determination and economic impact of inappropriate DNase use.
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Affiliation(s)
- Christopher Francis Janowak
- Section of General Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Bradley Robert Becker
- IngenioRX, Inc, Morristown, NJ, USA
- Univeristy of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
| | - Carolyn Dosen Philpott
- Univeristy of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
- UC Health - University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Amy Teres Makley
- Section of General Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Eric William Mueller
- Univeristy of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
- UC Health - University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Christopher Allen Droege
- Univeristy of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
- UC Health - University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Molly Elizabeth Droege
- Univeristy of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
- UC Health - University of Cincinnati Medical Center, Cincinnati, OH, USA
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Goel R, Singh GV, Shadrach BJ, Deokar K, Kumar S, Rajput KS. Efficacy and safety of intrapleural streptokinase in tubercular empyema thoracis - old wine in new wineskin. Trop Doct 2021; 52:23-26. [PMID: 34870518 DOI: 10.1177/00494755211050193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Tubercular empyema thoracis continues to be one of the leading causes of morbidity in low-income countries. Despite antitubercular therapy (ATT) and thoracostomy, empyema drainage is hampered by multiple septations, loculations, debris, and blood clots leading to complications. In a comparative experimental study to estimate the efficacy and safety of intrapleural streptokinase (IPSTK) in tubercular empyema, 30 cases of chronic multiloculated tubercular empyema were compared by radiological improvement by chest radiography, duration and volume of fluid drained, and degree of dyspnoea according to the modified Borg scale, depending on whether streptokinase was used or not. The former scored on all counts; we therefore conclude that intrapleural streptokinase is a safe, efficacious intervention in tubercular empyema. It decreases morbidity and reduces the need for surgery.
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Affiliation(s)
- Rishabh Goel
- Department of Tuberculosis & Chest Diseases, 30036Sarojini Naidu Medical College, Agra
| | - Gajendra Vikram Singh
- Associate Professor, Department of Tuberculosis & Chest Diseases, 30036Sarojini Naidu Medical College, Agra
| | - Benhur Joel Shadrach
- Department of Tuberculosis & Chest Diseases, 30036Sarojini Naidu Medical College, Agra
| | - Kunal Deokar
- Attending Consultant, Department of Pulmonary Medicine, Sapphire Hospital, Mumbai
| | - Santosh Kumar
- Professor and Head, Department of Tuberculosis & Chest Diseases, 30036Sarojini Naidu Medical College, Agra
| | - Karamvir Singh Rajput
- Department of Tuberculosis & Chest Diseases, 30036Sarojini Naidu Medical College, Agra
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Makey IA, Das NA, Jacob S, El-Sayed Ahmed MM, Makey CM, Johnson SB, Thomas M. Agitation Techniques to Enhance Drainage of Retained Hemothorax. Surg Innov 2020; 28:544-551. [PMID: 33339490 DOI: 10.1177/1553350620978002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. Retained hemothorax (RH) is a common problem in cardiothoracic and trauma surgery. We aimed to determine the optimum agitation technique to enhance thrombus dissolution and drainage and to apply the technique to a porcine-retained hemothorax. Methods. Three agitation techniques were tested: flush irrigation, ultrasound, and vibration. We used the techniques in a benchtop model with tissue plasminogen activator (tPA) and pig hemothorax with tPA. We used the most promising technique vibration in a pig hemothorax without tPA. Statistics. We used 2-sample t tests for each comparison and Cohen d tests to calculate effect size (ES). Results. In the benchtop model, mean drainages in the agitation group and control group and the ES were flush irrigation, 42%, 28%, and 2.91 (P = .10); ultrasound, 35%, 27%, and .76 (P = .30); and vibration, 28%, 19%, and 1.14 (P = .04). In the pig hemothorax with tPA, mean drainages and the ES of each agitation technique compared with control (58%) were flush irrigation, 80% and 1.14 (P = .37); ultrasound, 80% and 2.11 (P = .17); and vibration, 95% and 3.98 (P = .06). In the pig hemothorax model without tPA, mean drainages of the vibration technique and control group were 50% and 43% (ES = .29; P = .65). Discussion. In vitro studies suggested flush irrigation had the greatest effect, whereas only vibration was significantly different vs the respective controls. In vivo with tPA, vibration showed promising but not statistically significant results. Results of in vivo experiments without tPA were negative. Conclusion. Agitation techniques, in combination with tPA, may enhance drainage of hemothorax.
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Affiliation(s)
- Ian A Makey
- Department of Cardiothoracic Surgery, Mayo Clinic, FL, USA
| | - Nitin A Das
- Department of Cardiothoracic Surgery, University of Texas Health San Antonio, TX, USA
| | - Samuel Jacob
- Department of Cardiothoracic Surgery, Mayo Clinic, FL, USA
| | | | | | - Scott B Johnson
- Department of Cardiothoracic Surgery, University of Texas Health San Antonio, TX, USA
| | - Mathew Thomas
- Department of Cardiothoracic Surgery, Mayo Clinic, FL, USA
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Cost-Effectiveness Analysis of Fibrinolysis vs Thoracoscopic Decortication for Early Empyema. Ann Thorac Surg 2020; 112:1632-1638. [PMID: 33253674 DOI: 10.1016/j.athoracsur.2020.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/23/2020] [Accepted: 11/08/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Surgical decortication is recommended by national guidelines for management of early empyema, but intrapleural fibrinolysis is frequently used as a first-line therapy in clinical practice. This study compared the cost-effectiveness of video-assisted thoracoscopic surgery (VATS) decortication with intrapleural fibrinolysis for early empyema. METHODS A decision analysis model was developed. The base clinical case was a 65-year-old man with early empyema treated either by VATS decortication or intrapleural tissue plasminogen activator and deoxyribonuclease. The likelihood of key outcomes occurring was derived from the literature. Medicare diagnosis-related groups and manufacturers' drug prices were used for cost estimates. Successful treatment was defined as complete or nearly complete resolution of empyema on imaging. Effectiveness was defined as health utility 1 year after empyema. RESULTS Intrapleural tissue plasminogen activator and deoxyribonuclease were more cost-effective than VATS decortication for treating early empyema for the base clinical case. Surgical decortication had a slightly lower cost than fibrinolysis ($13,345 vs $13,965), but fibrinolysis had marginally higher effectiveness at 1 year (health utility of 0.80 vs 0.71). Therefore, fibrinolysis was the more cost-effective option. Sensitivity analyses found that fibrinolysis as the initial therapy was more cost-effective when the probability of success was greater than 60% or the initial cost was less than $13,000. CONCLUSIONS Surgical decortication and intrapleural fibrinolysis have nearly equivalent cost-effectiveness for early empyema in patients who can tolerate both procedures. Surgeons should consider patient-specific factors, as well as the cost and effectiveness of both modalities, when deciding on an initial treatment for early empyema.
