Instillation of Fibrinolytic Enzymes in the Treatment of Pleural Empyema

Abstract

Acute pleural empyema which is not amenable to pleural puncture or closed thoracic drainage should be treated operatively by decortication or, in persistent cavities, by open thoracostomy drainage. In the last 2 years we have instilled 500,000 IU of fibrinolysines (streptokinase and streptodornase) per day into the pleural cavity of 27 patients with pleural infections requiring closed intrapleural drainage. By means of this treatment, pus and fibrinous membranes are liquefied and necrotic tissue is discharge. Therapeutic success is indicated by considerably increased fluid drainage about one hour after instillation. This therapy was performed for an average of 5 days. In 12 patients (44%) pleural empyema could be cured. In the other 15 cases decortication, and in 3 of them open thoracostomy drainage, was necessary. In our opinion intrapleural instillation of fibrinolytic enzymes should be added to the well-recognized method of treatment of pleural empyema, although not replace them.

Effects of Streptokinase and Deoxyribonuclease on Viscosity of Human Surgical and Empyema Pus

“…There are several uncontrolled series supporting the use of fibrinolytics. [3][4][5][6][7] Two controlled randomized studies of intrapleural thrombolytics gave conflicting results. 8,9 The consensus is that intrapleural streptokinase alone is of some benefit in treating empyema, and it is widely used.…”

Management of complicated parapneumonic effusions and thoracic empyema

“…Twice‐daily intra­pleural SK 250 000 to total 1.5 million units did not cause significant activation of systemic fibrinolysis in humans 39 . Neither 18 consecutive doses of SK 250 000 units 14 nor 17 doses of urokinase 100 000 units 32 gave rise to side‐effects. Intrapleural SK has been safely administered 3 days post‐­thoracotomy 13 .…”

“…Chemical fibrin­olysis has been thus employed for 50 years, with a mixture of streptokinase/streptodornase being initially described 12 . Side‐effects from impurities dampened enthusiasm, but more purified strepto­kinase (SK) and urokinase led to reappraisal of this method 13−19 . The range of the fibrinolytic success rate in published series is 44−100% 15,20 …”

“…There has been renewed interest in streptodornase, the coagent originally used 14 . As an adjuvent or single fibrinolytic agent, it has been shown to liquefy pus more effectively in vitro than streptokinase 26,27 .…”

“…12 Side-effects from impurities dampened enthusiasm, but more purified streptokinase (SK) and urokinase led to reappraisal of this method. [13][14][15][16][17][18][19] The range of the fibrinolytic success rate in published series is 44-100%. 15,20 Only two double-blind RCT with chest tube drainage compared SK or urokinase with normal saline control.…”