Intrapleural instillation of Streptokinase and Urokinase has been utilized in the management of loculated pleural effusions associated with pleural sepsis and pleural clots. Both of these agents are less readily available for use due to the increasing use of Alteplase for fibrinolysis. We studied the use of Alteplase in the management of three cases of clotted hemothorax to assess both efficacy and safety of this agent.
Three consecutive patients with clotted hemothorax were subjected to intrapleural instillation of Alteplase. All three patients had small bore pleural catheters placed under CT scan guidance. After initial drainage of pleural fluid had declined to less than 50 cc/ 24 hours, Alteplase 4mg diluted in 100 cc of normal saline was instilled into the pleural space. Further instillation of Alteplase 4mg was performed after radiographic confirmation of incomplete resolution.
All three patients who underwent intrapleural instillation of Alteplase were female with a mean age of 64.33 years. The hemothorax occurred following minimally invasive direct coronary artery bypass surgery (MIDCAB) in two patients, and was due to blunt chest trauma in the other. An average of 3.33 instillations were required per patient. Complete resolution, which was defined as resolution of symptoms and complete drainage of fluid and no residual pleural space radiographically, occurred in 2 of the 3 patients. The third patient had a partial response defined as resolution of symptoms and a small residual pleural space. No complication occurred in any of the three patients. The mean duration of the hemothorax was 9 days (range 7–11 days).
The intrapleural instillation of Alteplase in our small group of patients was found to be both effective and safe. We recommend that Alteplase be considered as an alternative to Streptokinase for the treatment of clotted hemothorax.
The declining availability of Streptokinase requires an alternative intrapleural fibrinolytic agent. Alteplase should be safe and effective for this purpose although a larger study is needed to confirm these conclusions.
F. Tufail, None.