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Bibby AC, Dorn P, Psallidas I, Porcel JM, Janssen J, Froudarakis M, Subotic D, Astoul P, Licht P, Schmid R, Scherpereel A, Rahman NM, Maskell NA, Cardillo G. ERS/EACTS statement on the management of malignant pleural effusions. Eur J Cardiothorac Surg 2019; 55:116-132. [PMID: 30060030 DOI: 10.1093/ejcts/ezy258] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 03/28/2018] [Indexed: 12/26/2022] Open
Abstract
Malignant pleural effusions (MPE) are a common pathology, treated by respiratory physicians and thoracic surgeons alike. In recent years, several well-designed randomized clinical trials have been published that have changed the landscape of MPE management. The European Respiratory Society (ERS) and the European Association for Cardio-Thoracic Surgery (EACTS) established a multidisciplinary collaboration of clinicians with expertise in the management of MPE with the aim of producing a comprehensive review of the scientific literature. Six areas of interest were identified, including the optimum management of symptomatic MPE, management of trapped lung in MPE, management of loculated MPE, prognostic factors in MPE, whether there is a role for oncological therapies prior to intervention for MPE and whether a histological diagnosis is always required in MPE. The literature revealed that talc pleurodesis and indwelling pleural catheters effectively manage the symptoms of MPE. There was limited evidence regarding the management of trapped lung or loculated MPE. The LENT score was identified as a validated tool for predicting survival in MPE, with Brims' prognostic score demonstrating utility in mesothelioma prognostication. There was no evidence to support the use of oncological therapies as an alternative to MPE drainage, and the literature supported the use of tissue biopsy as the gold standard for diagnosis and treatment planning.Management options for malignant pleural effusions have advanced over the past decade, with high-quality randomized trial evidence informing practice in many areas. However, uncertainties remain and further research is required http://ow.ly/rNt730jOxOS.
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Affiliation(s)
- Anna C Bibby
- Academic Respiratory Unit, University of Bristol Medical School Translational Health Sciences, Bristol, UK
- North Bristol Lung Centre, North Bristol NHS Trust, Bristol, UK
| | - Patrick Dorn
- Division of Thoracic Surgery, University Hospital Bern, Bern, Switzerland
| | | | - Jose M Porcel
- Pleural Medicine Unit, Arnau de Vilanova University Hospital, IRB Lleida, Lleida, Spain
| | - Julius Janssen
- Department of Pulmonary Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Marios Froudarakis
- Department of Respiratory Medicine, Medical School of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Dragan Subotic
- Clinic for Thoracic Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Phillippe Astoul
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Hospital North Aix-Marseille University, Marseille, France
| | - Peter Licht
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
| | - Ralph Schmid
- Division of Thoracic Surgery, University Hospital Bern, Bern, Switzerland
| | - Arnaud Scherpereel
- Pulmonary and Thoracic Oncology Department, Hospital of the University (CHU) of Lille, Lille, France
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford Centre for Respiratory Medicine, University Hospitals, NHS Foundation Trust, Oxford, UK
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol Medical School Translational Health Sciences, Bristol, UK
- North Bristol Lung Centre, North Bristol NHS Trust, Bristol, UK
- Task force chairperson
| | - Giuseppe Cardillo
- Task force chairperson
- Department of Thoracic Surgery, Carlo Forlanini Hospital, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
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Hendriksen BS, Kuroki MT, Armen SB, Reed MF, Taylor MD, Hollenbeak CS. Lytic Therapy for Retained Traumatic Hemothorax. Chest 2019; 155:805-815. [DOI: 10.1016/j.chest.2019.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 12/06/2018] [Accepted: 01/02/2019] [Indexed: 01/08/2023] Open
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Affiliation(s)
- William Bremer
- Department of Radiology, University of Illinois College of Medicine, Chicago, Illinois
| | - Charles E Ray
- Department of Radiology, University of Illinois College of Medicine, Chicago, Illinois
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Bibby AC, Dorn P, Psallidas I, Porcel JM, Janssen J, Froudarakis M, Subotic D, Astoul P, Licht P, Schmid R, Scherpereel A, Rahman NM, Cardillo G, Maskell NA. ERS/EACTS statement on the management of malignant pleural effusions. Eur Respir J 2018; 52:13993003.00349-2018. [DOI: 10.1183/13993003.00349-2018] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 03/28/2018] [Indexed: 02/07/2023]
Abstract
Malignant pleural effusions (MPE) are a common pathology, treated by respiratory physicians and thoracic surgeons alike. In recent years, several well-designed randomised clinical trials have been published that have changed the landscape of MPE management. The European Respiratory Society (ERS) and the European Association for Cardio-Thoracic Surgery (EACTS) established a multidisciplinary collaboration of clinicians with expertise in the management of MPE with the aim of producing a comprehensive review of the scientific literature.Six areas of interest were identified, including the optimum management of symptomatic MPE, management of trapped lung in MPE, management of loculated MPE, prognostic factors in MPE, whether there is a role for oncological therapies prior to intervention for MPE and whether a histological diagnosis is always required in MPE.The literature revealed that talc pleurodesis and indwelling pleural catheters effectively manage the symptoms of MPE. There was limited evidence regarding the management of trapped lung or loculated MPE. The LENT score was identified as a validated tool for predicting survival in MPE, with Brims' prognostic score demonstrating utility in mesothelioma prognostication. There was no evidence to support the use of oncological therapies as an alternative to MPE drainage, and the literature supported the use of tissue biopsy as the gold standard for diagnosis and treatment planning.
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Falsarella PM, Rocha RD, Rahal Junior A, Mendes GF, Garcia RG. Minimally invasive treatment of complex collections: safety and efficacy of recombinant tissue plasminogen activator as an adjuvant to percutaneous drainage. Radiol Bras 2018; 51:231-235. [PMID: 30202126 PMCID: PMC6124593 DOI: 10.1590/0100-3984.2017.0086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To analyze the efficacy of recombinant tissue plasminogen activator (r-TPA)
injection in the evolution of percutaneous drainage of thick
collections. Materials and Methods This was a single-center study involving the retrospective analysis of
hospitalized patients undergoing percutaneous drainage of thick (superficial
or intracavitary) fluid collections, followed by injection of a fibrinolytic
agent (r-TPA) into the affected space. Results A total of 53 percutaneous drainage procedures, with r-TPA injection, were
performed in 51 patients. Abdominal and pelvic collections were the most
common, being seen in 38 (73%) of the procedures; in 35 (66%), the etiology
of the collection was attributed to postoperative complications. A total of
61 catheters were used in order to drain the 53 collections. Of those 61
catheters, 52 (85%) were large (12-16 Fr) and 9 (15%) were small (4-10 Fr).
The mean r-TPA dose was 5.7 mg/collection per day, and the mean time from
r-TPA injection to drain removal was 7.7 days. Percutaneous drainage in
combination with r-TPA injection was successful in 96% of the cases. None of
the patients showed coagulation changes during the study period. Conclusion The use of once-daily, low-dose r-TPA for up to three consecutive days, as an
adjunct to percutaneous drainage of thick collections, with or without
loculation, appears to be an effective technique.
