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Recent publications have advocated the use of intrapleural streptokinase administration in the treatment of empyema complicating community acquired pneumonia.1-3 Few complications have previously been described and the treatment appears suitable for most patients. We report two patients with empyema after cardiac surgery in whom administration of intrapleural streptokinase resulted in life threatening haemorrhage.
A 77 year old man presented six weeks after mitral valve repair with cough, fever and shortness of breath. Chest ultrasound demonstrated a loculated pleural effusion and a percutaneous diagnostic sample was consistent with a diagnosis of empyema. A pigtail catheter was inserted using ultrasound guidance and 250 000 IU of intrapleural streptokinase was instilled twice a day. Two days later he collapsed with haemorrhage into the chest drain. Resucitation required a six unit blood transfusion and insertion of a 28 F intercostal drain. The patient subsequently made a complete recovery.
A 50 year old man presented with a community aquired pneumonia and loculated empyema nine months after mitral valve repair. A pigtail drain was inserted under ultrasound guidance and streptokinase was administered twice a day. Following three days of treatment the drain was removed but shortly afterwards he collapsed with marked breathlessness. A chest radiograph demonstrated reaccumulation of the effusion and a 28 F intercostal drain was inserted which immediately drained 1500 ml of blood. Surgical decortication and evacuation of the haematoma was performed.
We have observed life threatening haemorrhage in two patients with empyema treated with intrapleural streptokinase. Both patients had recently undergone cardiac valve surgery. We postulate that empyema under these circumstances may represent a distinct, less organised pathological process with a lower fibrin content. We advise particular caution when treatment with intrapleural streptokinase is considered for patients following cardiac surgery.
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