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

STUDY OBJECTIVE: 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.

DESIGN: Retrospective review.

PATIENTS: 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.

INTERVENTIONS: 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.

MEASUREMENTS AND RESULTS: 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.

CONCLUSION: 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.