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Affiliation(s)
- Priscila Mina Falsarella
- MD, Physician in the Department of Interventional Radiology of the Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Rafael Dahmer Rocha
- MD, Physician in the Department of Interventional Radiology of the Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Antonio Rahal Junior
- MD, Physician in the Department of Interventional Radiology of the Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Guilherme Falleiros Mendes
- MD, Physician in the Department of Interventional Radiology of the Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Rodrigo Gobbo Garcia
- MD, Physician in the Department of Interventional Radiology of the Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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Abstract
Introduction Chest injuries occur in a significant portion of trauma patients and hemothorax is a common result. While the initial management of traumatic hemothorax is most commonly treated with tube thoracostomy, the management of retained hemothorax is a subject of debate. Recent literature has proposed different methods for treating or preventing retained hemothorax, yet the approach to this pathology is not straightforward. Methods The literature was reviewed for relevant studies regarding the prevention and management of post-traumatic retained hemothorax. What follows is a review of the recent literature and an algorithm for the approach to treating a traumatic retained hemothorax. Results Identifying a traumatic retained hemothorax and preventing subsequent complications such as pneumonia, empyema, and fibrothorax are significant issues faced by surgeons. Studies for preventing retained hemothorax have focused on initial chest tube size, location, and peri-procedural placement conditions, as well as thoracic lavage. Several treatment modalities exist, including second drainage procedure and intra-pleural fibrinolytic drug instillation, but video-assisted thoracoscopic surgery is the most common and successful approach. Regardless of the approach to evacuation, early intervention is paramount. Conclusion Further studies will help characterize appropriate candidates, timing, treatment modalities, and guide therapy for retained hemothorax.
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Affiliation(s)
- Joseph D Bozzay
- Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Naval Medical Research Center, Silver Spring, MD, USA
| | - Matthew J Bradley
- Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Naval Medical Research Center, Silver Spring, MD, USA
- Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
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Thoracic irrigation prevents retained hemothorax: A prospective propensity scored analysis. J Trauma Acute Care Surg 2017; 83:1136-1141. [PMID: 28930941 DOI: 10.1097/ta.0000000000001700] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Thoracic trauma resulting in hemothorax (HTx) is typically managed with thoracostomy tube (TT) placement; however, up to 20% of patients develop retained HTx which may necessitate further intervention for definitive management. Although optimal management of retained HTx has been extensively researched, little is known about prevention of this complication. We hypothesized that thoracic irrigation at the time of TT placement would significantly decrease the rate of retained HTx necessitating secondary intervention. METHODS A prospective, comparative study of patients with traumatic HTx who underwent bedside TT placement was conducted. The control group consisted of patients who underwent standard TT placement, whereas the irrigation group underwent standard TT placement with immediate irrigation using 1 L of warmed sterile 0.9% saline. Patients who underwent emergency thoracotomy, those with TTs removed within 24 hours, or those who died within 30 days of discharge were excluded. The primary end point was secondary intervention defined by additional TT placement or operative management for retained HTx. A propensity-matched analysis was performed with scores estimated using a logistic regression model based on age, sex, mechanism of injury, Abbreviated Injury Scale chest score, and TT size. RESULTS In over a 30-month period, a total of 296 patients underwent TT placement for the management of traumatic HTx. Patients were predominantly male (79.6%) at a median age of 40 years and were evenly split between blunt (48.8%) and penetrating (51.2%) mechanisms. Sixty (20%) patients underwent thoracic irrigation at time of initial TT placement. The secondary intervention rate was significantly lower within the study group (5.6% vs. 21.8%; OR, 0.16; p < 0.001). No significant differences in TT duration, ventilator days, or length of stay were noted between the irrigation and control cohort. CONCLUSION Thoracic irrigation at the time of initial TT placement for traumatic HTx significantly reduced the need for secondary intervention for retained HTx. LEVEL OF EVIDENCE Therapeutic Study, Level III.
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Intrapleural Fibrinolytic Therapy for Residual Coagulated Hemothorax After Lung Surgery. World J Surg 2016; 40:1121-8. [PMID: 26711639 DOI: 10.1007/s00268-015-3378-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
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.
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Management of Post-Traumatic Complications by Interventional Ultrasound: a Review. CURRENT TRAUMA REPORTS 2016. [DOI: 10.1007/s40719-016-0057-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Kugler NW, Carver TW, Paul JS. Thoracic irrigation prevents retained hemothorax: a pilot study. J Surg Res 2016; 202:443-8. [PMID: 27038661 DOI: 10.1016/j.jss.2016.02.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 02/19/2016] [Accepted: 02/26/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Upward of 20% of patients undergoing thoracostomy tube (TT) placement develop retained hemothorax (HTx) requiring secondary intervention. The aim of this study was to define the rate of secondary intervention in patients undergoing prophylactic thoracic irrigation. METHODS A prospective observational trial of 20 patients who underwent thoracic irrigation at the time of TT placement was conducted. Patients with HTx identified on chest x-ray were included. After standard placement of a 36-French TT, the HTx was evacuated using a sterile suction catheter advanced within the TT. Warmed sterile saline was instilled into the chest through the TT followed by suction catheter evacuation. The TT was connected to the sterile drainage atrium and suction applied. TTs were managed in accordance with our standard division protocol. RESULTS The population was predominantly (70%) male at median age 35 years, median ISS 13, with 55% suffering penetrating trauma. Thirteen (65%) patients underwent TT placement within 6 h of trauma with the remainder within 24 h. Nineteen patients received the full 1000-mL irrigation. The majority demonstrated significant improvement on postprocedure chest x-ray. The secondary intervention rate was 5%. A single patient required VATS on post-trauma day zero for retained HTx. Median TT duration was 5 d with median length of stay of 7 d. No adverse events related to the pleural lavage were noted. CONCLUSIONS Thoracic irrigation at the time of TT placement for traumatic HTx may decrease the rate of retained HTx.
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Affiliation(s)
- Nathan W Kugler
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Thomas W Carver
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jasmeet S Paul
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Omar A, Elfadl AEA, Ahmed Y, Refaat S. Using streptokinase for pleural adhesiolysis in sonographically septated pleural effusion. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2015. [DOI: 10.1016/j.ejcdt.2015.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Lansley SM, Cheah HM, Varano Della Vergiliana JF, Chakera A, Lee YCG. Tissue plasminogen activator potently stimulates pleural effusion via a monocyte chemotactic protein-1-dependent mechanism. Am J Respir Cell Mol Biol 2015; 53:105-12. [PMID: 25474480 DOI: 10.1165/rcmb.2014-0017oc] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pleural infection is common. Evacuation of infected pleural fluid is essential for successful treatment, but it is often difficult because of adhesions/loculations within the effusion and the viscosity of the fluid. Intrapleural delivery of tissue plasminogen activator (tPA) (to break the adhesions) and deoxyribonuclease (DNase) (to reduce fluid viscosity) has recently been shown to improve clinical outcomes in a large randomized study of pleural infection. Clinical studies of intrapleural fibrinolytic therapy have consistently shown subsequent production of large effusions, the mechanism(s) of which are unknown. We aimed to determine the mechanism by which tPA induces exudative fluid formation. Intrapleural tPA, with or without DNase, significantly induced pleural fluid accumulation in CD1 mice (tPA alone: median [interquartile range], 53.5 [30-355] μl) compared with DNase alone or vehicle controls (both, 0.0 [0.0-0.0] μl) after 6 hours. Fluid induction was reproduced after intrapleural delivery of streptokinase and urokinase, indicating a class effect. Pleural fluid monocyte chemotactic protein (MCP)-1 levels strongly correlated with effusion volume (r = 0.7302; P = 0.003), and were significantly higher than MCP-1 levels in corresponding sera. Mice treated with anti-MCP-1 antibody (P < 0.0001) or MCP-1 receptor antagonist (P = 0.0049) demonstrated a significant decrease in tPA-induced pleural fluid formation (by up to 85%). Our data implicate MCP-1 as the key molecule governing tPA-induced fluid accumulation. The role of MCP-1 in the development of other exudative effusions warrants examination.
