Diffuse Alveolar Hemorrhage as a Complication of Intrapleural Fibrinolytic Therapy

Shah, Radhika M.; Krochmal, Rebecca; Pickering, E.; Burrows, W.; Sachdeva, Ashutosh

doi:10.1097/lbr.0000000000000400

Cited by 5 publications

(5 citation statements)

References 5 publications

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“…While a few case studies suggest a possible correlation between intrapleural tPA and DNase and systemic bleeding, multiple more extensive trials exploring intrapleural fibrinolytic effects have not reported significant systemic bleeding ( 15 , 22 ). Without evidence of measurable systemic absorption, the question remains whether this is a safe therapy even in those who with higher systemic bleeding risks, such as those with recent gastrointestinal bleeding or intracranial hemorrhages.…”

Section: Discussionmentioning

confidence: 99%

“…While some studies evaluated the possible systemic effects of streptokinase, data is lacking on the potential systemic effects of our current tPA and DNase therapies. Only a few published case reports may suggest a possible correlation between systemic bleeding and intrapleural fibrinolytic therapy ( 22 ). However, in the more recent larger trial by Akulian et al , there were no reported episodes of major systemic bleeding associated with intrapleural tPA and DNase ( 15 ).…”

Section: Introductionmentioning

confidence: 99%

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Understanding the systemic effects of intrapleural tPA and DNase by evaluating effects on coagulation

Marston,

Rajdev,

Samson

et al. 2024

J Thorac Dis

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Background Complicated parapneumonic effusions and empyemas are common presentations that carry significant morbidity and mortality. Standard therapy includes antibiotics and chest tube placement. Due to the nature of the fluid, it is often difficult to drain completely using a chest tube. As outlined in multiple studies, intrapleural tissue plasminogen activator (tPA) and dornase alfa (DNase) are effective at helping clear these effusions and the avoidance of surgery. Despite research to better understand the effectiveness of the treatment and possible side effects, there continues to be a lack of data on potential systemic effects. Methods This prospective observational pilot study was conducted from May 2021 until June 2022. Basic demographics, complications, prothrombin time, activated partial thromboplastin time, D-Dimer, fibrinogen, and thromboelastography scans were measured both before and after infusion of chest tube tPA and DNase to assess for differences in coagulation using Signed Rank tests. Results A total of 17 patients were enrolled in the study. Two patients were excluded due to protocol deviations. The median change score for lysis of clot at 30 minutes (Ly30), our primary outcome of interest, was 0 (P=0.88). There were no significant changes in other coagulation measures when comparing pre and post treatment. One patient (5.9%) had intrapleural bleeding associated with therapy. Three patients (17.6%) underwent surgical intervention to further treat their complicated pleural effusion. Conclusions This is the first study to evaluate measurable changes in systemic coagulation after intrapleural tPA and DNase. Our data demonstrates no significant difference in coagulation after intrapleural tPA and DNase infusion, suggesting that there may not be clinically significant absorption.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Understanding the systemic effects of intrapleural tPA and DNase by evaluating effects on coagulation

Marston,

Rajdev,

Samson

et al. 2024

J Thorac Dis

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“…Although systemic absorption of intrapleural administered streptokinase is low, cumulative doses of intrapleural streptokinase may cause systemic fibrinolysis 19,20 . Case reports of fatal hemorrhage from aortic dissection 21 and diffuse alveolar hemorrhage following intrapleural streptokinase have been reported 22 . Risk for hemorrhage is high in those on systemic anticoagulation 16 .…”

Section: Discussionmentioning

confidence: 99%

“… 19 , 20 Case reports of fatal hemorrhage from aortic dissection 21 and diffuse alveolar hemorrhage following intrapleural streptokinase have been reported. 22 Risk for hemorrhage is high in those on systemic anticoagulation. 16 Absolute contraindications to intrapleural fibrinolysis include any trauma, surgery, or major hemorrhage within 48 hours, a bronchopleural fistula and history of allergic reaction to the drug.…”

Section: Discussionmentioning

confidence: 99%

Management of hemorrhagic pleural effusion with intrapleural streptokinase in a patient on peritoneal dialysis and dual antiplatelet therapy

Thapaliya

Bhattarai

Gautam

et al. 2023

Clinical Case Reports

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Pleural effusion is seen in up to 10 percent of patients on peritoneal dialysis (PD). 1 The differential diagnosis of pleural effusion in PD patients is extensive. It includes general causes of pleural effusion and causes unique to PD patients. Transudative pleural effusions in PD patients may be commonly due to volume overload and cardiac failure, or rarely due to pleuroperitoneal leakage. 2 Exudative effusions could occur due to infection, inflammation, or hemorrhage. The presence of a hemorrhagic pleural effusion can narrow the differential diagnoses to trauma,

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“…Consequently, dual therapy has replaced fibrinolytic monotherapy as the standard treatment. However, concerns have been raised regarding the use of fibrinolytics and DNase combined and the potential increased risk of serious haemorrhagic side effects, such as pleural haemorrhage and haemoptysis, compared with the use of fibrinolytics alone [ 13 , 14 ]. Moreover, owing to the high cost and limited availability of dual therapy involving specific fibrinolytic agents such as tPA and DNase, fibrinolytic monotherapy such as urokinase remains a widely used treatment option, particularly in settings with limited resources [ 15 , 16 ].…”

Section: Introductionmentioning

confidence: 99%

Association between intrapleural urokinase monotherapy and treatment failure in patients with pleural infection: a retrospective cohort study

et al. 2023

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Background Pleural infection, an infection of the pleural space, is frequently treated with antibiotics and thoracic tube drainage. In case of insufficient drainage, an intrapleural fibrinolytic agent is considered before surgical intervention. However, the effectiveness of fibrinolytic monotherapy is still controversial. Therefore, we aimed to examine the association between urokinase monotherapy and treatment failure in patients with pleural infection. Methods In this retrospective observational study, patients with pleural infection underwent chest tube insertion were divided into two groups including patients treated with or without intrapleural instillation of urokinase. The propensity score overlap weighting was used to balance the baseline characteristics between the groups. Treatment failure was defined by the composite primary outcome of in-hospital death and referral for surgery. Results Among the 94 patients, 67 and 27 patients were in the urokinase and non-urokinase groups, respectively. Urokinase monotherapy improved the composite outcome between the groups (19.4% vs. 48.1%, p = 0.01). After adjusting using propensity score overlap weighting, urokinase monotherapy improved the composite outcome compared to the non-urokinase group (19.0% vs. 59.5%, p = 0.003). Conclusions Urokinase monotherapy can be an important nonsurgical treatment option for patients with pleural infection. Trial registration The participants were retrospectively registered.

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Diffuse Alveolar Hemorrhage as a Complication of Intrapleural Fibrinolytic Therapy

Cited by 5 publications

References 5 publications

Understanding the systemic effects of intrapleural tPA and DNase by evaluating effects on coagulation

Understanding the systemic effects of intrapleural tPA and DNase by evaluating effects on coagulation

Management of hemorrhagic pleural effusion with intrapleural streptokinase in a patient on peritoneal dialysis and dual antiplatelet therapy

Association between intrapleural urokinase monotherapy and treatment failure in patients with pleural infection: a retrospective cohort study

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