Clinical and Experimental Pediatrics

The Korean Pediatric Society (대한소아청소년과학회)
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The effectiveness of urokinase in treatment of pleural effusion in children

소아의 흉수 치료에 있어서 유로키나제 효과

  • Nam, Ga-yeon (Department of Pediatrics, College of Medicine, Pusan National University) ;
  • Park, Hee-ju (Department of Pediatrics, College of Medicine, Pusan National University)
  • 남가연 (부산대학교 의과대학 소아과학교실) ;
  • 박희주 (부산대학교 의과대학 소아과학교실)
  • Received : 2007.05.08
  • Accepted : 2007.06.19
  • Published : 2007.07.15
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Abstract

Purpose : Pleural effusion is a common complications of pediatric bacterial pneumonia. Intrapleural administration of fibrinolytic agents such as urokinase have been used in the management of complicated parapneumonic effusions. But the safety and effectiveness of intrapleural urokinase instillations in children has not been confirmed. The aim of this study is to evaluate the safety and effectiveness of intraperitoneal urokinase in children. Methods : We reviewed a total of 29 children diagnosed as parapneumonic effusion with septation by chest CT or chest ultrasonography. We divided them into two groups. Fourteen children treated with urokinase after thoracostomy (Group A) were compared with 15 children treated only with thoracostomy (Group B). The urokinase, 3,000 IU/kg/day, was injected into the pleural cavity twice a day. Results : There was no statistical difference in sex and age between the two groups. Total drainage volume during thoracostomy in group A and B was 375.5 mL and 350.0 mL, respectively. It was not statistically significant. But the amounts of pleural fluid of group A on day 1, day 2 and day 3 were 102.5 mL, 100.0 mL, and 70.0 mL respectively and those of group B on day 1, day 2 and say 3 were 120.0 mL, 50.0 mL and 15.0 mL respectively. To compare group A with group B in the amounts of drainage volume on day 1 was not statistically significant, but the amounts of drainage volumes on day 2 and day 3 in group A were statistically more significant than group B (Day 1 P=0.371, Day 2 P=0.049, Day 3 P=0.048, respectively). The duration of fever, antibiotics, thoracostomy and total hospital days. Were not statistically significant between the two groups. But the frequency of complications in Group A was statictically significantly lower than in group B. Conclusion : Intrapleural instillation of urokinase facilitates the drainage of loculated pleural effusions, especially during the first 3 days, and it could reduce complications, such as pleural thickening, surgical managements, re-positioning of tube and re-thoracostomy. So intrapleural urokinase injection was and effective and safe treatment of pleural effusion in children (P=0.014).

서 론 : 유로키나제는 폐렴을 동반한 흉수 환아에서 흉관삽입술로도 배액이 어려운 경우 흉막강내로 주입함으로서 치료에 도움을 줄 수 있는 약제로 알려져있으나 소아를 대상으로 하여 유로키나제 사용에 대한 연구는 적고 아직 그 안정성과 효용성에 대한 보고도 미미한 실정이며, 국내에서 소아를 대상으로 한 보고는 거의 없는 실정이다. 방 법 : 2002년부터 2006년 7월까지 흉수 치료로 폐쇄식 흉관 삽입술을 시행하고 흉부 초음파 및 CT상 격막형성이 관찰된 29명의 환아를 대상으로 하였다. 폐쇄식 흉관 삽입술 시행하고 유로키나제 사용한 군(A군, 14명)과 유로키나제를 사용하지 않은 대조군(B군, 15명)을 후향적으로 조사하여 Mann-Whitney test, Fisher's exact test를 이용하여 비교하였다. 결 과 : 총 29명 중 A군과 B 군의 성별, 연령에 있어서의 차이는 없었다. 폐쇄식 흉관 삽입 기간동안의 총 흉수 배액량은 두군에서 통계적으로 유의한 차이를 보이지 않았고(P=0.776), 흉관 삽관 후 첫째날의 배액량은 통계적인 유의한 차이는 없었으나 둘째날과 셋째날은 통계적으로 의의있게 A군에서 배액량이 많았다(Day 1; P=0.371, Day 2: P=0.049, Day 3: P=0.048, respectively). 발열 일수, 항생제 사용 일수, 총 흉관 삽관 기간, 총 입원일수는 양군에서 통계적으로 유의한 차이를 보이지 않았다. 치료 종결 후 늑막 비후를 보인 경우, 내과적 치료 실패하여 수술이 필요했던 경우, 흉관의 위치 조정이나 흉관의 재삽입이 필요했던 경우는 A 군에서 1명, B군에서는 8명으로 A 군에서 통계적으로 의의있게 합병증의 빈도가 낮았다(P=0.014). 결 론 : 유로키나제의 사용으로 초기 효율적인 흉수의 배액이 가능하였고 흉막의 비후, 수술적 치료가 필요한 경우 흉관의 재삽입 또는 위치조정이 필요한 경우 등의 빈도가 더 낮아 유로키나제가 격막 형성된 폐렴성 흉수 환아의 치료에 안전하고 유용한 방법이었다.