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Affiliation(s)
- Sally M Lansley
- 1 Pleural Disease Unit, Lung Institute of Western Australia, Perth, Western Australia, Australia
| | - Hui Min Cheah
- 1 Pleural Disease Unit, Lung Institute of Western Australia, Perth, Western Australia, Australia.,2 School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia; and
| | | | - Aron Chakera
- 2 School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia; and.,Departments of 3 Renal Medicine and
| | - Y C Gary Lee
- 1 Pleural Disease Unit, Lung Institute of Western Australia, Perth, Western Australia, Australia.,2 School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia; and.,4 Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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18
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Evaluation of chest tube administration of tissue plasminogen activator to treat retained hemothorax. Am J Surg 2014; 207:960-3. [DOI: 10.1016/j.amjsurg.2013.08.052] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 08/02/2013] [Accepted: 08/02/2013] [Indexed: 11/21/2022]
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Evaluation of management of postpneumonic empyema thoracis in children. ANNALS OF PEDIATRIC SURGERY 2013. [DOI: 10.1097/01.xps.0000434491.39619.8c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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20
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Yigit AK, Yilmaz Y, Erdeve O, Gokce IK, Oguz SS, Uras N, Dilmen U. Intrapleural streptokinase for the treatment of complicated parapneumonic effusion and empyema in 2 newborns. J Pediatr Surg 2012; 47:e41-4. [PMID: 23084230 DOI: 10.1016/j.jpedsurg.2012.07.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Revised: 05/29/2012] [Accepted: 07/01/2012] [Indexed: 11/15/2022]
Abstract
The management of complicated parapneumonic effusions by conventional first-line treatment with closed intercostal tube drainage and antibiotic therapy may fail because of thick viscous fluid and multiple pleural space loculations. Intrapleural fibrinolytic treatment is a non-invasive therapeutic option. In this report, we present successful use of intrapleural streptokinase for complicated parapneumonic effusion and empyema in 2 newborns. Intrapleural fibrinolytic therapy with streptokinase appears to be a safe and effective adjunctive therapy of choice and may have significant benefit even in newborns with complicated parapneumonic effusion and empyema, and thus, it can obviate surgical intervention.
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Affiliation(s)
- Avidan Kizilelma Yigit
- Division of Neonatology, Zekai Tahir Burak Maternity Teaching Hospital, 06230 Ankara, Turkey.
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Management of post-traumatic retained hemothorax: a prospective, observational, multicenter AAST study. J Trauma Acute Care Surg 2012; 72:11-22; discussion 22-4; quiz 316. [PMID: 22310111 DOI: 10.1097/ta.0b013e318242e368] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The natural history and optimal management of retained hemothorax (RH) after chest tube placement is unknown. The intent of our study was to determine practice patterns used and identify independent predictors of the need for thoracotomy. METHODS An American Association for the Surgery of Trauma multicenter prospective observational trial was conducted, enrolling patients with placement of chest tube within 24 hours of trauma admission and RH on subsequent computed tomography of the chest. Demographics, interventions, and outcomes were analyzed. Logistic regression analysis was used to identify the independent predictors of successful intervention for each of the management choices chosen and complications. RESULTS RH was identified in 328 patients from 20 centers. Video-assisted thoracoscopy (VATS) was the most commonly used initial procedure in 33.5%, but 26.5% required two and 5.4% required three procedures to clear RH or subsequent empyema. Thoracotomy was ultimately required in 20.4%. The strongest independent predictor of successful observation was estimated volume of RH ≤300 cc (odds ratio [OR], 3.7 [2.0-7.0]; p < 0.001). Independent predictors of successful VATS as definitive treatment were absence of an associated diaphragm injury (OR, 4.7 [1.6-13.7]; p = 0.005), use of periprocedural antibiotics for thoracostomy placement (OR, 3.3 [1.2-9.0]; p = 0.023), and volume of RH ≤900 cc (OR, 3.9 [1.4-13.2]; p = 0.03). No relationship between timing of VATS and success rate was identified. Independent predictors of the need for thoracotomy included diaphragm injury (OR, 4.9 [2.4-9.9]; p < 0.001), RH >900 cc (OR, 3.2 [1.4-7.5]; p = 0.007), and failure to give periprocedural antibiotics for initial chest tube placement (OR 2.3 [1.2-4.6]; p = 0.015). The overall empyema and pneumonia rates for RH patients were 26.8% and 19.5%, respectively. CONCLUSION RH in trauma is associated with high rates of empyema and pneumonia. VATS can be performed with high success rates, although optimal timing is unknown. Approximately, 25% of patients require at least two procedures to effectively clear RH or subsequent pleural space infections and 20.4% require thoracotomy.
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Abstract
Numerous intrapleural therapies have been adopted to treat a vast array of pleural diseases. The first intrapleural therapies proposed focused on the use of fibrinolytics and DNase to promote fluid drainage in empyema. Numerous case series and five randomized controlled trials have been published to determine the outcomes of fibrinolytics in empyema treatment. In the largest randomized trial, the use of streptokinase had no reduction in mortality, decortication rates or hospital days compared with placebo in the treatment of empyema. Criticism over study design and patient selection may have potentially affected the outcomes in this study. The development of dyspnoea is common in the setting of malignant pleural effusions. Pleural fluid evacuation followed by pleurodesis is often attempted. Numerous sclerosing agents have been studied, with talc emerging as the most effective agent. Small particle size of talc should be avoided because of increased systemic absorption potentiating toxicity, such as acute lung injury. Over the past several years, the use of chronic indwelling pleural catheters have emerged as the preferred modality in the treating a symptomatic malignant pleural effusion. For patients with malignant-related lung entrapment, pleurodesis often fails due to the presence of visceral pleural restriction; however, chronic indwelling pleural catheters are effective in palliation of dyspnoea. Finally, the use of staphylococcal superantigens has been proposed as a therapeutic model for the treatment of non-small lung cancer. Intrapleural instillation of staphylococcal superantigens increased median survival by 5 months in patients with non-small cell lung cancer with a malignant pleural effusion.
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Affiliation(s)
- J Terrill Huggins
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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23
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Cobanoglu U, Sayir F, Bilici S, Melek M. Comparison of the methods of fibrinolysis by tube thoracostomy and thoracoscopic decortication in children with stage II and III empyema: a prospective randomized study. Pediatr Rep 2011; 3:e29. [PMID: 22355514 PMCID: PMC3283197 DOI: 10.4081/pr.2011.e29] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Revised: 07/23/2011] [Accepted: 10/26/2011] [Indexed: 11/23/2022] Open
Abstract
Today, in spite of the developments in imaging methods and antibiotherapy, childhood pleural empyema is a prominent cause of morbidity and mortality. In recent years, it has been shown that there has been an increase in the frequency of pleural empyema in children, and antibiotic resistance in microorganisms causing pleural empyema has made treatment difficult. Despite the many studies investigating thoracoscopic debridement and fibrinolytic treatment separately in the management of this disease, there is are not enough studies comparing these two treatments. The aim of this study was to prospectively compare the efficacy of two different treatment methods in stage II and III empyema cases and to present a perspective for treatment options.WE EXCLUDED FROM THE STUDY CASES WITH: i) thoracoscopic intervention and fibrinolytic agent were contraindicated; ii) immunosuppression or additional infection focus; iii) concomitant diseases, those with bronchopleural fistula diagnosed radiologically, and Stage I cases. This gave a total of 54 cases: 23 (42.6%) in stage II, and 31 (57.4%) cases in stage III. These patients were randomized into two groups of 27 cases each for debridement or fibrinolytic agent application by video-assisted thoracoscopic decortication (VATS). The continuity of symptoms after the operation, duration of thoracic tube in situ, and the length of hospital stay in the VATS group were of significantly shorter duration than in the streptokinase applications (P=0.0001). In 19 of 27 cases (70.37%) in which fibrinolytic treatment was applied and in 21 cases of 27 (77.77%) in which VATS was applied, the lung was fully expanded and the procedure was considered successful. There was no significant difference with respect to success rates between the two groups (P=0.533). The complication rate in our cases was 12.96% and no mortality was observed. Similar success rates in thoracoscopic drainage and enzymatic debridement, and the low cost of enzymatic drainage both served to highlight intrapleural streptokinase treatment as a reliable method in reducing the need for surgery in complicated empyema.
