Intrapleural streptokinase as adjunctive treatment for persistent empyema in pediatric patients

Intrapleural streptokinase as adjunctive treatment for persistent empyema in pediatric patients. H Rosen, V Nadkarni, M Theroux, R Padman and J Klein Chest 1993;103;1190-1193 DOI 10.1378/chest.103.4.1190 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/103/4/1190

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Intrapleural Streptokinase as Adjunctive Treatment for Persistent Empyema in Pediatric Patients* Har’el Raj

Rosen,

M.D.;

Padnian,

Successful

ofpersistent

ranged

from

drainage

occurred

Intrapheural

empyema

concurrently

effusions

pediatric reported

frequency such

from

become

adjunct

to

patients

tube

failing

decortication,

chest however,

in the

pediatric

cessful

use

of

treatment

intrapleural

efficacy therapy.

and

drainage

to

become

Our

coagulation

thoracotfor those

U/kg

tively

reviewed. the

All

patients

Department

did

The

1/1.5

chest

suc-

toms

of streptokinase is described

in

significantly

Patients

repeated

Plasma

of

Confirmation

STR

B, US

3

value for

pain,

and

and

in radiographic

Table

1 summarizes

pediatric months

empyema to 7

ofPatient

i-Summary

STR

Dose,

Average

years.

clinical

and

1190

US

ultrasound;

U!kg

Tube Pre-STR 4

91,000

Discharge

12

20

Clinical Outcome

Outcome Moderate

PT:

R, US

4

12,300

6

13

26

Mild

PT: 3 mo

2

18,600

6

8

10

Mild

PT:

tomography;

five

from 18 improve-

Radiographic

Out

PT:

computed

status

Chest

Daily,

Mild

Cl’

Charts of chest

on

ranged rapid

3 mo

3 wk 3 mo

Normal

3 mo

and

3 wk

STR

streptokinase;

FT

pleural

Intrapleural

thickening;

Streptokinase

PE

-

2 mo

PE

activity:

Normal

physical

PE

activity:

Normal

for Persistent

Downloaded from chestjournal.chestpubs.org by guest on July 14, 2011 © 1993 American College of Chest Physicians

activity:

Normal

2 wk

PE

and activity: Normal PE

and radiograph;

strepto-

clinical

and

CR =

after

obtained.

Day

19

CT

protocol

Data*

13

R, US,

daily symp-

improved.

information

5

None

The

volume

patients. Ages They experienced

14,300

5/7.0

next and

empyema

and + cocci

5 at

RESULTS

3

Gram

over

with

of Delaware

US

4/4.5

signs

findings,

Normal:

B,

sterile

tube

complications.

2i

S pneumoniae

for

characteristics,

bleeding

with

Continuous the

were

as

is rotated

until

before

14

3/3.5

patient

bleeding.

until

radiographs

demographic

chest

pattern.

H20

measured

chest

improvement

treatment,

cm

5 days)

was

serial

the

monitored

wall

was to 136,000

volume

via the

8

B

in all

of normal

U (12,300

distribution 20

-

clinically

chest

and

drainage,

the

(maximum

hemoglobin analyzed

space

15,800

Gram

empyema

to) 50-ml

5

2.12.5

thorasurgical

streptokinase

for 2 h and

at

were

daily

treatment

during

retrospec-

then

of anaphylaxis,

was

tube

Center

and for

documentation

to 1,500,000 diluted

is clamped

instillation.

Doses

+ cocci

tube

the

improve

103:1190-93)

candidates

and

intrapleural

report,

Radiographic

None

the

this

H ospital

Organism

into

In

No. yr

200,000

to improve

.

Age,

Instill

resumed

Medical

1993;

of intrapheural

ofstreptokinase

is

not

therapeutic

confirmed

analgesic

intervals

Table

No.!

use

15-mm

of Pediatrics,

of

streptokinase

antibiotics

considered

examination

with

suction

(Drs. Rosen and Nadkarni), and the A. I. duPont Institute (Drs. Theroux, Padman, and Klein), Wilmington, Del. Manuscript received May 8, revision accepted August 5. Reprint requests: Dr Nadkarni, Pediatric Critical Care, Medical Center ofDelaware, Newark, Delaware 19718

Case

dose)

solution

mm.

to

for the

status.

per

saline

METHODS

*Fro)m

fluid

pretreatment

antibiotic

were

long-term

intravenous

all were

Pleural

protocol

follows:

Alternatives

empyema

the

of intrapleural

including and

explored

of persistent

drainage

patients.

kinase

cases

therapy,

costomy decortication.

patients.

consecutive

assess

(Chest

widely

empyemas

to facilitate

small number of pediatric employed. Additional study

consequences

conventional

were

Five

to further

been

instillation

persistent

required

not

population. for

five pediatric

of

and via open therapy

drainage.3’5

have

a

or progress

thoracentesis

decortication mainstay

of with

may

it has

in whom

be

tool the been

in

a

21 to 91 percent.”2

thoracostomy

therapy. In children, omy has been the

to be

complication

loculated

tube

will

therapeutic

empyema

patients

improvement.

occurring

adjunctive

persistent

empyemas chest tube

appears

a common

ranging

formation,

a necessary

clinical

pneumonias

effusions

empyema

with

are

M.D.;

safe

patients. Their All experienced

of streptokinase

bacterial

Theroux,

by intrapleural

in the resolution of their streptokinase. Improved

instillation

P leural

Mary

M.D.

in five pediatric i8 months to 7 years.

improvement intrapleural

as

M.D.;

Klein,

is described

dramatic following

When

Nadkarni,

andJoel

treatment

streptokinase ages

Vinay

M.D.;

2 mo

PE

activity:

2 wk

examination.