Keywords

Acknowledgement

Supported by : 부산대학교 의과대학, 부산대학교 병원

References

  1. Freij BJ, Jusmiesz H, Nelson JD, Mccracken GH J. Parapneumonic effusions and empyema in hospitalized children: a retrospective review of 227 cases. Pediatr Infect Dis 1984;3:578-91 https://doi.org/10.1097/00006454-198411000-00021
  2. Taryle DA, Potts DE, Sahn SA. The incidence and clinical correlates of parapneumonic effusions in pneumonococcal pneumonia. Chest 1978;74:170-3 https://doi.org/10.1378/chest.74.2.170
  3. Sahn SA. Use of fibrinolytic agents in the management of complicated parapneumonic effusions and empyemas. Thorax 1998;53(2 suppl):65S-72S https://doi.org/10.1136/thx.53.2008.S65
  4. Heffner JE. Indications for draining a parapneumonic effusion: an evidence-based approach. Semin Respir Infect 1999;14:48-58
  5. Tillett WS, Sherry S. The effect in patients with streptococcal fibrinolysis (streptokinase) and streptococcal desoxyribonuclease on fibrinous purulent, and sanguinous pleural exudations. J Clin Invest 1949;28:173-90 https://doi.org/10.1172/JCI102046
  6. Tillett WS, Sherry S, Read CT. Use of streptokinase-streptodornase in the treatment of postpneumonic empyema. J Thorac Surg 1951;21:275-97
  7. Godley PJ, Bell RC. Major hemorrhage following administration of intrapleural streptokinase. Chest 1984;86:486-7 https://doi.org/10.1378/chest.86.3.486
  8. Holden RW. Plasminogen activators: pharmacology and therapy. Radiology 1990;174:993-1001 https://doi.org/10.1148/radiology.174.3.174-3-993
  9. Bryant RE, Salmon CJ. Pleural empyema. Clin Infect Dis 1996;22:747-62 https://doi.org/10.1093/clinids/22.5.747
  10. Robert GW, Peter CP. Intrapleural fibrinolysis for parapneumonic effusion and empyema in children, Radiology 2003;228:370-8 https://doi.org/10.1148/radiol.2282020486
  11. Moulton JS, Moore PT, Mencini RA. Treatment of loculated pleural effusions with transcatheter intracavitary urokinase. AJR 1989;153:941-5 https://doi.org/10.2214/ajr.153.5.941
  12. Lee KS, Im JG, Kim YH, Hwang SH, Bae WK, Lee BH. Treatment of thoracic multiloculated empyema with intracavitary urokinase: a prospective study. Radiology 1991;179:771-5 https://doi.org/10.1148/radiology.179.3.2027990
  13. Robinson LA, Moulton SL, Fleming WH, Alonso A, Galbraith TA. Intrapleural fibrinolytic treatment of multiloculated thoracic empyema. Ann Thorac Surg 1994;57:803-14 https://doi.org/10.1016/0003-4975(94)90180-5
  14. Pllack JS, Passik CS. Intrapleural urokinase in the treatment of loculated pleural effusions. Chest 1994;105:868-73 https://doi.org/10.1378/chest.105.3.868
  15. Moulton JS, Benkert RE, Wisiger KH, Chambers JA. Tretment of complicated pleural fluid collections with imageguided drainage and intracavitary urokinase. Chest 1995;108:1252-9 https://doi.org/10.1378/chest.108.5.1252
