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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

The Role of Video Thoracoscopic Surgery in Treatment of Pleural Infections


Pleural infections have high morbidity and mortality, and their incidence in all age groups is growing worldwide. Pleural effusion develops in 40% of pneumonia patients, but only 15% of patients develop thoracic empyema after antibiotic treatment. Pleural empyema can be differentiated into three phases, exudative (Stage I), fibrinopurulent (Stage II) and organizing (Stage III). It is important to emphases that it is representing as a continuously evolving process that can be stop by therapeutic intervention. The initial exudative stage can be often managed by antibiotics and placement of chest tube. However, it is not effective in the fibrinopurulent or organizing stages, due to fibrin deposits over the parietal pleura and loculation of fluid, that restricts the expansion of the lung. The variety of strategies in the treatment of parapneumonic pleural empyema demonstrates the ambiguity for the method of choice. Many publications demonstrated that an early and aggressive minimally invasive approach for empyema in stage II provides rapid relief from infection and guarantees lower morbidity rate, shorter hospital stay, lower costs and clinical resolution. Though, the role of video assisted thoracic surgery in organizing stage III of pleural empyema is still controversial. The objective of surgical treatment of pleural empyema is to drain infected collections from pleural cavity and to achieve a complete lung re-expansion which is usually trapped due to adhesion’s or thickening of the visceral pleura. Fibrinolysis has been shown to be superior to chest tube drainage alone. There are some trials who documented lower charges with fibrinolysis comparing to VATS procedures. However, a fibrinolitic therapy may make the subsequent operation more difficult. VATS provides higher diagnostic value as good visualization and magnification, direct visualization of all surgical regions, facilitates the evacuation of multilocular effusions, the division of a fibrin septa’s, debridement and decortication, as well as fluid sampling and pleural biopsy.

Keywords: Video-assisted surgery, pleural empyema, fibrinolysis, decortication.

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Successful right atrial thrombus lysis with alteplase in a nine month old infant


Objective. To present the case of an infant with a catheter related atrial thrombus resolved with local instillation of alteplase.
Clinical presentation. Echocardiography (ECHO) was performed in an infant with sepsis to estimate cardiac contractility, and a large mobile thrombus (28 x 8 mm) was detected in the right atrium. A left subclavian, double lumen, central venous line (CVL, 4 French, 8 cm), inserted 10 weeks previously, was left in place. Standard treatment with enoxaparine was commenced twice daily for 10 days at a dose of 1 mg/kg. Repeat ECHO showed no changes in thrombus size or mobility. Therefore, alteplase was administered into the distal catheter (1 mg in normal saline) at a dose of 110% of its priming volume. The dwelling time was 2 hours. Since no changes in thrombus size were observed, the same dose was given into the proximal catheter. ECHO performed 24 hours later showed a significant reduction in thrombus size. The third dose of alteplase was administered into the proximal catheter. ECHO showed complete dissolution of the right atrial thrombus. No bleeding was observed during and following therapy, and there were no signs of hemodynamic instability. The CVL was safely removed the same day and no endoluminal thrombus was seen.
Conclusion. Local instillation of alteplase in three doses was a safe and effective approach to the management of a large catheter-related intraatrial thrombus. Systemic thrombolytic therapy, associated with an increased risk of bleeding, and open heart surgery were avoided.

Key words: right atrial thrombus, alteplase, fibrinolysis, central venous line, infant

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