Intrapleural instillation of fibrinolytic agents for treatment of pleural empyema*

LEARNING OBJECTIVES On completion of this article, the reader should be able to: 1. Explain the mechanism of action of streptokinase. 2. Outline an alternative to surgical decortication of empyema. 3. Recognize that intrapleural instillation of fibrinolytic agents is not associated with bleeding complications. The authors have disclosed that they have no financial relationships with commercial companies pertaining to this educational activity. Visit the Pediatric Critical Care Medicine Online website (http://www.pccmjournal.com) for information on obtaining continuing medical education credit. Objective To describe the use of intrapleural instillation of fibrinolytic agents as adjunctive therapy for children with complicated pleural effusions and empyema. Design Retrospective chart review. Setting Tertiary care children’s hospital in an academic medical center. Patients Nineteen consecutive patients (median age, 36 months; range, 9 months to 13 yrs) with complicated pleural effusion or empyema by clinical, radiographic, and laboratory criteria who failed to have adequate drainage of the fluid collection by tube thoracostomy. Interventions Patients who remained symptomatic with fever or respiratory distress and who had pleural fluid that could not be drained by tube thoracostomy were treated by intrapleural instillation of either urokinase (13 patients) or streptokinase (six patients) 8–72 hrs after chest tube insertion. Measurements and Main Results Fibrinolytic therapy increased the volume of chest tube drainage in 15 (79%) of 19 patients. Fourteen of the 19 patients were successfully managed without referral for surgical drainage. No significant adverse events or side effects were noted. Conclusion Intrapleural instillation of fibrinolytic agents appears to be an effective and less invasive alternative to surgical drainage for children who have complicated pleural effusions or empyemas that do not drain adequately with tube thoracostomy alone.