Interact CardioVasc Thorac Surg 2009;8:129-133. doi:10.1510/icvts.2008.191262
© 2009 European Association of Cardio-Thoracic Surgery
Best evidence topic - Thoracic general |
Establishing a role for intra-pleural fibrinolysis in managing traumatic haemothoraces
Ian Hunta,*,
Chrish Thakarb,
Rachel Southonc and
Eric L.R. Bédarda
a Division of Thoracic Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
b Department of Thoracic Surgery, Harefield Hospital, Hill End Road, Middlesex, UK
c Library Services Manager, Royal Surrey County Hospital, Guildford, Surrey, UK
Received 20 August 2008;
accepted 2 September 2008
*Corresponding author. Royal Alexandra Hospital, 10240 Kingsway Avenue, Edmonton, Alberta, Canada, T5H 3V9. Tel.: +1-780-735-5981; fax: +1-780-735-4245.
E-mail address: ianjhunt{at}gmail.com (I. Hunt).
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Abstract
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A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether there is a role in using intra-pleural fibrinolysis or thrombolysis with an agent such as streptokinase aids in resolving haemothoraces following trauma. Twenty-four papers were identified using the search below. Eight papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of the papers are tabulated. We conclude that intra-pleural fibrinolytic does have a role in managing patients with unresolved haemathoraces with complete resolution clinically and radiologically in most patients in half of the studies reviewed. It may be used as an alternative to surgical intervention in certain patients, but little work has been done on comparing intra-pleural fibrinolysis directly to surgical evacuation. The choice of agent and number of administrations are variable but with a similar outcome. Few studies have compared agents. The timing of when to use these agents following the traumatic haemothorax was variable but its use was commonly reserved following ‘failure’ of chest drainage clinically or radiologically (so usually over a week following the original injury). The overall morbidity including bleeding complications from their use was reported as low.
Key Words: Evidence-based medicine; Thoracic surgery; Intra-pleural fibrinolysis; Intra-pleural thrombolysis; Intra-pleural streptokinase; Haemothorax
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1. Introduction
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A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
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2. Clinical scenario
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You are asked to see a patient on the orthopaedic ward who had been involved in a poly-trauma one week earlier. Following the accident she required closed fixation of a pelvic fracture, open fixation of a tibia fracture and a complex repair of her elbow. She also sustained multiple right-sided rib fractures and a haemothorax that required a chest drain at the time of her admission. Unfortunately the effusion failed to resolve and she now has a moderate clotted haemothorax on a recent chest CT. You are asked to assess her for a surgical evacuation of haemothorax but realise, considering all her orthopaedic injuries, this may be tricky. You wonder whether intra-pleural fibrinolysis through a chest drain would resolve her haemothorax?
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3. Three-part question
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In patients [with haemothorax] does [intrapleural fibrinoly sis] aid in the resolution [blood in the pleural cavity]?
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4. Search strategy
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Medline 1950–March 2008 and Embase 1974–April 2009 using the Dialog Datastar interface.
[HEMOTHORAX#.W.DE. OR Hematothorax.W.DE. OR (HEMOTHORAX OR HAEMOTHORAX OR hemothoraces OR hematothorax).TI,AB.] AND [THORACIC- INJURIES.DE. OR Thorax-Injury.DE. OR Thorax- Blunt- Trauma.DE. OR Thorax- Penetrating- Trauma.DE. OR ACCIDENTS- TRAFFIC.DE. OR Traffic- Accident.DE. OR TRAUMATIC.TI,AB.] AND [STREPTOKINASE.W..DE. OR FIBRINOLYTIC- AGENTS.DE. OR Fibrinolytic- Therapy.DE. OR Fibrinolysis#.W..DE. OR Thrombolytic- Therapy#.DE. OR (INTRAPLEURAL ADJ STREPTOKINASE).TI,AB.] Limit to English. This search was repeated in the Cochrane Central Register of Controlled Trials and selected papers references hand searched.
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5. Search outcome
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A total of 24 papers were identified of which eight were deemed to be relevant. These are presented in Table 1.
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6. Comments
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The role of intra-pleural fibrinolysis is well established in the management of pleural infection and empyemas particularly within the paediatric population, its role in managing traumatic haemothoraces is less clear. As a result of penetrating or blunt chest trauma, haemothorax is a common emergency usually initially managed by chest tube insertion. Subsequent complications from retained ‘clotted’ haemothorax include pulmonary restriction with fibrosis and/or empyema. This occurred in around 10% of the approximately 600 cases of traumatic haemothoraces reported by Oguzkaya et al. [5]. The majority of patients had a chest drain inserted following an unspecified chest injury or in a few cases following a pleural aspiration and went on to receive intra-pleural fibrinolytic when the haemothorax failed to resolve (Streptokinase [2–6, 8, 9] tissue plasminogen activator [7] and/or Urokinase [2, 6]). One study directly compared video-assisted thorascoscopy to intra-pleural streptokinase [5]. One study was animal-based [3] and half the studies included patients with haemothorax among patients with a mixture of empyemas or malignant effusions [4, 7–9].
