Therapeutic application of intrapericardial tissue plasminogen activator in a 4-month-old child with complex fibropurulent pericarditis.
ABSTRACT To describe a young child with complex fibropurulent pericarditis who was successfully treated with intrapericardial recombinant tissue plasminogen activator.
Individual case report.
Pediatric intensive care unit of a tertiary children's hospital.
A 4-month-old Asian girl with Staphylococcus aureus septic shock who later developed a loculated fibropurulent pericardial effusion that was refractory to management with a subxiphoid percutaneous pericardial drainage catheter.
Three doses of intrapericardial tissue plasminogen activator were administered at 12-hr intervals, allowed to dwell for 2 hrs, and subsequently drained via low continuous suction.
Immediately after intrapericardial tissue plasminogen activator was administered via a percutaneous pericardial drainage catheter, the patient had an increase in pericardial fluid drainage and resolution of a complex fibropurulent pericardial effusion. Pericardial fluid drainage ceased and then increased to 122 mL, 270 mL, and 80 mL of fluid, respectively, after each of the three doses of intrapericardial tissue plasminogen activator. Serial echocardiography confirmed the initial presence of the effusion, the subsequent loculated nature of the effusion, and ultimate resolution of the effusion after tissue plasminogen activator. The patient survived to hospital discharge without cardiac dysfunction.
The fibrinolytic effect of tissue plasminogen activator therapy promotes the resolution of complex fibropurulent pericardial effusions refractory to traditional pericardial drainage via percutaneous catheter and suction. Use of intrapericardial tissue plasminogen activator may preclude the need for surgical intervention in fibropurulent pericarditis.
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ABSTRACT: Purulent pericarditis (PP) is a potentially life-threatening disease. Reported mortality rates are between 20 and 30%. Constrictive pericarditis occurs over the course of PP in at least 3.5% of cases. The frequency of persistent PP (chronic or recurrent purulent pericardial effusion occurring despite drainage and adequate antibiotherapy) is unknown because this entity was not previously classified as a complication of PP. No consensus exists on the optimal management of PP. Nevertheless, the cornerstone of PP management is complete eradication of the focus of infection. In retrospective studies, compared to simple drainage, systematic pericardiectomy provided a prevention of constrictive pericarditis with better clinical outcome. Because of potential morbidity associated with pericardiectomy, intrapericardial fibrinolysis has been proposed as a less invasive method for prevention of persistent PP and constrictive pericarditis. Experimental data demonstrate that fibrin formation, which occurs during the first week of the disease, is an essential step in the evolution to constrictive pericarditis and persistent PP. We reviewed the literature using the MEDLINE database. We evaluated the clinical efficacy, outcome, and complications of pericardial fibrinolysis. Seventy-four cases of fibrinolysis in PP were analysed. Pericarditis of tuberculous origin were excluded. Among the 40 included cases, only two treated by late fibrinolysis encountered failure requiring pericardiectomy. No patient encountered clinical or echocardiographic features of constriction during follow-up. Only one serious complication was described. Despite the lack of definitive evidence, potential benefits of fibrinolysis as a less invasive alternative to surgery in the management of PP seem promising. Early consideration should be given to fibrinolysis in order to prevent both constrictive and persistent PP. Nevertheless, in case of failure of fibrinolysis, pericardiectomy remains the primary option for complete eradication of infection.Critical care (London, England) 04/2011; 15(2):220. DOI:10.1186/cc10022 · 5.04 Impact FactorThis article is viewable in ResearchGate's enriched formatRG Format enables you to read in context with side-by-side figures, citations, and feedback from experts in your field.
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ABSTRACT: The objective of this study is to assess the safety of fibrinolytic therapy using tissue plasminogen activator (tPA) in children with complex intra-abdominal abscesses. Intra-abdominal abscesses are common in children. Antibiotics and percutaneous drainage are the mainstays of treatment, but drainage may be less effective when the fluid is thick or septated. Fibrinolytic therapy using tPA is effective in a rat model of intra-abdominal abscesses, has recently been reported for the treatment of intra-abdominal abscesses in adults, and is commonly used in the treatment of empyema in children. This is a retrospective review of all patients over a 10-year period who had intra-abdominal collections managed with tPA abscess drainage. Sixty-four children had a total of 66 drains placed and 92 doses of tPA. Appendicitis was the cause of the abscesses in 52 of 64 children. Mean length of stay pre-tPA was 11.7 ± 7.63 days, mean time from drain insertion to tPA was 4.3 ± 3.78 days, and mean time from tPA to discharge was 8.6 ± 8.85 days. Thirty patients underwent an operation before tPA administration. No patients experienced bleeding complications, anastomotic or appendiceal stump leak, or wound dehiscence after the administration of tPA, and no patients had abnormalities in coagulation studies related to tPA administration. One child died of sepsis. Tissue plasminogen activator is safe for the management of thick or septated intra-abdominal abscesses in children. A prospective controlled study will be needed to evaluate the efficacy of this technique.Journal of Pediatric Surgery 07/2012; 47(7):1380-4. DOI:10.1016/j.jpedsurg.2011.12.006 · 1.31 Impact Factor