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Affiliation(s)
- Ufuk Cobanoglu
- Abidin Şehitoğlu, Van State Hospital Department of Thoracic Surgery, Van, Turkey
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Ahmed AH, Yacoub TE. Intrapleural therapy in management of complicated parapneumonic effusions and empyema. Clin Pharmacol 2010; 2:213-21. [PMID: 22291507 PMCID: PMC3262383 DOI: 10.2147/cpaa.s14104] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Empyema thoracis causes high mortality, and its incidence is increasing in both children and adults. Parapneumonic effusions (PPEs) develop in about one-half of patients hospitalized with pneumonia, and their presence increases mortality by about four-fold. PPEs can be divided into simple PPEs, complicated PPEs, and frank empyema. Two guideline statements on the management of PPEs in adults have been published by the British Thoracic Society (BTS) and the American College of Chest Physicians; a third guideline statement published by the BTS focused on management of PPEs in children. The two adult guideline statements recommend drainage of the pleural space in complicated PPEs and frank empyema. They also recommend the use of intrapleural fibrinolysis in those who do not show improvement. The pediatric guideline statement recommends adding intrapleural fibrinolysis to those treated by tube thoracostomy if they have loculated pleural space or thick pus. Published guideline statements on the management of complicated PPEs and empyema in adults and children recommend the use of intrapleural fibrinolysis in those who do not show improvement after pleural space drainage. However, published clinical trial reports on the use of intrapleural fibrinolysis for the treatment of pleural space sepsis suffer from major design and methodologic limitations. Nevertheless, published reports have shown that the use of intrapleural fibrinolysis does not reduce mortality in adults with parapneumonic effusions and empyema. However, intrapleural fibrinolysis enhances drainage of infected pleural fluid and may be used in patients with large collections of infected pleural fluid causing breathlessness or respiratory failure, but a proportion of these patients will ultimately need surgery for definite cure. Intrapleural streptokinase and urokinase seem to be equally efficacious in enhancing infected pleural fluid drainage in adults. In most of the published studies in adults, the use of intrapleural fibrinolysis was not associated with serious side effects. There is emerging evidence that the combination of intrapleural tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) is significantly superior to tPA or DNase alone or placebo in improving pleural fluid drainage in patients with pleural space infection. In children, intrapleural fibrinolysis has not been shown to reduce mortality, but has been shown to enhance drainage of the pleural space and was safe. In addition, two prospective, randomized trials have shown that intrapleural fibrinolysis is as effective as video-assisted thoracoscopic surgery for the treatment of childhood empyema and is a more cost-effective treatment and therefore should be the primary treatment of choice.
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Affiliation(s)
- Alaeldin H Ahmed
- Department of Medicine, Faculty of Medicine, University of Khartoum, Khartoum, Sudan.
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25
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Boersma WG, Stigt JA, Smit HJ. Treatment of haemothorax. Respir Med 2010; 104:1583-7. [DOI: 10.1016/j.rmed.2010.08.006] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Revised: 07/05/2010] [Accepted: 08/09/2010] [Indexed: 11/24/2022]
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Hamblin SE, Furmanek DL. Intrapleural Tissue Plasminogen Activator for the Treatment of Parapneumonic Effusion. Pharmacotherapy 2010; 30:855-62. [DOI: 10.1592/phco.30.8.855] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Kobr J, Pizingerova K, Sasek L, Fremuth J, Siala K, Racek J. Treatment of encapsulated pleural effusions in children: a prospective trial. Pediatr Int 2010; 52:453-8. [PMID: 19919636 DOI: 10.1111/j.1442-200x.2009.03006.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim of this study was to improve the efficacy of treatment of complicated pleural effusions. METHODS In this prospective study, 76 consecutive children (average age 5.0 +/- 4.14 years) fulfilling the required classification criteria were duly treated with chest tube placement and divided into two groups depending on the presence of encapsulated or non-encapsulated effusions. Treatment of the former group was supplemented by intrapleural fibrinolysis. The effectiveness of treatment was assessed in terms of chest tube dwell-time and total length of hospitalization. Regression analysis was performed using independent factors that were associated with these dependent factors. Value differences for P < 0.05 were considered significant. RESULTS The ultrasound pleural distance and lactic-dehydrogenase content in the pleural fluid was significantly associated with the length of treatment (P < 0.01). Improved response to treatment, reduced duration of hospitalization (9.2 +/- 1.9 vs 11.5 +/- 0.9; P < 0.01) and tube dwell-time (7.6 +/- 1.3 vs 9.5 +/- 0.9; P < 0.01) was achieved in the intrapleural-fibrinolysis-treated group (n= 38) compared with controls (n= 38), with virtually the same total tube output (606.1 +/- 257.5 vs 673.1 +/- 347.4; P= 0.175). All patients were completely cured. Following 104 applications of the fibrinolytic agent there was one change in coagulation parameters: hypofibrinogenemia (in 1%). CONCLUSIONS The authors recommend intrapleural fibrinolysis as an effective and safe alternative treatment strategy in treating encapsulated pleural effusions in children.
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Affiliation(s)
- Jiri Kobr
- Department of Paediatrics-PICU, Faculty of Medicine in Pilsen and Faculty Hospital in Pilsen, Czech Republic.
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Goralski JL, Bromberg PA, Haithcock B. Intrapleural hemorrhage after administration of tPA: a case report and review of the literature. Ther Adv Respir Dis 2010; 3:295-300. [PMID: 19934281 DOI: 10.1177/1753465809350748] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Intrapleural fibrinolytic enzymes have been used for over 60 years in the treatment of complicated pleural effusions to lyse loculations and promote resolution. Despite this extensive history of use, however, little is known about complications that may arise with the use of this therapy. Here we discuss a patient with chronic renal failure on hemodialysis who developed an intrapleural hemorrhage after the administration of intrapleural tPA to treat a complicated parapneumonic effusion. A review of the literature examines the efficacy and safety of this therapy, focusing on bleeding complications. Specific attention is paid to patients who have underlying coagulopathies or who are receiving anticoagulation. DATA SOURCES A review of the literature, as indexed in PubMed, was undertaken using the following search terms in combination: tPA, pleural effusion, complications of thrombolytics, and intrapleural hemorrhage. The search was inclusive of patients under the age of 18, but was limited by English language and human subjects. STUDY SELECTION/DATA EXTRACTION All relevant articles identified during the search were reviewed. Those studies that reported on bleeding complications, or lack thereof, were included in this review. Limitations of each article are noted in the text. CONCLUSIONS Multiple studies, including a 2000 ACP consensus statement and a 2008 Cochrane review, indicate the need for further investigations to evaluate the safety and efficacy of intrapleural thrombolytics for the treatment of complicated pleural effusions and empyemas. Limited studies specifically address bleeding complications, especially in subpopulations of patients receiving concurrent anticoagulant therapy.
