Lytic Therapy for Retained Traumatic Hemothorax

Hendriksen, Brandon S.; Kuroki, Marcos T.; Armen, Scott B.; Reed, Michael F.; Taylor, Matthew D.; Hollenbeak, Christopher S.

doi:10.1016/j.chest.2019.01.007

Cited by 30 publications

(19 citation statements)

References 22 publications

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“…Similarly, IPFT when compared to VATS has been shown to be inferior in the management of traumatic retained haemothorax in one study [14], and of similar efficacy in another [13,15]. While a recent meta-analysis concluded that the use of IPFT in traumatic retained haemothorax resulted in 81-92% of patients being discharged without further surgical intervention, the authors acknowledged the limited number and poor quality of studies included [16]. Due to limited data on non-traumatic haemothorax, management approaches have been derived from traumatic haemothorax.…”

Section: Discussionmentioning

confidence: 99%

Intrapleural fibrinolysis in acute non‐traumatic retained haemothorax

Foo

Herre

2021

Respirology Case Reports

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Haemothorax is an accumulation of blood in the pleural space. Retained haemothorax refers to blood that cannot be drained from the pleural cavity and is associated with an increased risk of empyema and fibrothorax often necessitating surgical evacuation. We describe our experience of using intrapleural fibrinolytic therapy in three patients with different bleeding risk and acute non‐traumatic retained haemothorax. The first was a 41‐year‐old female with disseminated Candida guilliermondii sepsis and an iatrogenic haemothorax, second was a 48‐year‐old female with transfusion‐dependent acute myeloid leukaemia and spontaneous haemothorax, and the third was a 72‐year‐old female with spontaneous haemothorax from newly diagnosed lung cancer. All patients received one to two doses of intrapleural alteplase without any bleeding complications and resolution of retained haemothorax. This case series demonstrates the successful application and safety of this approach as an alternative to surgery in a well‐resourced environment with close monitoring and ready access to blood transfusion.

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Section: Discussionmentioning

confidence: 99%

Intrapleural fibrinolysis in acute non‐traumatic retained haemothorax

Foo

Herre

2021

Respirology Case Reports

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“…[19][20][21][22][23][24] Based on the literature reviewed, we recommend higher dosing strategies and volumes-25 to 50 mg of alteplase in 50 to 100 mL of normal saline-than are currently utilized for other indications. [19][20][21][22][23][24]32 Intrapleural alteplase may also be a reasonable option for patients beyond the optimal time window for VATS. Future studies are needed to determine the optimal dosing regimen and administration technique of intrapleural alteplase for retained hemothorax.…”

Section: Resultsmentioning

confidence: 99%

“…A meta-analysis was recently published on fibrinolytic therapy for retained traumatic hemothorax. 32 A subgroup including 2 of the aforementioned studies 19,23 as well as an abstract 33 demonstrate an operative avoidance rate of 83% (95% CI = 71%-94%) in 39 patients.…”

Section: Dosing Strategies and Efficacymentioning

confidence: 99%

Intrapleural Tissue Plasminogen Activator for Traumatic Retained Hemothorax

et al. 2019

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Objective: To describe the efficacy, safety, dosing regimen, and administration technique of intrapleural alteplase for the treatment of retained hemothorax. Data Sources: A PubMed, EMBASE, and Google Scholar search (January 2000 to February 2019) was conducted with the search terms intrapleural, fibrinolytic, fibrinolysis, alteplase, tissue plasminogen activator, and hemothorax. Study Selection and Data Extraction: Articles were included if they described the use of intrapleural alteplase in adult patients with a retained hemothorax; single patient case reports and abstracts were excluded. Data Synthesis: A total of 6 retrospective reviews and 1 meta-analysis were identified for inclusion. A variety of dosing strategies have been defined for the administration of intrapleural alteplase ranging from 6 to 100 mg, volume of fluid from 50 to 120 mL of normal saline, and the number of total doses has ranged from 1 to 8 over the treatment course. A majority of studies showed a greater than 80% success rate and less than 7% bleeding rate. Relevance to Patient Care and Clinical Practice: Because of the paucity of data for use of alteplase in retained hemothorax and administration of a high-risk medication, this review provides dosing and administration recommendations based on reported safety and efficacy. Conclusion: Administration of intrapleural alteplase should be considered in patients with retained hemothorax as an alternative to surgical intervention. In contrast to intrapleural alteplase administration for other indications such as empyema, higher doses and volumes of alteplase are recommended for retained hemothorax.

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“…In a review by Hendriksen et al, lytic therapy led to avoidance of surgery in 87% of cases. 18 Also, intrapleural alteplase showed 80% success rate with 7% bleeding rate, with higher doses and volumes required for retained hemothorax. 19 However, in a retrospective study comparing use of streptokinase to VATS for evacuation of retained hemothorax, eight out of 31 cases in which streptokinase was used, failed to show complete radiological improvement and three cases developed empyema, whereas, only four out of 34 patients who underwent VATS showed incomplete radiological improvement and there was no empyema.…”

Section: Managementmentioning

confidence: 93%

Traumatic retained hemothorax: is it time for video assisted thoracoscopic surgery

et al. 2020

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Thoracic trauma is a significant cause of morbidity and mortality, if not treated promptly. 80% to 85% of chest injuries can be treated with chest tube insertion alone. However, in about four to 20% of population, there is incomplete clearance of hemothorax following tube insertion and can lead to a condition called retained hemothorax. The purpose of this review is to establish the role and effectiveness of Video assisted thoracoscopic surgery (VATS) in successful evacuation of retained hemothorax following blunt thoracic trauma. Relevant articles from databases like Pubmed, Google scholar, Medline and Cochrane library were included. A retained hemothorax is defined as the persistence of residual clots in the pleural cavity, which is radiologically evident, 72 hours following initial tube thoracostomy. The various options to manage this condition include observation, insertion of second thoracostomy tube, intrapleural fibrinolytic, VATS or thoracotomy. Based on review of existing studies, VATS evacuation was found to have shorter hospital stay, lesser costs and shorter duration of tube drainage. There was also lesser rate of conversion to thoracotomy as compared to other methods and fewer complications like fibrothorax and empyema. In hemodynamically unstable patients, which is a contraindication to VATS, use of intrapleural fibrinolytics like streptokinase may be considered as an alternative option to provide clearance of the retained hemothorax. Retained hemothorax, when encountered following thoracic trauma, can be effectively managed by VATS. The decision to use VATS for hemothorax evacuation should be made promptly for maximum results, especially within three to seven days following trauma.

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Lytic Therapy for Retained Traumatic Hemothorax

Cited by 30 publications

References 22 publications

Intrapleural fibrinolysis in acute non‐traumatic retained haemothorax

Intrapleural fibrinolysis in acute non‐traumatic retained haemothorax

Intrapleural Tissue Plasminogen Activator for Traumatic Retained Hemothorax

Traumatic retained hemothorax: is it time for video assisted thoracoscopic surgery

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