Treatment of complicated pleural effusion with intracavitary urokinase in children

Intrapleural administration of fibrinolytic agents such as urokinase (UK) h as been advocated as an alternative method to manage complicated pleural ef fusion (CPE). Despite the increasing number of empyemas successfully treate d with UK in adults, the experience in children is limited to a few cases. We report the results of image-guided catheter drainage (IGCD) with intraca vitary instillation of UK in six children with CPE. Urokinase (25,000-100,0 00 IU) was diluted in 20 ml of normal saline and instilled into the pleural cavity via a percutaneously placed drainage catheter. After 4 hr, the clam ped catheter was released and connected to water-seal suction at a negative pressure of 20 cm H2O. UK instillation was repeated daily until no further drainage occurred. During IGCD, repeated radiographic and ultrasound imagi ng determined the location and amount of any remaining pleural fluid. Mean duration of hospital stay before initiating UK therapy was 4.3 days. M ean duration of catheter drainage before initiating UK therapy was 3.5 days , and the mean total drainage was 86 mi. All patients had an increase in ch est tube drainage within 24 hr after the first instillation of UK. The mean net total drainage after UK instillation was 281 mi, most of the drainage being occurring in the first 2 days of treatment. Mean hospital stay follow ing UK treatment was 5.8 days, and the average total duration of hospital s tay was 13.8 days. No complications and no adverse events occurred during t reatment with UK. Complete resolution of the consequences of the pleural ef fusion was observed in ail patients at follow-up. Our results suggest that IGCD with adjunctive UK therapy is a reliable, sim ple, and safe approach to treat CPE, and it can reduce the risks associated with thoracotomy and decortication. (C) 2000 Wiley-Liss. Inc.