Urokinase in the Management of Complicated Parapneumonic Effusions in Children

Krishnan, Sankaran; Amin, Nikhil; Dozor, Allen J.; Stringel, Gustavo

doi:10.1378/chest.112.6.1579

Cited by 92 publications

(61 citation statements)

References 18 publications

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“…Our review of the literature reveals only a few case reports in which urokinase fibrinolytic therapy was used in the management of complicated pleural effusions in children, 12 and as far as we can tell, ours is the first case in which t-PA (alteplase) was used in the management of a complicated parapneumonic effusion in a pediatric patient. Given the ease of application, apparent safety, and the lack of appreciable side effects, intrapleural t-PA offers a promising treatment alternative in the management of this difficult problem.…”

Section: Discussionmentioning

confidence: 84%

Alteplase in the Treatment of Complicated Parapneumonic Effusion: A Case Report

Bishop¹,

Pon²,

Ushay³

et al. 2003

Pediatrics

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Section: Discussionmentioning

confidence: 84%

Alteplase in the Treatment of Complicated Parapneumonic Effusion: A Case Report

Bishop¹,

Pon²,

Ushay³

et al. 2003

Pediatrics

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“…A grande discussão sobre o uso de fibrinolíticos como tratamento adjuvante em crianças com empiema, é que este tipo de abordagem requer prolongado tempo de internação e tem significativos índices de ineficácia 39 . Associado a isso, não há estudo prospectivo randomizado comparando o uso de fibrinolíticos com outros métodos de tratamento do derrame parapneumônico complicado na criança.…”

Section: Enzimas Intrapleuraisunclassified

Abordagem cirúrgica da efusão pleural parapneumônica e suas complicações

Fraga¹,

Kim

2002

J. Pediatr. (Rio J.)

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Objective: surgical treatment of parapneumonic pleural effusion in children is controversial. The type of intervention is based mainly on personal experience and on the small number of reported cases. This article aims at presenting a literature review and the authors' experience in the surgical management of parapneumonic pleural effusion in children.Sources: data were searched in the Medline and Lilacs databases.Summary of the findings: complicated parapneumonic effusion should be surgically drained if thoracentesis reveals the presence of pus, positive Gram stain or culture, or pH less than 7.0 or glucose less than 40 mg/dl. The surgical drainage depends on the stage of parapneumonic pleural effusion: at the acute stage closed thoracostomy drainage is enough; at the fibrinopurulent stage thoracoscopy is indicated; at organizational stage thoracotomy can be performed in children with stable anesthetic conditions, and open thoracostomy drainage should be used in patients in a poor state of health. Echography is very important to evaluate the staging of parapneumonic effusion.Conclusions: surgical treatment of complicated parapneumonic effusion should be done as early as possible, and the kind of procedure depends on the stage of pleural effusion. In children with complicated parapneumonic effusion echography is very important to evaluate the staging of parapneumonic effusion.J Pediatr (Rio J) 2002; 78 (Supl.2): S161-S170: pleural effusion, surgical drainage, surgery. ResumoObjetivo: o tratamento cirúrgico do derrame parapneumônico na criança é controverso, sendo a abordagem baseada fundamentalmente na experiência pessoal e no pequeno número de casos relatados. O objetivo deste artigo é o de apresentar uma revisão bibliográ-fica dos principais trabalhos e experiência dos autores no tratamento cirúrgico do derrame parapneumônico na criança. Fonte dos dados: foram utilizados dados de artigos científicos pesquisados através dos bancos de dados Medline e Lilacs.Síntese dos dados: o derrame parapneumônico tem indicação de drenagem cirúrgica quando apresenta, à toracocentese, aspecto purulento, bactéria no Gram ou cultura, e análise bioquímica com pH menor que 7,0 e glicose menor que 40mg/dl. A drenagem cirúrgica depende da fase do derrame. Na fase aguda, é suficiente a drenagem torácica fechada; na fase fibrinopurulenta, é indicada toracoscopia; na fase organizada, a toracotomia é realizada em crianças com condições anestésicas, e a pleurostomia, naquelas debilitadas e com estado geral comprometido. A ecografia é útil, e, na maioria das vezes, fundamental, para definir a fase do derrame pleural.Conclusões: o tratamento cirúrgico do derrame parapneumôni-co complicado deve ser feito o mais precocemente possível, e o tipo de procedimento a ser realizado depende da fase do derrame pleural. Nas crianças que necessitam de drenagem cirúrgica, a ecografia é fundamental, para determinar a fase evolutiva do derrame parapneumônico.J Pediatr (Rio J) 2002; 78 (Supl.2): S161-S170: derrame pleural, drenagem postural, cirurg...