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Affiliation(s)
- Jennifer L Goralski
- University of North Carolina at Chapel Hill, Division of Pulmonary and Critical Care Medicine, Chapel Hill, NC, USA.
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Erdeve O, Atasay B, Arsan S, Ucar T, Kavaz A, Tutar E. Intrapleural streptokinase treatment for postoperative coagulated hemothorax in a newborn. Pediatr Int 2009; 51:307-9. [PMID: 19379267 DOI: 10.1111/j.1442-200x.2008.02800.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Omer Erdeve
- Division of Neonatology, Ankara University, School of Medicine, Ankara, Turkey.
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30
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Azfar Ali H, Lippmann M, Mundathaje U, Khaleeq G. Spontaneous hemothorax: a comprehensive review. Chest 2008; 134:1056-1065. [PMID: 18988781 DOI: 10.1378/chest.08-0725] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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Cameron R, Davies HR. Intra-pleural fibrinolytic therapy versus conservative management in the treatment of adult parapneumonic effusions and empyema. Cochrane Database Syst Rev 2008:CD002312. [PMID: 18425881 DOI: 10.1002/14651858.cd002312.pub3] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Pleural effusions and empyema may complicate lower respiratory tract infections. Treatment of these collections of pus includes surgical drainage and the use of intra-pleural fibrinolysis to break down fibrin bands that may cause loculation. OBJECTIVES To conduct a systematic review of the benefit of adding intrapleural fibrinolytic therapy to intercostal tube drainage in the treatment of complicated para pneumonic effusions and empyema to reduce mortality or the need for subsequent surgical debridement of the pleural space. SEARCH STRATEGY We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Trial authors were contacted for further information and details regarding the possibility of unpublished trials was requested. The most recent search was conducted in November 2006. SELECTION CRITERIA All studies in the review were Randomised Controlled Trials in adult patients with post-pneumonic empyema or complicated parapneumonic effusions who had not had prior surgical intervention or trauma. The intervention was an intrapleural fibrinolytic agent (streptokinase or urokinase) via an intercostal chest drain (ICD) versus control, or a comparison of the two agents. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data . Study authors were contacted for further information. MAIN RESULTS Seven studies met the eligibility criteria of the review, recruiting 761 participants. The only consistent end points in all trials were treatment failure, as gauged by the requirement for additional intervention including surgery or death. In studies where patients had either loculation and empyema, there was no significant difference in the risk of death with fibrinolytics (RR 1.08; 95% CI 0.69 to 1.68). When treatment failure was considered as surgical intervention, fibrinolytics reduced the risk of this outcome (RR 0.63; 95% CI 0.46 to 0.85), but there is discordance between earlier positive studies and the more recent negative study by Maskell. AUTHORS' CONCLUSIONS Intrapleural fibrinolytic therapy confers significant benefit in reducing the requirement for surgical intervention for patients in the early studies included in this review but not in the more recently published Maskell study. The reasons for this difference are uncertain. Separate subgroup analysis of proven loculated/septated effusions from the available data in our meta-analysis suggests a potential overall treatment benefit with fibrinolytics, but these results should be treated with caution as the data are incomplete and the benefit is not significant in the subgroup of high quality trials (Cochrane Grade A). Intrapleural fibrinolytics have not been shown to significantly increase adverse events, but the confidence interval is too wide to firmly exclude this possibility.
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Affiliation(s)
- R Cameron
- Northern Sydney Central Coast Area Health Service, NSW, Australia.
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Padman R, King KA, Iqbal S, Wolfson PJ. Parapneumonic effusion and empyema in children: retrospective review of the duPont experience. Clin Pediatr (Phila) 2007; 46:518-22. [PMID: 17579104 DOI: 10.1177/0009922806299096] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Management of pediatric parapneumonic effusions and empyema remains controversial. Treatment includes antibiotics, chest tube, fibrinolytic therapy, video-assisted thoracoscopy and debridement, and open thoracotomy and decortication. A retrospective 10-year study was done to identify patient selection variables for specific therapies. Charts (n = 101) with diagnoses of empyema without comorbidity were reviewed, a database was developed, and variables between patients who did and did not receive thoracoscopic debridement were compared at admission and during hospitalization. The difference in positive culture reports with video-assisted thoracoscopy compared with medical management was significant (P < .018). Postsurgical patients used the intensive care unit and had 2 or more chest tubes with greater frequency than medically managed patients (P < .014, P < .002). Antibiotics, video-assisted thoracoscopy, and chest tube within 48 hours of admission shortened hospitalization by 4 days (P < .001) compared with delayed video-assisted thoracoscopy done after 48 hours of admission.
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Affiliation(s)
- Raj Padman
- Division of Pulmonary, Alfred I. duPont Hospital for Children, Nemours Children's Clinic, Wilmington, DE 19899, USA.
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Fuller MK, Helmrath MA. Thoracic empyema, application of video-assisted thoracic surgery and its current management. Curr Opin Pediatr 2007; 19:328-32. [PMID: 17505195 DOI: 10.1097/mop.0b013e32810c8e9d] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Pneumonia in children is frequently complicated by pleural effusions, which rarely progress to empyema. Appropriate clinical management depends on correctly diagnosing the stage of the disease process. Recently, increasing use of video-assisted thoracic debridement has altered the traditional management of pleural effusions and empyema in children, resulting in decreasing reliance on thoracentesis and earlier surgical intervention. RECENT FINDINGS We review the current literature supporting the clinical indications for video-assisted thoracic debridement compared with traditional management, including the use of thoracentesis, chest tube placement, fibrinolytic therapy and open thoracotomy in children with empyema. Recent studies support the early application of video-assisted thoracic debridement in children with empyema compared with traditional therapy, as it decreases the number of procedures and studies performed and the duration of chest tube drainage and is associated with less pain and shorter recovery period than open thoracotomy. SUMMARY We propose a clinical algorithm supporting the early use of video-assisted thoracic debridement in the management of empyema in children.
