The use of fibrinolytic therapy for parapneumonic effusion in pregnancy: a case report and a review

The use of intrapleural fibrinolytics for complicated parapneumonic effusion has been shown to be an effective and safe alternative to surgery. However, there is limited evidence about its use during pregnancy. We present a case and a review of the literature of pregnant women who had successful treatment of their complicated parapneumonic effusion with intrapleural fibrinolytics. To our knowledge this is the first review of cases of pregnant women with parapneumonic effusion managed with intrapleural fibrinolytic.

Management of thoracic empyema in children: a survey of the Australia and New Zealand Association of Paediatric Surgeons (ANZAPS)

PURPOSE

To define the spectrum of management for thoracic empyema in children in Australia and New Zealand.

METHODS

Online survey of members of the Australian and New Zealand Association of Paediatric Surgeons (ANZAPS), limited to consultant/attending paediatric surgeons.

RESULTS

A total of 54/80 (67.5%) members, from 16 paediatric surgical centres, responded. The majority (33/54, 61%) preferred chest drain with fibrinolytics, whilst 21/54 (39%) preferred video-assisted thoracoscopic surgery (VATS) with drain insertion. Urokinase was the most commonly used fibrinolytic (64%). There were no significant differences in management preferences between practising surgeons in Australia and New Zealand (p = 0.54), nor between consultants who had been practising a shorter (< 5 years) or longer (> 20 years) amount of time (p = 0.21). The practices described by the surveyed ANZAPS members were in line with the Thoracic Society of Australia and New Zealand recommendations for the management of paediatric empyema.

CONCLUSION

Across Australia and New Zealand there exists significant variation surrounding the intra- and post-intervention management of thoracic empyema in children. The surveyed paediatric surgeons demonstrated a preference for fibrinolytics over the use of VATS. All management regimens were within published local guidelines.

Use of fibrinolytics for the management of massive pulmonary embolism in a patient with a history of subdural hemorrhage

INTRODUCTION

Management of massive pulmonary embolism in patients with hemodynamic instability encompasses the use of fibrinolytics. Use of fibrinolytic therapy is currently recommended in this patient population by ACCP, AHA, and EHA if treatment benefit outweighs the risk of bleeding. There is currently no data challenging or exploring the risk of using fibrinolytic therapy for the management of massive PE in patients with a history of intracranial hemorrhage.

CASE PRESENTATION

A 38-year old female with suspected massive pulmonary embolism was admitted with a chief complaint of chest pain and right leg pain. Shortly after a confirmatory CT of bilateral PE, the patient had multiple cardiac arrests along with severe shock that led to a general agreement among the team to proceed with IV and then catheter-directed TPA as well as thrombectomy. Following fibrinolytic therapy, the patient was started on a heparin drip along with epinephrine for hemodynamic support. CT chest angiography showed the resolution of emboli following treatment with the fibrinolytic agent. CT of the head taken approximately 24 h post tPA initiation was used to rule out intracranial hemorrhage or other complications resulting from tPA administration.

CONCLUSION

In patients with a history of intracranial hemorrhage, catheter guided fibrinolytic and thrombectomy may be effective treatment options of massive pulmonary embolism.

Pediatric empyemas - Has the pendulum swung too far?

BACKGROUND

The management of childhood empyemas has transformed over the past decade, with current trends favoring chest tube placement and intrapleural fibrinolytic therapy. Although this strategy often avoids the need for video-assisted thoracoscopic surgery (VATS), hospital length of stay can be long.

METHODS

To characterize national trends and outcomes associated with empyema management, the Pediatric Health Information System (PHIS) database was queried to identify children (2 months-18 years) treated for an empyema between January 2010 and December 2017. The cohort was divided into those treated with primary VATS and those treated with chest tube and intrapleural fibrinolysis. Number of chest radiographic studies obtained, frequency of pediatric intensive care unit (PICU) admission, mechanical ventilation requirements, and length of hospitalization were compared between groups.

