Treatment of Complicated Parapneumonic Effusion With Fibrinolytic Therapy Versus VATs Decortication
Treatment of Complicated Parapneumonic Effusion With Fibrinolytic Therapy Versus VATs Decortication
This study aims to standardize the treatment of pleural space (parapneumonic) infections by
 comparing the difference in outcomes between 2 methods of treatment: early VATS (Video
 Assisted Thorascopic Surgery) decortication versus fibrinolytic therapy. During treatment,
 the patient's coagulopathy status will also be evaluated.
The treatment of parapneumonic infections (infection in the pleural space) at the Denver
 Health Medical Center is not standardized, and timing for advanced interventions such as
 fibrinolytic therapy or surgical decortication remain unclear. The definitive treatment
 strategy in these patients may be sub-optimal, and lead to prolonged hospitalization and
 morbidity. This is concerning as the mortality rate of community acquired pneumonia triples
 in the presence of a parapneumonic process (5-15%) and can reach over 25% if it becomes
 bilateral(1). Prompt recognition of pleural space infections is essential for reducing
 morbidity and mortality. This is attributable to the progression of the disease from a simple
 fluid collection amenable to pleural space drainage, to necrotizing empyema requiring
 thoracotomy decortication and open drainage. The keys to management of parapneumonic
 effusions are early diagnosis, appropriate therapeutic intervention, and recognition of
 failure of conservative management. The investigators propose that a standardized pathway for
 identifying and treating parapneumonic effusions will be an important quality improvement. A
 key gap in the literature remains if patients with parapneumonic infections that cannot be
 drained with a chest tube should undergo a trial in intrapleural fibrinolytic therapy, or if
 they should go directly to video assisted thoracic surgery (VATS) for decortication of all
 infectious material.
Inclusion Criteria:

 -  18 years old and older

 -  Admitted with pleural effusion that undergoes thoracentesis by medical/pulmonary
 service

 -  Pleural fluid pH <7.3

 -  SICU placed chest tube

 -  Subsequent transfer to SICU

 Exclusion Criteria:

 -  Existing malignancy

 -  Malignant cells from initial pleural fluid sample

 -  End stage liver disease (Child's B or greater)

 -  Coagulopathy

 -  Unable to tolerate surgical procedure

 -  Frank purulent drainage (needs OR regardless)

 -  Recent surgery of abdomen or thorax precluding the use of tPA

 -  Baseline neurologic impairment requiring a proxy for consent