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Affiliation(s)
- Megan K Fuller
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
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Kimbrell BJ, Yamzon J, Petrone P, Asensio JA, Velmahos GC. Intrapleural Thrombolysis for the Management of Undrained Traumatic Hemothorax: A Prospective Observational Study. ACTA ACUST UNITED AC 2007; 62:1175-8; discussion 1178-9. [PMID: 17495721 DOI: 10.1097/ta.0b013e3180500654] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tube thoracostomy is usually sufficient treatment for traumatic hemothorax. Occasionally, significant residual collections remain undrained. Open thoracotomy and video-assisted thoracoscopic surgery (VATS) have been used to manage undrained traumatic hemothoraces (UTHs). Both techniques are invasive and harbor risks. More recently, intrapleural administration of thrombolytic agents (streptokinase and urokinase) has been reported as an effective nonoperative treatment of residual collections caused by a variety of diseases. The role of intrapleural thrombolysis (IT) for the treatment of an UTH is inadequately explored. METHODS Patients with an UTH, defined as more than 300 mL of intrathoracic blood estimated by computed tomographic scan on the third day after chest tube insertion, were followed prospectively for 16 months. IT was instituted according to a standardized protocol using streptokinase or urokinase. IT effectiveness, defined by the incidence of successful resolution of the UTH, and IT safety, defined by the incidence of uncomplicated therapy, was calculated. RESULTS Of 203 patients with a traumatic hemothorax, managed by tube thoracostomy, 25 (12.3%) developed an UTH. Successful resolution of the UTH was achieved in 23 (92%) patients within 3.4+/-1.4 days. No bleeding or other significant complications related to IT were recorded. CONCLUSIONS IT should be the initial treatment of choice for the management of an UTH.
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Affiliation(s)
- Brian J Kimbrell
- Department of Surgery, Los Angeles County and the University of Southern California Medical Center, Keck School of Medicine, USA.
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35
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Noukoua Tchuisse C, Ghaye B, Dondelinger RF. Imaging and Treatment of Thoracic Fluid and Gas Collections. Emerg Radiol 2007. [DOI: 10.1007/978-3-540-68908-9_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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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.
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Affiliation(s)
- Oner Dikensoy
- Pulmonary Division, St. Thomas Hospital and Vanderbilt University, Nashville, TN, USA.
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Villena Garrido V, Ferrer Sancho J, Hernández Blasco L, de Pablo Gafas A, Pérez Rodríguez E, Rodríguez Panadero F, Romero Candeira S, Salvatierra Velázquez A, Valdés Cuadrado L. [Diagnosis and treatment of pleural effusion]. Arch Bronconeumol 2007. [PMID: 16945266 DOI: 10.1157/13090586] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Villena Garrido V, Ferrer Sancho J, Hernández Blasco L, de Pablo Gafas A, Pérez Rodríguez E, Rodríguez Panadero F, Romero Candeira S, Salvatierra Velázquez A, Valdés Cuadrado L. [Diagnosis and treatment of pleural effusion]. Arch Bronconeumol 2007; 42:349-72. [PMID: 16945266 DOI: 10.1016/s1579-2129(06)60545-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bouros D, Tzouvelekis A, Antoniou KM, Heffner JE. Intrapleural fibrinolytic therapy for pleural infection. Pulm Pharmacol Ther 2006; 20:616-26. [PMID: 17049447 DOI: 10.1016/j.pupt.2006.08.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2006] [Accepted: 08/08/2006] [Indexed: 11/26/2022]
Abstract
Pneumonia with secondary pleural infection causes considerable morbidity and mortality. Intrapleural instillation of fibrinolytic agents to dissolve fibrinous adhesions is intended to improve pleural fluid drainage and prevent pleural loculations. In the last 20 years their application in the every day clinical practice has dragged much of attention and several studies have supported their use in the management of parapneumonic pleural effusions (PPE) and pleural empyema (PE). However, recent published data cast doubt on the effectiveness of intrapleural fibrinolytic agents in promoting drainage of infected pleural effusions. Pending future clinical trials, fibrinolytic therapy may be used selectively in patients who fail drainage with appropriately sized, image-guided chest tubes if reasons exist to delay or avoid definitive surgical drainage. The scope of this article is to systematically review evidence for the efficacy of intrapleural fibrinolytic therapy in the treatment of PPE and PE with emphasis on controlled trials and present some of the future perspectives.
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Affiliation(s)
- Demosthenes Bouros
- Department of Pneumonology, Medical School University of Thrace, Alexandroupolis 68100, Greece.
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Tsuji H, Nagata M, Inoue T, Minami T, Iwai H, Ohnishi S, Yukawa H, Ogura M, Yamashita T, Nagata K. [Clinical phase I trial of concurrent chemo-radiotherapy with S-1 for T2NO glottic carcinoma]. Gan To Kagaku Ryoho 2006; 33 Suppl 1:163-6. [PMID: 16897995 DOI: 10.2217/14750708.3.1.163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
We conducted a phase I study to determine a recommended dose (RD) of S-1 for chemo-radiotherapy consisting of S-1+ radiotherapy for T 2 N 0 larynx cancer. The method of administration used to assess the RD was irradiation with 2 Gy/day for 5 days a week until a total dose of 60 Gy, and concomitant administration of S-1 once a day for 2 weeks beginning on the day therapy was started followed by 2 weeks off the drug and 2 weeks on the drug with the dose escalating from S-1 60 mg/body/day (level 1) to 80 mg/body/day (level 2), and then to 100 mg/body/day (level 3). 18 patients were enrolled. 4 patients developed an adverse event of grade 3 radiation dermatitis which became a dose-limiting toxicity (DLT) at level 3. We then concluded that 100 mg/body/day was the maximum tolerated dose (MTD) of S-1 and decided that the RD of S-1 was 80 mg/body/day.
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Affiliation(s)
- Hiroyuki Tsuji
- Dept. of Otolaryngology, Kanazawa Medical University, Ishikawa, Japan
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41
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Abstract
Several issues are involved in determining a patient's risk for postoperative hemorrhage and in managing this potential postoperative complication. The impact of minimally invasive procedures on the incidence of this complication is addressed in this article.
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Affiliation(s)
- Virginia R Litle
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Mount Sinai Medical Center, 1190 Fifth Avenue, New York, NY 10029, USA
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Abstract
Pleural fibrosis can result from a variety of inflammatory processes. The response of the pleural mesothelial cell to injury and the ability to maintain its integrity are crucial in determining whether normal healing or pleural fibrosis occurs. The pleural mesothelial cell, various cytokines, and disordered fibrin turnover are involved in the pathogenesis of pleural fibrosis. The roles of these mediators in producing pleural fibrosis are examined. This article reviews the most common clinical conditions associated with the development of pleural fibrosis. Fibrothorax and trapped lung are two unique and uncommon consequences of pleural fibrosis. The management of pleural fibrosis, including fibrothorax and trapped lung, is discussed.
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Affiliation(s)
- Michael A Jantz
- Division of Pulmonary and Critical Care Medicine, University of Florida, 1600 SW Archer Road, Room M352, PO Box 100225, Gainesville, FL 32610-0225, USA.
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Ozkan OS, Ozmen MN, Akhan O. Percutaneous management of parapneumonic effusions. Eur J Radiol 2006; 55:311-20. [PMID: 15885958 DOI: 10.1016/j.ejrad.2005.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2005] [Revised: 03/07/2005] [Accepted: 03/10/2005] [Indexed: 11/28/2022]
Abstract
Parapneumonic effusions continue to be a significant source of morbidity and mortality. Treatment at earlier stages before fibrous peel and loculations occur has a much better prognosis. Using image guidance, addition of intracavitary fibrinolytic instillation, close follow-up with drainage of residual or new collections are some of the other factors that improve prognosis. In this article, we discussed treatment strategies, percutaneous management of parapneumonic effusions, its alternatives and results.
