Use of urokinase in childhood pleural empyema

Abstract

Urokinase is an enzyme with a fibrinolytic effect that facilitates pleural empyema drainage through a chest tube. The aim of this study was to assess the risk of pneumothorax, the need for pleural debridement surgery, the persistence of fever, and the number of days in hospital in a group of children with parapneumonic pleural empyema treated with urokinase. This was an uncontrolled retrospective study on children suffering from parapneumonic empyema. Data collected on 17 children treated with urokinase were compared with 11 children treated prior to the advent of urokinase (the "historic" group). The urokinase was instilled in the pleural cavity over a period ranging from 2-8 days, amounting to a median total dose per kilogram of body weight of 18,556 IU (range, 7,105-40,299). Surgical treatment of the empyema involved drainage tube placement and/or debridement of the pleural cavity. Three children developed pneumothorax during their hospital stay, and one more case occurred 6 months after the child had recovered from his empyema; there were 3 cases of pneumothorax during the acute phase in the "historic" group (P = 0.54). Five children in the urokinase group were debrided and 12 were only drained, as opposed to 9 and 2, respectively, in the "historic" group (P = 0.02). The overall hospital stay was 17 days for the urokinase group, and 24 for the "historic" group (P = 0.02). No bleeding or other major complications were reported in the group treated with urokinase. In conclusion, urokinase treatment does not carry a risk of pneumothorax, while it does reduce hospital stay and the need for pleural debridement.

Complicated pneumonia in children

“…In cases where drainage is slow, due to the fluid being thick or loculated, twice-daily intrapleural fibrinolytics such as urokinase have been shown to reduce duration of hospital stay [52], incidence of residual pleural thickening [56] and allow resolution of empyema without surgical intervention in up to 93% of cases [52]. Although in one small study, the failure rate was reported at almost 70% [57], in our experience, in 180 children with empyema who required chest drains between 2002 and 2007, of whom 80% received intrapleural urokinase, ,3% went on to have a surgical procedure. Chest tubes are removed when f50 mL per day is draining and the integrity of the drain is confirmed; chest radiographs should be repeated 3-4 h after drain removal to ensure that re-accumulation or pneumothorax has not occurred.…”

Parapneumonic Effusion in Children

“…81 UK and streptokinase have the same effectiveness in treating PPE and empyemas. 62 Urokinase is preferred over streptokinase because of its lower allergenic risk, but it is more expensive.…”

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

“…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.…”