Intrapleural Administration Of Streptokinase Research Articles

P36 Respiratory functional status after intrapleural t-PA administration for complicated parapneumonic effusions

Introduction and ObjectivesIn a large-scale, multicentered randomised trial, intrapleural administration of streptokinase has been proved unsuccessful among patients with pleural infection but >80% of them had visibly purulent pleural fluid...

Streptokinase for malignant pleural effusions: a randomized controlled study

Effective palliative treatment in malignant pleural effusion can only be carried out when the lung is fully expanded after drainage of effusion. We investigated the efficacy of intrapleural fibrinolytics for lysing fibrin deposits and improving lung reexpansion in patients with malignant pleural effusion. We randomly allocated 47 patients with malignant pleural effusion into 2 groups: a fibrinolytic group of 24 were given 3 cycles of 250,000 U intrapleural streptokinase; the control group of 23 received pleural drainage only. Pleurodesis with 5 mg of talc slurry was performed in all patients who had lung reexpansion after drainage. Patient characteristics, pleural drainage, lung expansion assessed by chest radiography, and pleurodesis outcomes were compared between the 2 groups. Patient characteristics were similar in both groups. Lung reexpansion was adequate for performing talc pleurodesis in 96% of patients in the fibrinolytic group and 74% in the control group. In the fibrinolytic group, the mean volume of daily pleural drainage before streptokinase administration was 425 mL, and it increased significantly to 737 mL after streptokinase infusion. Intrapleural administration of streptokinase is advisable for patients with malignant pleural effusion.

Massive hemothorax following administration of intrapleural streptokinase

The administration of intrapleural streptokinase (IPSK) is widely practiced in the management of loculated empyema thoracis. To our knowledge, there have been only 4 cases of hemorrhagic complications attributed to the administration of IPSK reported in the literature. In this article, we report a case of a 17-year-old girl who received IPSK and developed shock, anemia, coagulopathy and massive hemothorax. Our discussion focuses on the hemorrhagic complication of chest tube insertion and the role of IPSK in blood clot lysis and inhibition of local hemostasis.

To Lyse or Not to Lyse: That Is the Question

Synopsis: In patients with pleural infections, the administration of intrapleural streptokinase does not improve mortality, the rate of surgery, or the hospital length of stay. Synopsis: Maskell NA et al. U.K. Controlled Trial of Intrapleural Streptokinase for Pleural Infections. N Engl J Med. 2005;352:685–874.

U.K. Controlled Trial of Intrapleural Streptokinase for Pleural Infection

Intrapleural fibrinolytic agents are used in the drainage of infected pleural-fluid collections. This use is based on small trials that did not have the statistical power to evaluate accurately important clinical outcomes, including safety. We conducted a trial to clarify the therapeutic role of intrapleural streptokinase. In this double-blind trial, 454 patients with pleural infection (defined by the presence of purulent pleural fluid or pleural fluid with a pH below 7.2 with signs of infection or by proven bacterial invasion of the pleural space) were randomly assigned to receive either intrapleural streptokinase (250,000 IU twice daily for three days) or placebo. Patients received antibiotics and underwent chest-tube drainage, surgery, and other treatment as part of routine care. The number of patients in the two groups who had died or needed surgical drainage at three months was compared (the primary end point); secondary end points were the rates of death and of surgery (analyzed separately), the radiographic outcome, and the length of the hospital stay. The groups were well matched at baseline. Among the 427 patients who received streptokinase or placebo, there was no significant difference between the groups in the proportion of patients who died or needed surgery (with streptokinase: 64 of 206 patients [31 percent]; with placebo: 60 of 221 [27 percent]; relative risk, 1.14 [95 percent confidence interval, 0.85 to 1.54; P=0.43), a result that excluded a clinically significant benefit of streptokinase. There was no benefit to streptokinase in terms of mortality, rate of surgery, radiographic outcomes, or length of the hospital stay. Serious adverse events (chest pain, fever, or allergy) were more common with streptokinase (7 percent, vs. 3 percent with placebo; relative risk, 2.49 [95 percent confidence interval, 0.98 to 6.36]; P=0.08). The intrapleural administration of streptokinase does not improve mortality, the rate of surgery, or the length of the hospital stay among patients with pleural infection.

Predicting Factors for Outcome of Tube Thoracostomy in Complicated Parapneumonic Effusion or Empyema