  16. Sankaran K, Nikhil A, Allen JD, Gustaco S. Urokinase in the management of complicated parapneumonic effusions in children. Chest 1997;112:1579-83 https://doi.org/10.1378/chest.112.6.1579
  17. Bouros D, Schiza S, Tzanakis N, Chalkiadakis G, Drositis J, Siafakas NM. Intrapleural urokinase versus noraml saline in the treatment of complicated parapneumonic effusion and empyema. Ann J Respir Crit Care Med 1999;159:37-42 https://doi.org/10.1164/ajrccm.159.1.9803094
  18. De Benedictis FM, De Giorgi G, Niccoli A, Troiani S, Rizeo F, Lemmi A. Treatment of complicated pleural effusion with intracavitary UK in children. Pediatri Pulmonol 2000;29:438-42 https://doi.org/10.1002/(SICI)1099-0496(200006)29:6<438::AID-PPUL5>3.0.CO;2-N
  19. Kornecki A, Sivan Y. Treatment of loculated pleural effusion with intrapleural urokinase in children. J pediatr surg 1997;32:1473-5 https://doi.org/10.1016/S0022-3468(97)90566-2
  20. Stringel G, Hartman AR. Interapleural instillation of urokinase in the treatment of loculated pleural effusion in children. J Pediatr surg 1994;19:1539-40
  21. Krishnan S, Amin N, Dozor AJ, Stringel G. Urokinase in the management of complicated parapnemonic effusion in children. Chest 1997;112:1579-83 https://doi.org/10.1378/chest.112.6.1579
  22. Cochran JB, Tecklenburg FW, Turner RB. Intrapleural instillation of fibrinolytic agents for treatment of pleural empyema. Pedatr Crit Care Med 2003;4:39-43 https://doi.org/10.1097/00130478-200301000-00007
  23. Lijnen HR, Collen D. Molecular mechanism of thrombolytic therapy. Hemostasis 1986;16:3
  24. Bouros D, Schiza S, Patsourakis G, Chalkiadakis G, panagou P, Siafakas NM. Intrapleural streptokinase versus urokinase in the treatment of complicated parapneumonic effusions: a prospective, double-blind study. Am J Respir Crit Care Med 1997;155:291-5 https://doi.org/10.1164/ajrccm.155.1.9001327
  25. Najib MR, Stephen JC, Rovert JO. The approach to the patient with a parapneumonic effusion. Clin Chest Med 2006;27:253-66 https://doi.org/10.1016/j.ccm.2005.12.005
  26. Fraedrich G, Hofmann P, Effenhauser P. Instillation of fibrinolytic enzymes in the treatment of pleural empyema. Thrac Cardiovasc Surg 1982;30:36-8 https://doi.org/10.1055/s-2007-1022203
  27. Borbato A, Panizzolo C, Moncioltti C, Marcucci C, Stefanutti G, Gamba PG. Use of urokinase in childhood pleural empyema. Pediatr Pulmonology 2003;35:50-5 https://doi.org/10.1002/ppul.10212
  28. Rosen H, Nadkarni V, Theroux M, Padman R, Klein J. Intrapleural streptokinase as adjunctive treatment for persistent empyema in pediatric patients. Chest 1993;103:1190-3 https://doi.org/10.1378/chest.103.4.1190