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Retrospective analysis of large-dose intrapleural alteplase for complicated pediatric parapneumonic effusion and
Jessica L Taylor1, Meixia Liu2, David S Hoff1
1Department of Pharmacy, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota.
Insights
Large-dose intrapleural alteplase effectively drains fluid in pediatric empyema cases. This treatment is safe, with common side effects including pain and oxygen desaturation, warranting careful monitoring.
Area of Science:
- Pediatric Pulmonology
- Thoracic Surgery
- Critical Care Medicine
Background:
- Complicated parapneumonic effusion and empyema in children require antibiotics and pleural drainage.
- Intrapleural fibrinolysis aids pleural drainage, but optimal dosing of alteplase remains debated.
Purpose of the Study:
- To assess the efficacy and safety of a high-dose intrapleural alteplase regimen in pediatric patients.
- To identify clinical factors differentiating responders from non-responders to intrapleural alteplase therapy.
Main Methods:
- Retrospective review of pediatric patients treated with intrapleural alteplase for parapneumonic effusions.
- Efficacy assessed by comparing pre- and post-treatment chest tube output, duration of drainage, need for surgery, and hospital stay.
- Safety evaluated by adverse event frequency and severity; responders defined as those not requiring surgery.
Main Results:
- Seventy-three pediatric patients received intrapleural alteplase; 84% were responders, not requiring surgery.
- Chest tube output significantly increased post-treatment (10.7 to 24.2 mL/hr, p=0.006), with a median hospital stay of 9 days.
- Common adverse events included pain (20.5%) and oxygen desaturation (16.4%); 12% required blood transfusion.
Conclusions:
- High-dose intrapleural alteplase is an effective treatment for facilitating pleural drainage in pediatric complicated parapneumonic effusion or empyema.
- Pain and oxygen desaturation are the most frequent adverse effects, necessitating vigilant clinical monitoring for potential bleeding complications.
Objectives:
Medical treatment of complicated parapneumonic effusion or empyema in pediatric patients includes antibiotics and pleural space drainage. Intrapleural fibrinolysis may facilitate pleural drainage; however, there is a lack of consensus regarding the optimal dosing regimen. The primary purpose of this study was to evaluate the efficacy and safety of a large-dose intrapleural alteplase regimen in pediatric patients. Secondarily, this investigation sought to differentiate the clinical characteristics of responders and non-responders to intrapleural alteplase therapy.
Methods:
All patients with parapneumonic effusions treated with intrapleural alteplase between June 2003 and December 2011 were reviewed retrospectively. Efficacy was assessed by comparing chest tube output, in mL/hr and mL/kg/hr, for 24 hours before and after the first dose of alteplase. Additional efficacy outcomes included duration of in situ chest tubes, a need for surgical intervention for pleural effusion, and length of hospital stay. Safety was assessed by frequency and severity of adverse events. Non-responders and responders were compared based on demographic and disease characteristics. Responders were defined as patients who did not require surgical intervention after intrapleural alteplase therapy.
Results:
Seventy-three patients, aged 0.5 to 22.5 years, received intrapleural alteplase to facilitate pleural drainage. Median alteplase dose was 7 mg (range, 3 to 10 mg; median 0.38 mg/kg). Chest tube output increased from 10.7 to 24.2 mL/hr (p = 0.006), and median length of hospital stay was 9 days. Eighty-four percent of patients were responders. The most common adverse events were pain (20.5%) and oxygen desaturation greater than 10% from baseline (16.4%). High-flow nasal cannula was the most common intervention for oxygen desaturation to 80% to 90%. Nine patients (12%) required a blood transfusion during the study.
Conclusion:
Large-dose intrapleural alteplase is effective in facilitating pleural drainage in pediatric patients with complicated parapneumonic effusion or empyema. Common adverse effects include pain and oxygen desaturation. The potential for bleeding warrants clinical monitoring.
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