To determine the predicting factors for outcome of tube thoracostomy in patients with complicated parapneumonic effusion (CPE) or empyema. Retrospective chart review over a 55-month period at a tertiary referred medical center. The medical charts of patients with empyema or CPE were reviewed. Data including age, gender, clinical symptoms, important underlying diseases, leukocyte count, duration of preadmission symptoms, interval from first procedure to second procedure, the time from first procedure to discharge (recovery time), the amount of effusion drained, administration of intrapleural streptokinase, chest tube size and position, loculation of pleural effusion, and characteristics and culture results of pleural effusion were recorded and compared between groups of patients with successful and failed outcome of tube thoracostomy drainage. One hundred twenty-one patients were selected for study. One hundred of these patients had received tube thoracostomy drainage with 53 successful outcomes and 47 failed outcomes of chest tube drainage. Nineteen patients received decortication directly, and the other two received antibiotics alone. Univariate analysis showed that pleural effusion leukocyte count, effusion amount, and loculation of pleural effusion were significantly related to the outcome of chest tube drainage. Multiple logistic regression analysis demonstrated that loculation and pleural effusion leukocyte count < or = 6,400/uL were the only independent predicting factors related to failure of tube thoracostomy drainage. Loculation and pleural effusion leukocyte count < or = 6,400/microL were independent predicting factors of poor outcome of tube thoracostomy drainage. These results suggest that if the initial attempt at chest tube drainage fails, early surgical intervention should be considered in good surgical candidates with loculated empyema or pleural effusion with leukocyte count < or = 6,400/microL.

Intrapleural administration of streptokinase in complicated purulent pleural effusion: a CT-guided strategy.

To determine the usefulness and the results of a strategy using intrapleural streptokinase (SK) instillation guided by repeated computed tomography (CT) scan examinations in pleural empyemas unresponsive to chest tube drainage. A retrospective chart review. The medical Intensive Care Unit and Department of Radiology, in a university hospital. Sixteen patients with empyema who had a persistent pleural effusion despite drainage, among 37 patients with infectious pleural effusion. In the 16 patients, CT examination was performed before and at least once after SK. Intrapleural SK was instilled, either through the chest tube or via a needle puncture, according to the CT scan results. The first CT scan confirmed a persistent effusion in all, showing a multiloculated effusion in 13 patients, and an ectopic loculus in one. The first SK instillation resulted in a dramatic increase of fluid drained per day (from 68 +/- 28 ml to 567 +/- 262 ml; p < 0.001), leading to complete resolution in 11 patients, while the others required a second CT scan-guided procedure. In one, the chest tube was misplaced, while in two, transparietal injection was needed. Finally, a complete resolution was observed in 14 (87.5%) of the patients. Two patients had a poor initial response to SK and were eventually scheduled for video-thoracoscopy. A single episode of chills and fever was observed among 32 SK instillations. CT-guided SK instillation in pleural empyema appears to be safe, and allowed complete resolution in 87.5% of our patients.

Intrapleural administration of streptokinase in complicated purulent pleural effusion: a CT-guided strategy

Intrapleural administration of streptokinase in complicated purulent pleural effusion: a CT-guided strategy

Early Administration of Intrapleural Streptokinase in the Treatment of Multiloculated Pleural Effusions and Pleural Empyemas

In the treatment of multiloculated pleural effusions and empyemas tube thoracostomy often fails and more aggressive surgical therapy is required. Intrapleural administration of fibrinolytics is a valuable alternative. Between October 1994 and December 1995 28 patients (aged 22 to 62 years) with multiloculated pleural effusions were treated with intrapleural instillations of streptokinase after unsuccessful conventional chest tube drainage. Twenty-three pleural effusions were grossly purulent, others were loculated effusions with low pH. The most common cause of the pleural effusions was pneumonia. Duration of illness before hospitalization was 3 to 105 (mean 21.8) days. Treatment with streptokinase was started most commonly one day after chest tube placement. Once a day after clamping the chest tube streptokinase was administered intrapleurally for 10-15 minutes as a solution of 250,000 units in 100 ml normal saline. The tube remained clamped for 3 hours. Two to 8 (mean 3.7) instillations per patient were needed. Twenty-one cases (72.4%) showed excellent resolution of pleural effusion and needed no more therapy. However, one patient died in hospital due to purulent meningitis and bilateral pneumonia. Eight patients needed further surgical treatment, e.g. decortication, in 5 cases together with wedge lung resection. Eleven patients experienced some adverse effects of streptokinase therapy, most frequently chest pain and elevation of body temperature in one case pleural effusion became hemorrhagic, and one patient had nasal bleeding. We conclude that usage of intrapleural streptokinase in the treatment of multiloculated pleural effusions (including pleural empyemas) reduces the need for major surgical interventions in quite a large group of patients.

Role of streptokinase in the treatment of acute loculated parapneumonic pleural effusions and empyema.

Intrapleural administration of streptokinase has been shown in a few small series to be effective treatment for complicated parapneumonic effusions and pleural empyemas, but techniques of instillation of streptokinase differ. The role of streptokinase in promoting drainage was investigated prospectively in a larger series of patients with complicated parapneumonic effusions and pleural empyemas. Twenty consecutive patients with parapneumonic effusions, 15 with complicated parapneumonic effusions and five with pleural empyemas, drawn from 160 patients presenting with pleural effusions were studied. The age of the patients ranged from 15 to 92 years. Initial thoracocentesis showed mean (SD) values of pH 7.1 (0.15), glucose 45.9 (17.5) mg/dl, white blood cell count 12,000 (6627)/mm3. Streptokinase was administered intrapleurally in a single daily dose of 250,000 units in 100 ml normal saline via the chest tube once the drainage was < 100 ml/24 hours. Patients were treated for 3-10 (mean 6) days. Following administration of streptokinase a clinical and radiological improvement was noted in all but one patient who died on the fourth day of hospitalisation due to widespread adenocarcinoma. Another patient with clinical but minimal radiological improvement underwent thoracotomy, but a clear pleural space with only fibrotic changes was found. The mean (SD) volume of fluid drained 24 hours before streptokinase was 42.5 (39) ml, which increased in the first 24 hours after streptokinase to 334 (130) ml. Radiological evaluation showed an excellent improvement in 14 of the 20 patients, a moderate improvement in three, and minimal improvement in the remaining three patients. One patient developed a high fever as an adverse reaction to streptokinase. All 19 patients who completed the treatment were well at follow up 6-30 months (mean 15 months) later. Intrapleural instillation of streptokinase is an effective and safe mode of treatment for complicated parapneumonic effusions and pleural empyemas and alleviates the need for thoracotomy.