Empyema

(Rosen

et a!)

VOLUME

OF DRAINAGE

(ml) ** * *

400 * *

300 *

200 * *

100

*

0

*Sfr.o:ejflfUSed

DAY

S 1. Chest

FIGURE

ment

of their

tokinase. drainage

tube

empyema

Figure

Concurrently,

drainage

patients

in

markedly

is no

accepted

intrapleural

standard

streptokinase

The 18-month-old to be treated

None tion, after

of the

wall

pyretics phen,

patients

with

discomfort

of physical of activity

CASE5

streptokinase.

tube

infusion.

improved

clini-

for

10).

dose), Since

administration

pediatric

of

patient,

the

patient is the youngest intrapleural streptokinase.

experienced

were

clinical

during or fever and

managed

with

and analgesics All patients

examinations at follow-up

and (Fig

re-

deteriora-

or anaphylaxis Transient easily

(acetaminophen) low-dose narcotics).

results levels

of intrapleural

J

5

Representative chest in Figure 2 (prestrep-

in the

bleeding complications, streptokinase treatment.

chest

CASE4

4

, duration of chest clamping, and varied and were chosen empiri-

dose of streptokinase patient positioning catty. ported

3

strep-

chest

tokinase), Figure 3 (after second streptokinase and Figure 4 (on discharge, hospital day there

to dosing

intrapleural

to streptokinase

cally following streptokinase. radiographs for case 5 are shown

CASE3

in relation

changes

in relation all

volume

following

1 depicts

volume

#{149} CASE2

CASEI

2

anti-

(acetaminohad normal age-appropriate

1-4).

DISCUsSIoN

Streptokinase is a purified proteolytic duced from a bacterial protein ofgroup streptococci. Streptokinase converts plasmin, degrades

.

.

an enzyme

with

fibrin

as well

clots

proteolytic

.

enzyme proC 3-hemoIytic plasminogen to .

activity.

as fibrinogen.6

.

Plasmm

.

FIGURE

after

2. Chest radiograph 6 days of thoracostomv

ultrasound

and

computed

of 7-year-old patient drainage. Loculations

with

empvema

co)Ilfirmed

Iw

tornograph:

CHEST

I 103

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I 4 I APRIL,

1993

1191

A FIcuRF

3. Chest

radiograph streptokinase

intrapheural

The pleural and

patient

Sporadic

case

description,

but

two

to liquify in 1949

reports

these

after

doses

of

4. Chest discharge improved.

FIGURE

hospital markedly

use of fibrinolytic enzymes exudates was first reported

Sherry.7

initial

of the same (2 days later).

have

have

fibrinous by Tillett

followed

rarely

the

involved

pediatric patients.812 Fraedrich et al’#{176} reported successful resolution of empyemas in 44 percent of a series of 27 patients of various ages treated with intrapleural streptokinase. The patients’ ages ranged

case case

report report

been

described

consideration or thrombolytic

urokinase

and

tissue

plasminogen

agents

activator)

has

(eg, not

as the

infection

of such

is consistent with current theory that streptokinase “dissolves” locutations and septations permitting the free flow of pleural fluid.6’7 However, an alternative

patients pediatric surgical

decortication

explanation

result

in significant

and

could

pleura.

children

be

of further

The

tends

rapid

to support

Serious side effects, have not been described streptokinase infusion, 1192

that fluid

streptokinase by local action

clinical

the

induces on the

improvement

former

the lung

in these

explanation.

such as spontaneous as resulting from with the exception

bleeding, intrapleural of a single

for allergic

Intrapleural

and less

emotionally. than $50

pleural hundred

per

previous

however,

no the

strepto-

is an important fibrinolytic thus may be

reactions.

of streptokinase therapeutic empyema

The patient 250,000-U

study therapeutic

Intrapleural

Although patients,

appears

to

tool to facilitate in the few pediatric

it has been employed. Its use in considered possible candidates for may reduce their morbidity and medical cost savings, financially

streptokinase dollars.

