Réanimation médico – chirurgicale CH SAINTES ARCO 2005 Réanimation médico – chirurgicale CH SAINTES

ARDS – PLEUROPNEUMOPATHIE – FIBRINOLYSE PLEURALE Mr P 34 ans Admis en HGE pour diarrhées, vomissement, fièvre, frisson, douleur thoracique et ictère Tabac 1 pqt /j Alcoolique chronique

ARDS – PLEUROPNEUMOPATHIE – FIBRINOLYSE PLEURALE Evolution marquée: par une hépatite supposée alcoolique aiguë non corticothérapée (Madray < 31) Fièvre motivant AAC débuté à J3 Découverte d’un épanchement pleural et échec de ponction pleurale à J4 puis à J5, détresse respiratoire aiguë

ARDS – PLEUROPNEUMOPATHIE – FIBRINOLYSE PLEURALE A l’admission en réa: 38°C FC 140 /min, TA 15/7 FR 32 /min, tirage, SpO2 80% (O2 15l/min au MAR) Encéphalopathie Ictère PaO2 8,7 Kpa / FiO2 100% 23700 GB BiliT 137 ASAT 107, ALAT 70 TP 42% PLQ 45000 LBA : 104 cfu/ml S intermedius

ARDS – PLEUROPNEUMOPATHIE – FIBRINOLYSE PLEURALE Intubation Evacuation après drainage thoracique: 100cc Fibrinolyse pleurale: 720 cc GSA sous FiO2 100% - PEP 10 : PaO2: 9,8 Kpa

ARDS PLEURO PNEUMOPATHIE FIBRINOLYSE PLEURALE Mr P J1 REA

ARDS – PLEUROPNEUMOPATHIE – FIBRINOLYSE PLEURALE J3 réanimation: Arrêt du NO PaO2: 17 Kpa / FiO2 60 % PEP 8 38,5°C Extubation à J9

ARDS – PLEUROPNEUMOPATHIE – FIBRINOLYSE PLEURALE Mme M 46 ans Admise en pneumologie pour pneumopathie Tabac 1 pqt/j Alcool ++++ Mise sous augmentin + O2

ARDS – PLEUROPNEUMOPATHIE – FIBRINOLYSE PLEURALE Evolution marquée par une aggravation progressive avec détresse respiratoire aiguë. Echec de ponction pleurale à J3 J1 J3 J3

ARDS – PLEUROPNEUMOPATHIE – FIBRINOLYSE PLEURALE A l’admission en réa à J4: 38°2 C FR 32/min, SpO2 89 %, tirage TA 12/7 17000 GB Liquide pleural: Gly<0,1g/l LDH>15000 Protides > 45 g/l BNP 32 Echographie cardiaque normale

ARDS – PLEUROPNEUMOPATHIE – FIBRINOLYSE PLEURALE

ARDS – PLEUROPNEUMOPATHIE – FIBRINOLYSE PLEURALE Poursuite Antibiothérapie AAC et lévofloxacine Drainage de 150 cc Fibrinolyse intrapleurale avec évacuation de 1225 cc À J6 et 48 h de réanimation: PaO2 23 Kpa (lunettes) Apyrexie Sortie de réa après 72h

ARDS – PLEUROPNEUMOPATHIE – FIBRINOLYSE PLEURALE TDM à J7 Sortie de réanimation

ARDS – PLEUROPNEUMOPATHIE – FIBRINOLYSE PLEURALE Mme R 36 ans Admise en HGE pour AEG Alcoolisme chronique

ARDS – PLEUROPNEUMOPATHIE – FIBRINOLYSE PLEURALE Dégradation progressive malgré AAC. À J2 fibro bronchique + LBA : 105-6 S aureus MR. Adjonction de roxythromicine puis de teicoplanine. Evolution vers détresse respiratoire majeure.

