Intrapleural urokinase versus normal saline in the treatment of complicated parapneumonic effusions and empyema - A randomized, double-blind study

Intrapleural administration of fibrinolytic agents has been shown to be eff ective and safe in the treatment of loculated parapneumonic pleural effusio ns. However, controlled studies of the possible role of the activity of uro kinase (UK) through the volume effect are lacking. We therefore investigate d the hypothesis that UK is effective through the lysis of pleural adhesion s and not through the volume effect. Thirty-one consecutive patients with m ultiloculated pleural effusions were randomly assigned to receive either in trapleural UK (15 patients) or normal saline (NS) (16 patients) for 3 d, in a double-blind manner. All patients had inadequate drainage through a ches t tube (< 70 ml/24 h). UK was given daily through the chest tube in a dose of 100.000 IU diluted in 100 ml of NS. Controls were given the same volume of NS intrapleurally. Response was assessed by clinical outcome, fluid drai nage, chest radiography, pleural ultrasonography (US) and/or computed tomog raphy (CT). Clinical and radiographic improvement was noted in all but two patients in the UK group but in only four in the control group. The net mea n volume drained during the 3-d treatment period was significantly greater in the UK group (970 +/- 75 ml versus 280 +/- 55 ml, p < 0.001). Pleural fl uid drainage was complete in 13 (86.5%) patients in the UK group (two patie nts were treated through video-assisted thoracoscopy) but in only four (25% ) in the control group. Twelve patients in the control group were subsequen tly treated with UK and six of them had complete drainage; the remaining si x patients had complete drainage after video-assisted thoracoscopy. Our res ults suggest that UK is effective in the treatment of loculated pleural eff usions through the lysis of pleural adhesions and not through the volume ef fect.