Additional immediate

of both

or anaphylactic

in whom patients

that factors

antibody formation antibodies have

who may require later in life, and

instillation

be a safe adjunctive drainage of persistent

of

systemic thrombolytic strepextent to which intrapleural the production of antistreptoyet to be determined. The

antibodies,

for a patient therapy

at risk

Our

production

to bleeding. seen in our

result

of tokinase 4 The streptokinase results in kinase antibodies has formation

and

described. data demonstrate that instillation of streptokinase dramatically increases the volume of chest tube drainage concurrent with clinical improvement. This

been

However, predisposing

possibility of antistreptokinase must be considered. Antistreptokinase

of empyema

fibrinolytic

and multiple

that may have contributed serious complications were

coccal

alternative

of the same patient at the time later). Results o)f physical examinations activity level and respiratory rate.

by Godley indicated

from 9 years to 73 years, but the number of pediatric patients tinder study was not specified. Lysy et al described resolution of a parapneumonic effusion in a 4-year-old girl with pneumococcal pneumonia using streptokinase infusion. To our knowledge, treatment using

radiograph (2 days Normal

would

cost dose

A course

therefore

is needed

to

efficacy

Streptokinase

of streptokinase .

total

further

of intrapleural

for Persistent

Downloaded from chestjournal.chestpubs.org by guest on July 14, 2011 © 1993 American College of Chest Physicians

Empyema

is

of intra-

several

assess

the strep-

(Rosen

at a!)

tokinase

in the

long-term

pediatric

effects

approach.

population,

and

possible

Likewise,

the

The

authors

duration

the

to

Invest

BJ, Kusmiesz

monic

effusions

review

spective 2 Taryle

DA,

correlates monia.

Chest R,

Murry

Pediatr

Sahn

SA.

effusions

McCracken

GH.

Infect The

Dis

ii

clinical

G,

Warden

H,

Hill

empyemas

R.

in children.

Role

of

Ann

12

lung

5 Golladay

ES,

Am J Surg VJ,

empyema.

Fraedrich

G,

Henke

R, Pietsch

J,

Holcomb

Wagner

CW.

Management

ofempyema

G,

selecting

Sheller

13 14

in children.

Godley

Hofmann

therapy:

current

D,

Surg

M, Alberts

1982;

WM,

C,

J Chin

exudations. M.

empyema.

Use

A, Reifen in the

Am BC.

of

R, Dudai

treatment

of

25:284-87 P, Jarder

R. Instillation

of pleural

empyema.

30:36-8 K, Goldman

A. Intrapleural

J Fla

effusions.

76:1019-33

J.

treatment

P, Bell

Foreman ofthoracic

of parapneumonic

Leatherman

effusions.

G,

treatment

Chandler

management

in the

Reisz treatment

Efferhauser

in the

Intrapleurally

of acute Rev Major

Spottl

F, Kaiser

streptokinase-antibodies.

R. Rapid

administered

streptoki-

nonpurulent

parapneu-

loculated

Respir

Dis

1992;

hemorrhage

streptokinase.

tating 1974;

S. Thrombolytic

pleural

A, Werczberger

enzymes

of intrapleural

appro-

159:6i8-21

Sherry

J,

of streptococcal deoxyribonuclease

of streptokinase Isr J Med Sci 1989;

Cardiovasc

Mitchell

monic

W, Heller

1989;

instillation

nase

Thorac

patients

300:196-200

M . Intrapleural organizing

G, in the

A, Lieberson

streptokinase

pneu-

1990;

Med Assoc 1989;

et al. Postpneumonic empyema in childhood: priate therapy. J Pediatr Surg i989; 24:659-64

6 Marder

and

in pneumonococcal

in

streptococcal

sanguinous

Saizman

V, Gavish

Thorac

3:578-91

49:940-47

5, Neblett

J Med Sci

of fibrinolytic

a retro-

1984;

incidence

10

Parapneu-

children:

and

5,

74:170-73

in symptomatic

1990;

JD,

in hospitalized

cases.

DE,

1978;

decortication Surg

of227

Potts

Nelson

empyema

of parapneumonic

3 Gustafson

4 Hoff

H,

purulent,

streptokinase

Am

effect and

1949; 28: 173-90

9 Lysy

and

S. The

(streptokinase)

intrapleural as-

Purse.

3i8:1512-20

8 Willsie-Ediger

REFERENCES 1 Freij

1988; Sherry

on fibnnous,

yet

editorial

WS,

fibrinohysin

dosing

has

appreciate

7 Tillett

of this

of dose,

clamp

J Med

N EngI

as the

complications

importance

interval, positioning, and be systematically evaluated. ACKNOWLEDGMENT: sistance of Natalie

as well

Chest detection

145:680-84

following 1984;

administration

86:486-87

and

quantitation

Throbos

Diathes

of precipiHaemorrh

32:608-16

status.

CHEST

I 103

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I 4 I APRIL,

1993

1193

Intrapleural streptokinase as adjunctive treatment for persistent empyema in pediatric patients. H Rosen, V Nadkarni, M Theroux, R Padman and J Klein Chest 1993;103; 1190-1193 DOI 10.1378/chest.103.4.1190 This information is current as of July 14, 2011 Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/103/4/1190 Cited Bys This article has been cited by 15 HighWire-hosted articles: http://chestjournal.chestpubs.org/content/103/4/1190#related-urls Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.

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