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Affiliation(s)
- Orhan S Ozkan
- Department of Radiology, Hacettepe University School of Medicine, 06100 Sihhiye/Ankara, Turkey
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Herrera-Kiengelher L, Chi-Lem G, Báez-Saldaña R, Torre-Bouscoulet L, Regalado-Pineda J, López-Cervantes M, Pérez-Padilla R. Frequency and Correlates of Adverse Events in a Respiratory Diseases Hospital in Mexico City. Chest 2005; 128:3900-5. [PMID: 16354861 DOI: 10.1378/chest.128.6.3900] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES To estimate the frequency of severe adverse events (AEs) during hospital stay as well as their type and correlates in a referral hospital for respiratory diseases, using methods similar to those used in the Harvard Medical Malpractice Study. DESIGN Retrospective review of medical records in a stratified sample of 836 patients drawn from a total of 4,555 hospital admissions registered during the year 2001. SETTING A referral tertiary-care hospital for patients with respiratory diseases located in Mexico City. MAIN OUTCOME MEASURES Weighted prevalence of AEs and odds ratios for correlates. RESULTS The overall weighted prevalence for AEs was 9.1% (95% confidence interval, 7.5 to 10.4%). Of these patients, 17% had a related transient disability, 52% had a prolonged hospital stay, and 26% had an AE that according to the reviewers contributed to their death. Of the total number of AEs, 74% were qualified as potentially preventable. Among all types of AEs, we identified as most relevant for a chest hospital the delayed surgical treatment of empyema, representing 11% of the total. CONCLUSIONS The frequency of AEs in a tertiary-care respiratory hospital is similar to that reported in general hospitals. A strategy to improve the treatment of empyema is needed.
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Affiliation(s)
- Loredmy Herrera-Kiengelher
- National Institute of Respiratory Diseases and National Institute of Public Health, Secretary of Health, Mexico, Tlalpan, Mexico
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Schiza SE, Antoniou KM, Economidou FN, Siafakas NM. Pharmacotherapy in complicated parapneumonic pleural effusions and thoracic empyema. Pulm Pharmacol Ther 2005; 18:381-9. [PMID: 15998594 DOI: 10.1016/j.pupt.2004.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2004] [Revised: 12/01/2004] [Accepted: 12/03/2004] [Indexed: 10/25/2022]
Abstract
Parapneumonic pleural effusions (PPE) and pleural empyema (PE) present a frequently diagnostic and therapeutic challenge in clinical practice. Although pleural diseases have received increased attention during the past decade, there are still many unanswered questions concerning the diagnosis and treatment of PPE and PE. A lack of controlled studies concerning the management of PPE and PE was noted in recent guidelines. The use of fibrinolytics intrapleurally appears to enhance intercostals tube drainage, reducing the requirement for subsequent surgical mechanical debridement. Recently, there has been interest in other intrapleural agents including combination drugs consisting of streptokinase and streptodornase-alpha, Dnase. Factors to be considered in evaluating whether or not intrapleural instillation of fibrinolytics is effective include an assessment of clinical responses. This review discusses the use of fibrinolytic agents as a novel therapeutic options for treating the various stages of parapneumonic effusions and empyemas.
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Affiliation(s)
- Sophia E Schiza
- Department of Thoracic Medicine, University Hospital of Heraklion, P.O. Box 1352, 71110 Heraklion, Greece
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Abstract
Pleural disease remains a commonly encountered clinical problem for both general physicians and chest specialists. This review focuses on the investigation of undiagnosed pleural effusions and the management of malignant and parapneumonic effusions. New developments in this area are also discussed at the end of the review. It aims to be evidence based together with some practical suggestions for practising clinicians.
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Affiliation(s)
- A R Medford
- Southmead Hospital, Acute Lung Unit, Southmead Hospital, Bristol, UK
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Oğuzkaya F, Akçali Y, Bilgin M. Videothoracoscopy versus intrapleural streptokinase for management of post traumatic retained haemothorax: a retrospective study of 65 cases. Injury 2005; 36:526-9. [PMID: 15755435 DOI: 10.1016/j.injury.2004.10.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2004] [Revised: 10/05/2004] [Accepted: 10/05/2004] [Indexed: 02/02/2023]
Abstract
BACKGROUND Post traumatic retained haemothorax (PRH) may cause pulmonary restrictions or septic pleural complications. Currently, minimally invasive procedures such as videothoracoscopy or intrapleural fibrinolysis have replaced open surgery in an effort to avoid these complications. OBJECTIVE We have reviewed retrospectively our use of videothoracoscopy versus intrapleural streptokinase for the management of PRH over the last 10 years. PATIENTS AND METHOD There were 56 males and nine females in the study. Thirty-one cases had been managed by intrapleural streptokinase (group I), and videothoracoscopy was performed on 34 cases (group II). Therapeutic results for both groups were determined by chest radiographs. RESULTS In the population from which we drew our study group, retained haemothoraces occurred in 10.9% of 596 cases with traumatic haemothorax. In group I, 22 patients had radiological improvement; the others underwent thoracotomy. In this group, mean hospitalisation time was 14.5(+/-4.2) days, and three cases were complicated by empyema. In group II, all patients except four had complete radiological improvement; two of them required a decortication. In this group, mean hospital stay was 9.8(+/-3.7) days. There were no deaths in either group. The differences between group I and group II for length of hospital stay and number of thoracotomies was statistically significant. CONCLUSION Videothoracoscopy is therefore a more effective procedure than intrapleural streptokinase for the management of PRH.
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Affiliation(s)
- Fahri Oğuzkaya
- Department of Thoracic Surgery, Erciyes University Medical Faculty, 38039 Kayseri, Turkey.
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Zacharski LR, Sukhatme VP. Coley's toxin revisited: immunotherapy or plasminogen activator therapy of cancer? J Thromb Haemost 2005; 3:424-7. [PMID: 15748226 DOI: 10.1111/j.1538-7836.2005.01110.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- L R Zacharski
- Department of Veterans Affairs Medical Center, White River Junction, VT 05009, USA
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50
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Skeete DA, Rutherford EJ, Schlidt SA, Abrams JE, Parker LA, Rich PB. Intrapleural Tissue Plasminogen Activator for Complicated Pleural Effusions. ACTA ACUST UNITED AC 2004; 57:1178-83. [PMID: 15625447 DOI: 10.1097/01.ta.0000141879.67441.52] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study is aimed at evaluating the safety and efficacy of intrapleural tissue plasminogen activator (TPA) for complicated pleural effusions, including posttraumatic hemothorax. METHODS Data were retrospectively collected from hospitalized patients over a 4-year period (1999-2003) who were treated with intrapleural TPA after failing drainage by tube thoracostomy. Pre- and post-TPA imaging studies were reviewed and scored by a blinded radiologist. RESULTS Forty-one consecutive patients with 42 effusions were identified with the following indications: 6 traumatic hemothoraces (14%), 22 loculated pleural effusions (52%), 2 line-associated hemothoraces (5%), and 12 empyemas (29%). Nine patients (22%) required operative drainage including two with posttraumatic hemothoraces. All patients managed nonoperatively demonstrated radiographic improvement after TPA administration. One patient (2.4%) developed hematuria, requiring transfusion. No trauma patient required TPA-related blood transfusion and no deaths were attributable to TPA therapy. CONCLUSION Intrapleural TPA administration appears safe for use in complicated pleural effusions and may decrease the need for operative intervention.
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Affiliation(s)
- Dionne A Skeete
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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