RESULTS

A total of 3,365 otherwise healthy children met inclusion criteria. Among them, 523 (16%) were managed with primary VATS and 2,842 (84%) were managed with chest tube and fibrinolytic therapy. Of those who were treated with chest tube and fibrinolysis, 193 (6.8%) subsequently underwent VATS. The percentage of children treated with chest tube and fibrinolysis increased from 65% in 2010 to 95% in 2017 (p<0.001). After adjusting for age, race, ethnicity, payer, and region, children who underwent primary VATS received fewer chest radiographic studies, were less likely to be admitted to the PICU or require mechanical ventilation and had a shorter PICU and hospital length of stay compared to those who were treated with chest tube and fibrinolytic therapy (p<0.001 for all analyses).

DISCUSSION

Although national trends favor chest tube and fibrinolysis, primary VATS are associated with a shorter hospital and PICU length of stay and a lower requirement for mechanical ventilation. Future studies should aim to risk stratify children who may suffer from a protracted course with the goal to offer primary VATS to this subset of children and return them to normal life more expeditiously.

LEVEL OF EVIDENCE

III.

Treatment of ST-Segment Elevation Myocardial Infarction During COVID-19 Pandemic

The number of cases of the coronavirus-induced disease-2019 (COVID-19) continues to increase exponentially worldwide. In this crisis situation, the management of ST-segment elevation myocardial infarction (STEMI) is challenging. In this review, we outline the risks and benefits of primary PCI vs. thrombolysis for STEMI. While thrombolysis may seem like a good choice, many patients have a contraindication and could end up using more resources. Also, with a high probability of the angiogram showing non-obstructed coronary arteries during acute infections, primary PCI should be the preferred strategy.

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During the COVID-19 pandemic, management of STSTEMI is challenging.

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Many patients have a contraindication to thrombolysis and end up using resources with this treatment.

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There is a high probability that an infected patient will show a normal angiogram.

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Primary PCI should be the preferred strategy in STEMI patients, with precautions.

Role of Intrapleural Urokinase in Empyema Thoracis

OBJECTIVE

To study the role of fibrinolytic therapy in pediatric empyema in relation to duration of hospital stay, need for surgical intervention and survival to discharge.

METHODS

Retrospective analysis of case records of children <16 y of age admitted in a tertiary care hospital during January 2013 - December 2017 with diagnosis as empyema thoracis was done. Clinico-laboratory characteristics and the primary and secondary outcomes between the group which received intrapleural urokinase (IPU) and the group which did not (non IPU), were compared.

RESULTS

Of the 84 cases, 40 children received IPU. Mean duration of hospital stay in IPU group (17.51 + 4.57 d) was significantly less than non IPU group (24.32 + 10.18 d, CI -10.19 to -3.64, p < 0.001), so was the duration of intercostal drain (ICD) insertion (9.08 + 3.12 d - IPU group vs. 11.20 + 3.95 d - non IPU group, CI -3.68 to -0.50, p < 0.01). No statistically significant difference was found between the groups with regard to need for surgical intervention [IPU - 4 (10%), non IPU - 9 (20.4%), p = 0.23]. There was no mortality or adverse reaction to urokinase in either group.

CONCLUSIONS

IPU holds promising results in terms of reduction of hospital stay and duration of ICD insertion. It may be the initial choice of treatment in septated empyema where surgical options are not easily available or cost-effective especially in resource limited settings.

Tenecteplase utility in acute ischemic stroke patients: A clinical review of current evidence

INTRODUCTION

Acute ischemic stroke is a leading cause of disability in the United States. Treatment is aimed at reducing impact of cerebral clot burden and life-long disability. Traditional fibrinolytic treatment with recombinant tissue plasminogen activator (tPA) has shown to be effective but at high risk of major bleeding. Multiple studies have evaluated tenecteplase as an alternative to tPA.

OBJECTIVE

This review evaluates literature and utility of tenecteplase for treatment of acute ischemic stroke.

DISCUSSION

Tenecteplase is modified, third generation fibrinolytic with greater specificity for fibrin bound clots. Current data in acute myocardial infarction suggest decreased bleeding events compared to alteplase. Multiple trials have investigated superiority of tenecteplase compared to tPA for treatment of acute ischemic stroke. Current guidelines designate tenecteplase as an alternative treatment for mild acute ischemic stroke patients based on recent literature.