Regarding the safety and adverse effects of using an intrapleural fibrinolytic, most studies mentioned concerns about potential allergic reactions and transient fevers with using streptokinase and one study specifically excluded patients previously exposed to or with known streptokinase allergy [2]. In studies where complications were mentioned, no allergic reaction or adverse outcome such as coagulopathy was recorded in six of the studies [2–4, 6, 8, 9], though one study mentioned two patients developing transient disorientation immediately following intrapleural instillation [4], and another described local pain on instillation as an issue [6]. In that study, the authors added a local anaesthetic to the intrapleural thrombolytic with a reported improvement in pain. One study specifically addressed safety of TPA and noted one case (2.4% of cases but in a mixed group of patients) of bleeding, but the patient was receiving anticoagulation for haemodialysis [7]. The study concluded that its use was safe even following traumatic haemothoraces.
The dose and method of administration of the intrapleural fibrinolytic was relatively consistent across studies. For streptokinase 250,000 IU instilled in 100 ml of saline given via a chest tube which was subsequently clamped for 4 h. For Urokinase, 100,000 IU was used [2, 4–6, 8, 9]. In the TPA study dose varied but most commonly 50 mg was used in 120 ml saline [7]. The time interval between diagnosis and use of intrapleural fibrinolytic ranged from 0 to 30 days, and in two studies the average time interval was 11 days [2, 4]. The number of treatments again varied between 2 to 10, but in the same two studies averaged around five treatments over five days [2, 4].
Efficiency of intrapleural fibrinolytic agents was measured clinically in terms of patient symptoms and chest tube drainage, radiologically in terms of resolution of pleural collection and re-expansion of lung, and avoidance of further drainage procedures including surgery. All studies recorded an increase in fluid drainage following intrapleural administration of fibrinolytic for haemothorax. Six studies found complete response, defined variably but typically described as resolution of symptoms with complete drainage of fluid and no residual space radiographically occurred in at least half the patients examined [2, 5–9], and in four studies over 90% of patients had successful clinical and radiological resolution of clotted haemothorax [2, 4, 6, 8]. Partial resolution again defined variably but usually referred as resolution of symptoms but with some retention of clot radiologically was recorded inconsistently. Decision to offer surgery in partial responders or non-responders was also inconsistent. In four studies around 20 – 30% patients were partial responders [2, 6, 7, 9]. Little comment can be made regarding which agent is most effective though one study using streptokinase and urokinase found no difference [6].
The need for subsequent surgery was quite variable and probably reflects patient selection and the heterogeneous nature of patients studied, but overall was around 10%. The usual approach was thoracotomy and decortication but more recent studies included VATS [5, 6]. In the study comparing VATS with intrapleural streptokinase, the authors noted significant differences in favour of VATS evacuation in terms of length of hospital stay and avoidance of thoracotomy, as well as a lower incidence of subsequent empyema formation [5].
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7. Clinical bottom line
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Fibrinolytic agents appear to have a role in treating retained haemothorax with significant clinical and radiological improvement demonstrated in most of the studies reviewed. Its use appeared to be reserved following ‘failure’ of chest drainage alone so was typically administrated over a week following the original injury. Few papers examined directly choice of agent, influence of timing and length of treatment.
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References
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- Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact J Cardiovasc Thoracic Surg 2003;2:405–409.[Abstract/Free Full Text]
- Inci I, Ozcelik C, Ulkii R, Tuna A, Eren N. Intrapleural fibrinolytic treatment of traumatic clotted hemothorax. Chest 1998;1:160–165.
- Cangir AK, Yüksel C, Dakak M, Özgencil E, Genc O, Akay H. Use of intrapleural streptokinase in experimental minimal clotted hemothorax. Eur J Cardiothorac Surg 2005;27:667–670.[Abstract/Free Full Text]
- Jerjes-Sánchez C, Ramirez-Rivera A, Elizalde JJ, Delgado R, Cicero R, Ibarra-Perez C, Arroliga AC, Padua A, Portales A, Villarreal A, Perez-Romo A. Intrapleural fibrinolysis with streptokinase as an adjunctive treatment in hemothorax and empyema: a multicenter trial. Chest 1996;109:1514–1519.[CrossRef][Medline]
- O
 uzkaya Y, Akçali M, Bilgin M. Videothoracoscopy versus intrapleural strep-tokinase for management of post traumatic retained haemothorax: a retrospective study of 65 cases. Injury 2005;36:526–529.[CrossRef][Medline] - Kimbrell BJ, Yamzon J, Petrone P, Asensio JA, Velmahos GC. Intrapleural thrombolysis for the management of undrained traumatic hemothorax: a prospective observational study. J Trauma Inj Infect Crit Care 2007;62:1175–1179.[CrossRef]
- Skeete DA, Rutherford EJ, Schlidt SA, Abrams JE, Parker LA, Rich PB. Intrapleural tissue plasminogen activator for complicated pleural effusions. J Trauma, Inj Infect Crit Care 2004;57:1178–1183.[CrossRef]
- Aye RW, Froese DP, Hill LD. Use of purified streptokinase in empyema and hemothorax. Am J Surg 1991;161:560–562.[CrossRef][Medline]
- Bergh NP, Ekroth R, Larsson S, Nagy P. Intrapleural streptokinase in the treatment of haemothorax and empyema. Scand J Thorac Cardiovasc Surg 1977;11:265–268.[Medline]
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Abstract
1. Introduction