[Fibrinolytic therapy in surgically treated intensive care patients]

Conventional thrombolytic therapy with streptokinase (SK) at the standard dose (loading dose, 250,000 IU; maintenance dose, 100,000 IU/h) after recent surgery may provoke a tendency towards severe bleeding secondary to plasminaemia associated with clotting disorders. In contrast, ultrahigh-dose SK therapy regimen (loading dose, 4 million IU; maintenance dose, 1-2 million IU/h) can minimize the risk of bleeding. Since the circulating plasminogen (Plg) can immediately bind to SK to form the so-called SK-Plg activator complex, free plasminogen is no longer available for conversion to systemic plasmin. In a pilot study, greater than 30 patients presenting with acute respiratory distress syndrome (ARDS) received ultrahigh-dose SK therapy following recent surgery. Although the period between surgery and thrombolysis was 2.5 days on average, no major haemorrhages occurred. In addition, a surprisingly high survival of 50% was reported. Although the efficacy of the ultrahigh-dose SK regimen in ARDS has not been definitively confirmed, this regimen is well accepted for the treatment of severe pulmonary embolism after surgery. Another promising indication for the use of this therapy is catheter-induced thrombosis of the major central veins. Additional, albeit rare, situations in which this treatment can be used include intrabronchial administration of thrombolytic agents after blood aspiration or their selective intravenous use following severe venous thrombosis in high-risk patients. This paper demonstrates the feasibility of thrombolytic therapy in these indications and discusses the benefit/risk ratio of the different agents tested.