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“…fibrinolytic therapy; fibrinolysis; plasminogen activator inhibitor 1; pleural injury; urokinase; tissue plasminogen activator INTRAPLEURAL FIBRINOLYTIC THERAPY (IPFT) activates the endogenous fibrinolytic system, resolving intrapleural adhesions and complex fibrinous deposits that sequester pockets of inflammation loculations, thus improving drainage and clinical outcome, in part by decreasing surgical interventions (10). There are multiple reports of successful (88 -100% efficacy) IPFT in adult (1,7,8,16,17,29,42,47,48,66,67,72) and in pediatric (2,3,6,11,20,40,41,58,59,61,63,67) patients with empyema although outcomes in adult patients are inconsistent in these trials. Thus IPFT represents a less invasive and costly alternative to video-assisted thoracic surgery or other surgical interventions, which demonstrate comparable efficacy (16,44,45,58,60,71) in pediatric practice.…”

mentioning

confidence: 99%

The time course of resolution of adhesions during fibrinolytic therapy in tetracycline-induced pleural injury in rabbits

Komissarov

Florova

Azghani

et al. 2015

American Journal of Physiology-Lung Cellular and Molecular Phys

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The time required for the effective clearance of pleural adhesions/organization after intrapleural fibrinolytic therapy (IPFT) is unknown. Chest ultrasonography and computed tomography (CT) were used to assess the efficacy of IPFT in a rabbit model of tetracycline-induced pleural injury, treated with single-chain (sc) urokinase plasminogen activators (scuPAs) or tissue PAs (sctPA). IPFT with sctPA (0.145 mg/kg; n ϭ 10) and scuPA (0.5 mg/kg; n ϭ 12) was monitored by serial ultrasonography alone (n ϭ 12) or alongside CT scanning (n ϭ 10). IPFT efficacy was assessed with gross lung injury scores (GLIS) and ultrasonography scores (USS). Pleural fluids withdrawn at 0 -240 min and 24 h after IPFT were assayed for PA and fibrinolytic activities, ␣-macroglobulin/ fibrinolysin complexes, and active PA inhibitor 1 (PAI-1). scuPA and sctPA generated comparable steady-state fibrinolytic activities by 20 min. PA activity in the scuPA group decreased slower than the sctPA group (k obs ϭ 0.016 and 0.042 min Ϫ1 ). Significant amounts of bioactive uPA/␣-macroglobulin (but not tPA; P Ͻ 0.05) complexes accumulated at 0 -40 min after IPFT. Despite the differences in intrapleural processing, IPFT with either fibrinolysin was effective (GLIS Յ 10) in animals imaged with ultrasonography only. USS correlated well with postmortem GLIS (r 2 ϭ 0.85) and confirmed relatively slow intrapleural fibrinolysis after IPFT, which coincided with effective clearance of adhesions/organization at 4 -8 h. CT scanning was associated with less effective (GLIS Ͼ 10) IPFT and higher levels of active PAI-1 at 24 h following therapy. We concluded that intrapleural fibrinolysis in tetracycline-induced pleural injury in rabbits is relatively slow (4 -8 h). In CT-scanned animals, elevated PAI-1 activity (possibly radiation induced) reduced the efficacy of IPFT, buttressing the major impact of active PAI-1 on IPFT outcomes. fibrinolytic therapy; fibrinolysis; plasminogen activator inhibitor 1; pleural injury; urokinase; tissue plasminogen activator INTRAPLEURAL FIBRINOLYTIC THERAPY (IPFT) activates the endogenous fibrinolytic system, resolving intrapleural adhesions and complex fibrinous deposits that sequester pockets of inflammation loculations, thus improving drainage and clinical outcome, in part by decreasing surgical interventions (10). There are multiple reports of successful (88 -100% efficacy) IPFT in adult (1,7,8,16,17,29,42,47,48,66,67,72) and in pediatric (2,3,6,11,20,40,41,58,59,61,63,67) patients with empyema although outcomes in adult patients are inconsistent in these trials. Thus IPFT represents a less invasive and costly alternative to video-assisted thoracic surgery or other surgical interventions, which demonstrate comparable efficacy (16,44,45,58,60,71) in pediatric practice. IPFT also represents a preferred choice in high-risk (1, 22) and otherwise inoperable patients (10,43,49,56,57,69) or those with empyema/ loculation who refuse surgery. The reasons for the inconsistent results of IPFT in adult patients remain unclear but likely reflect...

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Urokinase in the Management of Complicated Parapneumonic Effusions in Children

Cited by 92 publications

References 18 publications

Alteplase in the Treatment of Complicated Parapneumonic Effusion: A Case Report

Alteplase in the Treatment of Complicated Parapneumonic Effusion: A Case Report

Abordagem cirúrgica da efusão pleural parapneumônica e suas complicações

The time course of resolution of adhesions during fibrinolytic therapy in tetracycline-induced pleural injury in rabbits

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