CONCLUSION

Recent emerging literature and limited recommendation guidance from governing medical societies leave many emergency medicine providers to weigh benefit versus risk of fibrinolytic therapy and tenecteplase's place in therapy. This review evaluates the available literature regarding tenecteplase and its utility in the treatment of acute ischemic stroke patients.

Local Fibrinolytic Therapy for Intraventricular Hemorrhage: A Meta-Analysis of Randomized Controlled trials

BACKGROUND

The safety and efficacy of intraventricular fibrinolysis (IVF) in patients with intraventricular hemorrhage (IVH) are unclear. We aimed to determine these issues and to evaluate whether there are differences between recombinant tissue-plasminogen activator (rt-PA) and urokinase according to subgroup analyses.

METHODS

A meta-analysis was undertaken of randomized controlled trials in patients with IVH that compared the administration of rt-PA or urokinase through extraventricular drainage (EVD) with normal saline through EVD or EVD placement alone.

RESULTS

Six randomized controlled trials involving 607 patients with IVH were included; 2 trials investigated urokinase and 4 rt-PA. IVF reduced death from any cause at the end of follow-up (risk ratio [RR] 0.63, 95% confidence interval [CI] 0.47-0.83), which was driven mostly by rt-PA (RR 0.65, 95% CI 0.48-0.86). Urokinase did not reduce mortality (RR 0.30, 95% CI 0.06-1.53). However, rt-PA did not reduce the proportion of survivors with poor functional outcome (RR 1.36, 95% CI 1.04-1.77), or the composite endpoint of death and poor functional outcome (RR 0.96, 95% CI 0.83-1.11). IVF neither reduced the need for shunt placement (RR 1.06, 95% CI 0.75-1.49) nor increased ventriculitis (RR 0.57, 95% CI 0.35-0.93) and rebleeding (RR 1.65, 95% CI 0.79-3.45).

CONCLUSIONS

Although the use of IVF in patients with IVH appears generally safe, its benefit is limited to a reduction in mortality at the expense of an increased number of survivors with moderately-severe to severe disability. Subgroup analyses do not suggest an advantage of IVF with urokinase over rt-PA.

Trends in treatment of infectious parapneumonic effusions in U.S. children's hospitals, 2004-2014

PURPOSE

The purpose of this study was to examine trends in the treatment of patients with infectious parapneumonic effusions in U.S. children's hospitals over the past decade.

METHODS

The PHIS database was queried for patients younger than 18years old with pneumonia and pleural effusion in three yearlong periods over the past decade. Variables included age, gender, payer, race/ethnicity, hospital region, hospital type, markers of illness severity, and treatment group (antibiotics alone, chest tube thoracostomy±thrombolytics, video-assisted thoracoscopy (VATS), or thoracotomy).

RESULTS

5569 patients were included in the final analysis. The proportion of patients treated with antibiotics alone increased from 62% to 74% from 2004 to 2014 (p<0.001). Among patients requiring pleural space drainage, the frequency of VATS peaked in 2009 (50.8%), dropping to 36.4% in 2014 (p<0.001), while tube thoracostomy, usually with fibrinolytics, rose from 39.0% in 2009 to 53.2% in 2014 (p<0.001).

CONCLUSION

In a select cohort of free-standing, tertiary care U.S. children's hospitals, antibiotic administration alone remains the most common treatment approach to infectious parapneumonic effusions. VATS treatment for those patients requiring pleural space drainage is being gradually supplanted by thoracostomy tube placement with instillation of fibrinolytics.

Are some children with empyema at risk for treatment failure with fibrinolytics? A multicenter cohort study

BACKGROUND

Guidelines recommend that children with empyema be treated initially with chest tube insertion and intrapleural fibrinolytics. Some patients have poor outcomes with this approach, and it is unclear which factors are associated with treatment failure.

METHODS

Possible risk factors were identified through a review of the literature. Treatment failure was defined as need for repeat pleural drainage and/or total length of stay greater than 2weeks.