Intrapleural Urokinase in the Treatment of Loculated Pleural Effusions

The purpose of this study was to assess the value of intrapleural urokinase (UK) instillations in enhancing tube drainage of loculated, complex pleural effusions. Tube thoracostomy has variable success in the treatment of complex pleural effusions, with limitations because of viscous fluid, improper tube position or kinking, and, most importantly, loculation. In the past, intrapleural administration of streptokinase has been used to lyse locules. In this study, eight patients with nine loculated pleural processes were treated with intrapleural instillations of UK. Six patients had previously undergone unsuccessful conventional tube drainage. Loculation was suggested by persistent fluid despite an adequate trial of simple drainage, radiographic demonstration of septation, or drainage of a volume of fluid far less than expected by a computed tomography scan. After instillation of a UK solution, the tubes were clamped for 30 to 180 min and then placed back to suction. Five pleural cavities with disease 6 to 18 days old showed complete resolution, and clinical improvement occurred. Three pleural processes showed improvement and one showed no improvement, with disease ranging from 23 days to 3 months. No complications were seen. These results suggest that UK instillations may enhance tube drainage of loculated pleural fluid in the early phase, before fibrosis has developed.

Intrapleurally Administered Streptokinase in the Treatment of Acute Loculated Nonpurulent Parapneumonic Effusions

Adequate pleural drainage is believed to be an essential component of the management of low pH-low glucose parapneumonic effusion. Parapneumonic effusions may become loculated rapidly, preventing adequate drainage with a single chest tube. Administration of intrapleural streptokinase may be effective in promoting drainage for loculated, nonpurulent low pH-low glucose parapneumonic effusions when fibrin adhesions may not yet be organized. Intrapleural streptokinase was used in 12 patients with relatively large, symptomatic, loculated, nonpurulent parapneumonic effusions in whom the initial thoracentesis demonstrated a pH less than or equal to 7.0 and/or glucose less than or equal to 40 mg/dl, and when inadequate drainage was demonstrated roentgenographically despite tube thoracostomy. Mean pleural fluid WBC was 9,750/mm3 (range, 1 to 27 K), and pleural fluid glucose and pH were 33 +/- 21 mg/dl and 6.95 +/- 0.19, respectively. A solution of streptokinase, 250,000 units in normal saline, was given intrapleurally via the chest tube. Effectiveness of intrapleural streptokinase was assessed radiographically and by monitoring the volume of fluid drained from the chest tube after streptokinase instillation. A greater than 50% improvement in the CXR was seen in nine of 12 patients after intrapleural administration of streptokinase. The volume of fluid out in the first 48 h post-streptokinase was 849 +/- 836 ml (range, 100 to 3,000). In addition, clinical improvement (decreased chest discomfort, less dyspnea, or reduced fever) was noted in eight of 12 patients after streptokinase treatment. We conclude that intrapleural administration of streptokinase is an effective adjunct to the management of nonpurulent, loculated parapneumonic effusions that may reduce the need for multiple chest tubes or surgical drainage.

Major Hemorrhage following Administration of Intrapleural Streptokinase

Severe spontaneous bleeding has not been reported to complicate therapy with intrapleural streptokinase (SK). Recent data have demonstrated intrapleural SK to be devoid of systemic fibrinolytic effect. This report presents a patient who suffered major hemorrhage following the administration of 500,000 units of SK intrapleurally.

REACTION TO STREPTOKINASE AND STREPTODORNASE

To the Editor: —The unusual reaction to the intrapleural administration of streptokinase and streptodornase described by Baum and Oransky inThe Journal, July 12, 1952, page 1012, has been observed although not reported previously (Miller and Long: U. S. Armed Forces M. J. 3: 1061 [July] 1952). In essence, a large amount of fluid accumulates very rapidly in the pleural cavity. An outpouring of serum is one of the local reactions to streptokinase. This influx of fluid and the liquefaction of fibrin in the pleural cavity may displace the mediastinum and cause cardiorespiratory embarrassment if the accumulated fluid is not released. The use of intercostal closed catheter drainage, in all but minimal instances of hemothorax, when streptokinase and streptodornase are injected, will prevent the reaction described by Baum and Oransky. The enzymes are dissolved in 20 cc. of sterile isotonic sodium chloride solution and injected through the catheter, which is