PLEUROPNEUMOPATHIE – FIBRINOLYSE PLEURALE A l’admission en réa : 35.5°C – dénutrition – Encéphalopathe - Cyanose, FR 40/min - FC 145/min, TA 80/45 - Oligurie, clairance créat 15ml/min - 18700 GB, 80000 plq -Échocardiographie normale

ARDS – PLEUROPNEUMOPATHIE – FIBRINOLYSE PLEURALE TDM après évacuation pleurale droite

ARDS – PLEUROPNEUMOPATHIE – FIBRINOLYSE PLEURALE Intubation Évacuation pleurale D: 380 cc Drainage G: 80 cc Fibrinolyse pleurale G: 700 cc GSA: (FiO2 100% - PEP 5) pH 7,19 PaCO2 7,5 PaO2 19,5 Levophed 0,8 gamma/kg/min

PLEUROPNEUMOPATHIE – FIBRINOLYSE PLEURALE J3 : PaO2: 17,5 / FiO2: 50 % - Sevrage du lévophed - Clairance: 44 ml/min J6 sortie de réa

PLEURESIES BACTERIENNES TRAITEMENT : évacuation –fibrinolytiques (Bouros . AJRCCM 1999)

PLEURESIES BACTERIENNES TRAITEMENT : évacuation (Colice CHEST 2000)

PLEURESIES BACTERIENNES TRAITEMENT : évacuation (Colice CHEST 2000)

A Randomized Trial of Empyema Therapy* Michael A. Wait, MD, FCCP; Sashi Sharma, MD; Joyce Hohn, MD; and Anthony Dal Nogare, MD Study objectives: To determine the optimal treatment of empyema thoracis (within the fibrino-purulent phase of illness) comparing pleural drainage and fibrinolytic therapy vs video-assisted thoracoscopic surgery (VATS), with regard to efficacy and duration of hospitalization. Design: Twenty patients with confirmed parapneumonic empyema thoracis were randomized to chest tube pleural drainage plus streptokinase (CT-SK) vs VATS. Setting: University-based teaching hospital providing for Dallas County. Patients and methods: Equivalent groups of patients with parapneumonic empyema thoracis were randomized to receive either of two therapies: CT-SK (n59) or VATS (n511). Outcomes analysis with respect to treatment efficacy, hospital duration, chest tube duration, hospital costs, and need for subsequent procedures was performed. Results: Each group suffered one mortality (p5not significant). When compared with the CT-SK group, the VATS group had a significantly higher primary treatment success [10/11, 91% vs 4/9, 44%; p<0.05 Fisher’s Exact Test], lower chest tube duration (5.861.1 vs 9.861.3 days; p50.03), and lower number of total hospital days (8.760.9 vs 12.861.1 days; p50.009). Clinically relevant but not statistically significant differences in hospital costs ($16,64262,841 vs $24,05263,466, p50.11) also favored the VATS group. Of note, all the CT-SK treatment failures could be salvaged with VATS, and none required thoracotomy. Conclusions: In patients with loculated, complex fibrinopurulent parapneumonic empyema thoracis, a primary treatment strategy of VATS is associated with a higher efficacy, shorter hospital duration, and less cost than a treatment strategy that utilizes catheter-directed fibrino-lytic therapy. (CHEST 1997; 111:1548-51)

Controlled Trial of Intrapleural Streptokinase in the Treatment of Pleural Empyema and Complicated Parapneumonic Effusions* Nyat Kooi Chin, MBBS; and Tow K. Lim, MBBS Objective: To compare the efficacy of adjunctive intrapleural streptokinase (SK) with simple closed chest tube drainage (Drain) in the treatment of empyemas and complicated parapneumo-nic effusions. Method: This was a controlled study of 52 patients (mean age, 57 years; 41 men) with pleura space sepsis. Forty patients (77%) had empyema and 12 had complicated parapneumonic effusions. Twenty-nine patients were treated with Drain only while 23 received, in addition, repeated daily SK, 250,000 U in saline solution (mean, 5.3 days). Results: The two groups of patients had comparable degrees of peripheral blood leukocytosis, frequency of loculated effusions, pleural fluid pH, and lactate dehydrogenase levels. Infective organisms were isolated in 54% of which 32% were anaerobic and 21% were polymicrobial infections. The incidence of surgical decortication was 17% and mortality was 15%. A significantly larger volume of pleural fluid was drained from patients in the SK treatment group (2.0 [1.5] L) than those in the Drain treatment group (1.0 [1.01] L). There were no significant differences, however, between the two treatment groups in terms of duration before defervescence, duration of hospital stay, the need for surgical intervention, or mortality rates. Conclusion: We conclude that thrombolytic therapy increased the volume of fluid drained from pleural empyemas but did not markedly reduce morbidity and mortality. (CHEST 1997; 111:275-79)

