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ARCO 2005

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.

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ARCO 2005

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  1. ARCO 2005 Réanimation médico – chirurgicale CH SAINTES

  2. 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

  3. 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

  4. 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

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

  6. ARDS PLEUROPNEUMOPATHIE FIBRINOLYSE PLEURALEMr PJ1 REA

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

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

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

  10. 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

  11. ARDS – PLEUROPNEUMOPATHIE – FIBRINOLYSE PLEURALE

  12. 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

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

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

  15. 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.

  16. 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

  17. ARDS – PLEUROPNEUMOPATHIE – FIBRINOLYSE PLEURALE TDM après évacuation pleurale droite

  18. 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

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

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

  21. PLEURESIES BACTERIENNES TRAITEMENT : évacuation (Colice CHEST 2000)

  22. PLEURESIES BACTERIENNES TRAITEMENT : évacuation (Colice CHEST 2000)

  23. 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)

  24. 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)

  25. 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-controlledtrial to determine whether streptokinase instillations adjunctiveto chest tube drainage reduce the need for surgery and improveoutcome 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 eithernormal saline or normal saline with streptokinase (250,000 IU).Nine patients were excluded for various reasons before pleuralrinses were started. Streptokinase (n = 22) was instilled over4.5 ± 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 surgerywere the main outcome measures. No difference was observed after3 days. After 7 days, streptokinase-treated patients had a higherclinical success rate (82 vs. 48%, p = 0.01) and fewer referralsfor surgery (45 vs. 9%, p = 0.02). No significant radiologicor functional differences were observed between groups duringfollow-up over 6 months. We conclude that intrapleural streptokinaseadjunctive to chest tube drainage reduces the need for surgeryand improves the clinical treatment success in patients withpleural empyema.

  26. 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 parapneumonicpleural effusions. However, controlled studies of the possiblerole of the activity of urokinase (UK) through the volume effectare lacking. We therefore investigated the hypothesis that UKis effective through the lysis of pleural adhesions and not throughthe volume effect. Thirty-oneconsecutive patientswith multiloculatedpleural effusions were randomly assigned to receive eitherintrapleuralUK (15 patients) or normal saline (NS) (16 patients)for 3 d,in a double-blind manner. All patients had inadequate drainagethrough a chest tube (< 70 ml/24 h). UK was given daily throughthe chest tube in a dose of 100.000 IU diluted in 100 ml of NS.Controls were given the same volume of NS intrapleurally. Responsewas 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 twopatients in the UK group but in only four in the control group.The net mean volume drained during the 3-d treatment period wassignificantly 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 throughvideo-assisted thoracoscopy) but in only four (25%) in the controlgroup. Twelve patients in the control group were subsequentlytreated with UK and six of them had complete drainage; the remainingsix patients had complete drainage after video-assisted thoracoscopy. Our results suggest that UK is effective in the treatment of loculatedpleural effusions through the lysis of pleural adhesions and notthrough the volume effect.

  27. Am. J. Respir. Crit. Care Med., Volume 159, Number 1, January 1999, 37-42Intrapleural 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

  28. Am. J. Respir. Crit. Care Med., Volume 159, Number 1, January 1999, 37-42Intrapleural 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

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