RESULTS

We retrospectively identified 314 children with empyema treated with fibrinolytics at The Hospital for Sick Children (2000-2013, n=195), Children's Hospital, London Health Sciences Centre (2009-2013, n=39), and McMaster Children's Hospital (2007-2014, n=80). Median length of stay was 11days (range 5-69days). Thirteen percent of children required repeat drainage procedures, and 34% experienced treatment failure. There were no deaths. White blood cell count, erythrocyte sedimentation rate, C-reactive protein, albumin, urea to creatinine ratio, and signs of necrosis on initial chest x-ray were not associated with treatment failure. Multivariable logistic regression demonstrated increased risk with positive blood culture (odds ratio=2.7), immediate admission to intensive care (odds ratio=2.6), and absence of complex septations on baseline ultrasound (odds ratio=2.1). Male gender and platelet count were associated with treatment failure in the univariate analysis but not in the multivariable model.

CONCLUSIONS

Predicting which children with empyema are at risk for treatment failure with fibrinolytics remains challenging. Risk factors include positive blood culture, immediate admission to intensive care, and absence of complex septations on ultrasound. Routine blood work and inflammatory markers have little prognostic value.

[The management of complicated parapneumonic effusions in France]

INTRODUCTION

There are no French guidelines for the management of complicated parapneumonic effusions. A national observational study was carried out to assess the main features of current clinical practice for this condition.

MATERIAL AND METHODS

A questionnaire was sent by email to the 1500 members of the Société de Pneumologie de Langue Française (SPLF) between 15th November and 15th December 2012.

RESULTS

There were 92 responders, i.e. a response rate of 6%. Of these, 87 physicians mentioned that they were involved in the management of patients with complicated parapneumonic effusions with a median number of cases of 10 per year (IQR: 5-20). Chest tube drainage was the main approach used for pleural fluid aspiration (n=51/87), followed by repeated thoracentesis (n=29/87) and early surgery (1/87). Five physicians answered both chest tube drainage or repeated thoracentesis and one physician either chest tube drainage or early surgery. Pleural fibrinolytics were never used by 20% of physicians, only in case of loculations by 70% and by 10% of respondents in all cases. Only 3 physicians combined fibrinolytics with DNAse. A double antibiotic dose was used by one third of physicians. All the physicians used respiratory physiotherapy during hospitalization and to aid recovery. Follow-up practices were heterogeneous.

CONCLUSIONS

The management of complicated parapneumonic effusions varies significantly in France. National guidelines may be helpful to define best practice and aid in its implementation.

Newer Pharmaceutical Agents for STEMI Interventions

ST-elevation myocardial infarction (STEMI) causes 12.6% of deaths worldwide. Treatment strategies involve early revascularization by percutaneous coronary intervention and/or fibrinolytics, with adjunctive pharmacologic therapy. While antiplatelet therapy remains the cornerstone of pharmacologic management, newer antithrombotic therapies are showing benefit in the reduction of long-term thrombotic events following acute vessel occlusion. Future directions in adjunctive STEMI management include the use of hematopoietic stem cell therapy or growth factors to induce proliferation and differentiation of cardiac myocytes.

Paediatric complicated pneumonia: Diagnosis and management of empyema

Pneumonia can be complicated by an empyema, progressing from an exudative effusion, to a fibrinopurulent stage with loculations, and then organized with a thick fibrinous peel. The predominant causative organisms are Streptococcus pneumoniae, Staphyloccocus aureus (including methicillin-resistant S aureus) and Streptococcus pyogenes. Recently, an increased incidence of paediatric complicated pneumonia has been reported. For diagnostic imaging, a chest radiograph followed by a chest ultrasound is preferred. Computed tomography chest scans, with associated radiation, should not be routinely used. Antibiotic coverage should treat the most common causative organisms. Additional invasive or surgical management is recommended to reduce the duration of illness in cases not promptly responding to antibiotics or with significant respiratory compromise. Choice of management should be guided by best evidence and local expertise. Video-assisted thorascopic surgery or insertion of a small-bore percutaneous chest tube with instillation of fibrinolytics are the best current options.