INTRAPLEURAL STREPTOKINASE IN THE MANAGEMENT OF EMPYEMA

Background - Significant morbidity and mortality result from the ineff ective evacuation of empyema. Failure of conventional first line treat ment with closed intercostal tube drainage and antibiotic therapy may result in fibrin deposition and loculated empyema. Enzymatic debrideme nt using intrapleural instillation of streptokinase is a non-invasive therapeutic option which may obviate the need for surgical interventio n. Methods - Eleven adults with multiloculated post-pneumonic empyemas who had failed to respond satisfactorily to intercostal tube drainage and antibiotic therapy were treated with intrapleural streptokinase b etween November 1992 and January 1993. A small catheter was inserted u nder ultrasound guidance into a loculation within the pleural space. A liquots of 250 000 units of streptokinase in 100 ml normal saline were instilled into the pleural cavity and the tube clamped for four hours . Response was assessed by clinical outcome, measurement of drain outp ut after unclamping, and subsequent pleural ultrasound, chest radiogra phy, or both. Results - Streptokinase enhanced drainage in all patient s. Complete resolution of the empyema with re-expansion of the underly ing lung was effected in eight patients, all of whom remain well. Furt her resolution of minimal pleural thickening was shown on subsequent c hest radiographs. Two patients with considerably thickened visceral pl eura following empyema drainage underwent successful decortication. Th e other, with myocarditis and a pyopneumothorax, underwent surgery for non-resolution of the pneumothorax but died perioperatively from card iac failure. The number of streptokinase instillations per patient ran ged from two to six (median three), and the volume of empyema fluid dr ained per patient ranged from 100 ml to 4870 mol (median 900 ml). Stre ptokinase was well tolerated in all patients. Conclusions - Intrapleur al streptokinase is an effective adjunct in the management of complica ted empyema and may reduce the need for surgery.