American Journal of Respiratory and Critical Care Medicine Vol 170. pp American Journal of Respiratory and Critical Care Medicine Vol 170. pp. 49-53, (2004) Intrapleural Streptokinase for Empyema and Complicated Parapneumonic Effusions Andreas H. Diacon, Johan Theron, Macé M. Schuurmans, Bernard W. Van de Wal and Chris T. Bolliger We conducted a single-center, randomized, placebo-controlled trial to determine whether streptokinase instillations adjunctive to chest tube drainage reduce the need for surgery and improve outcome in patients with pleural empyema. Fifty-three patients (frank pus aspirated, 81%; microbiological agent cultured, 62%; mean effusion pH, 6.6 ± 0.4) received antibiotic treatment, chest tube drainage, and once-daily pleural rinses with either normal saline or normal saline with streptokinase (250,000 IU). Nine patients were excluded for various reasons before pleural rinses were started. Streptokinase (n = 22) was instilled over 4.5 ± 2 days and saline (n = 22) was instilled over 3 ± 1.3 days. One patient in each group died during treatment. Clinical treatment success and need for referral to surgery were the main outcome measures. No difference was observed after 3 days. After 7 days, streptokinase-treated patients had a higher clinical success rate (82 vs. 48%, p = 0.01) and fewer referrals for surgery (45 vs. 9%, p = 0.02). No significant radiologic or functional differences were observed between groups during follow-up over 6 months. We conclude that intrapleural streptokinase adjunctive to chest tube drainage reduces the need for surgery and improves the clinical treatment success in patients with pleural empyema.

Am. J. Respir. Crit. Care Med Am. J. Respir. Crit. Care Med., Volume 159, Number 1, January 1999, 37-42 Intrapleural Urokinase versus Normal Saline in the Treatment of Complicated Parapneumonic Effusions and Empyema. A Randomized, Double-Blind Study DEMOSTHENES BOUROS, SOPHIA SCHIZA, NIKOLAOS TZANAKIS, GEORGE CHALKIADAKIS, JOHN DROSITIS, and NIKOLAOS SIAFAKAS Intrapleural administration of fibrinolytic agents has been shown to be effective and safe in the treatment of loculated parapneumonic pleural effusions. However, controlled studies of the possible role of the activity of urokinase (UK) through the volume effect are lacking. We therefore investigated the hypothesis that UK is effective through the lysis of pleural adhesions and not through the volume effect. Thirty-one consecutive patients with multiloculated pleural effusions were randomly assigned to receive either intrapleural UK (15 patients) or normal saline (NS) (16 patients) for 3 d, in a double-blind manner. All patients had inadequate drainage through a chest tube (< 70 ml/24 h). UK was given daily through the chest tube in a dose of 100.000 IU diluted in 100 ml of NS. Controls were given the same volume of NS intrapleurally. Response was assessed by clinical outcome, fluid drainage, chest radiography, pleural ultrasonography (US) and/or computed tomography (CT). Clinical and radiographic improvement was noted in all but two patients in the UK group but in only four in the control group. The net mean volume drained during the 3-d treatment period was significantly greater in the UK group (970 ± 75 ml versus 280 ± 55 ml, p < 0.001). Pleural fluid drainage was complete in 13 (86.5%) patients in the UK group (two patients were treated through video-assisted thoracoscopy) but in only four (25%) in the control group. Twelve patients in the control group were subsequently treated with UK and six of them had complete drainage; the remaining six patients had complete drainage after video-assisted thoracoscopy. Our results suggest that UK is effective in the treatment of loculated pleural effusions through the lysis of pleural adhesions and not through the volume effect.

Am. J. Respir. Crit. Care Med Am. J. Respir. Crit. Care Med., Volume 159, Number 1, January 1999, 37-42 Intrapleural Urokinase versus Normal Saline in the Treatment of Complicated Parapneumonic Effusions and Empyema. A Randomized, Double-Blind Study DEMOSTHENES BOUROS, SOPHIA SCHIZA, NIKOLAOS TZANAKIS, GEORGE CHALKIADAKIS, JOHN DROSITIS, and NIKOLAOS SIAFAKAS * * * * = p < 0.001

Am. J. Respir. Crit. Care Med Am. J. Respir. Crit. Care Med., Volume 159, Number 1, January 1999, 37-42 Intrapleural Urokinase versus Normal Saline in the Treatment of Complicated Parapneumonic Effusions and Empyema. A Randomized, Double-Blind Study DEMOSTHENES BOUROS, SOPHIA SCHIZA, NIKOLAOS TZANAKIS, GEORGE CHALKIADAKIS, JOHN DROSITIS, and NIKOLAOS SIAFAKAS