Treatment of complicated pleural fluid collections with image-guided drainage and intracavitary urokinase

We report the results of image-guided catheter drainage with adjunctive enzymatic pleural debridement in the treatment of empyemas and other complicated pleural fluid collections.

Retrospective review.

One hundred eighteen patients with complicated pleural fluid collections were treated with image-guided drainage. There were 79 empyemas, 27 sterile loculated parapneumonic effusions, 10 sterile hemothoraces, and 2 sterile postoperative exudative effusions. Forty-one patients had failed prior large-bore thoracostomy drainage. The estimated age of the effusions at the time of image-guided drainage ranged from 1 to 175 days with a mean estimated age of 13 days.

Patients were treated with image-guided placement of one or more 12F to 16F chest drains. Adjunctive urokinase instillation was used in 98 cases. Urokinase (100,000 to 250,000 U/mL) was instilled in 20 to 240-mL aliquots and reaspirated in 1 to 4 h. One to four instillations were performed per day until drainage was complete.

Drainage was successful in 111 cases (94%). Two patients died of sepsis with incomplete drainage. Five patients underwent decortication (three recovered and two died postoperatively). Fifty-three patients (45%) required placement of more than one drain. The mean duration of drainage was 6.3 days. Patients treated with pleurolysis required a mean of five instillations of urokinase. The mean total dose of urokinase used per case was 466,000 U. There were no complications.

Image-guided drainage with adjunctive pleural urokinase therapy is a safe and effective method of closed thoracostomy drainage of complicated pleural fluid collections and can obviate surgery in most cases.