Intrapleural Streptokinase in Parapneumonic / Complicated Pleural Effusion/Empyema: Experience in Dhaka Shishu (Children) Hospital

Background: Parapneumonic effusion/complicated pleural effusion/empyema thoracis in children causes significant morbidity. Standard treatment of pleural effusion includes tube drainage and antibiotics. But the tube drainage often fails. Intrapleural Streptokinase has been used in empyema thoracis as well as complicated pleural effusion with good success rate. Though its efficacy is documented in Western literatures and textbooks, there are no clinical trials in children has been reported from Bangladesh. Objectives: We evaluated the efficacy of intra-pleural Streptokinase in the management of Parapneumonic effusion / complicated pleural effusion/ empyema thoracis even in advanced stages. Patients and Methods: A total of 3 patients with parapneumonic effusion requiring intercostal tube drainage, aged 4 year 6 month to twelve years were included in the study who were admitted in Pediatric respiratory medicine unit in Dhaka Shishu (Children) Hospital. Intercostal chest tube drain was given in all patients and inj: Streptokinase (10,000 units/kg/dose) was instilled into the pleural cavity and kept the Streptokinase for 4 hour in pleural cavity. Response was assessed by clinical outcome, after unclamping and serial chest ultrasounds and subsequent chest radiography. Results: Streptokinase enhanced drainage of pleural fluid and complete resolution of effusion in all the 3 patients. Conclusions: Intrapleural Streptokinase is the preferred treatment for treating pediatric empyema/parapneumonic effusion/complicated pleural effusion even in advanced stages and can avoid surgery. Bangladesh J Child Health 2020; VOL 44 (2) :104-108

Spontaneous Septic Embolic Encephalitis and Endophthalmitis in a Recovering Polytrauma Patient: A Case Report

In polytrauma cases with thoracic injury and long-term chest tube drain, there is a risk of pulmonary arteriovenous fistula formation, which mostly remains undiagnosed. The pulmonary arteriovenous fistulas lead to the right to left shunt and could be a potential source of systemic septic embolism. Here, we describe a recovering polytrauma patient, who spontaneously developed septic embolic encephalitis and endogenous endophthalmitis, with no evident source of septic systemic embolism. We suspect the pulmonary arteriovenous fistulas due to thoracic injury or chest tube drain could be the possible source of septic systemic embolism, which needs to be evaluated in such cases after excluding common causes.

A Bullet Injury to the Liver Complicated by Biliary Broncho Pleural Fistula and IVC Thrombosis: Case Presentation and Review for Management Guidelines

This is a case report of a 20-year-old male who presented to our hospital after sustaining a gunshot to the left upper abdominal quadrant with an exit right below the right scapula. On investigation, he was found to have a large right sided hemothorax and an extensive laceration in the liver. A right chest tube drain was inserted, initially drained blood and days later started draining bile. Consequently, the patient started coughing up bile and diagnosis of a biliary-broncho-pleural fistula was made. ERCP with sphincterotomy and stenting of a left hepatic duct injury was subsequently performed. The patient also developed an IVC thrombus that was discovered incidentally on follow up imaging and was treated with anticoagulation

Penetrating Chest Trauma

This case describes the management of penetrating trauma to the abdomen and thorax caused by a rocket-propelled grenade. The patient presents with an open pneumothorax, which should be initially managed in the field with a 3-sided occlusive dressing or, ideally, with an Asherman chest seal. Definitive management includes placement of a chest tube drain and possibly surgical exploration and repair.

A stress ulcer duodenal perforation complicating diaphragmatic rupture with multiple bone fracture in a polytrauma patient due to fall from a tree

Polytrauma in a 55 years male due to blunt trauma like fall from a height involving fracture of long bones, undisplaced fracture pelvis, fracture multiple ribs with a preliminary diagnosis of eventration of the hemidiaphragm in a apparently hemodynamically stable patient with a normal CT scan of brain, though poses a major physiological challenge, however runs a better prognosis. But with the passing of hours as patient develops respiratory distress and chest and abdomen CECT confirms a large lacerated hemidiaphragm with herniation of abdominal visceras occupying the hemithorax with lung collapse, alarms the gravity of the injury. An uncommon stress ulcer duodenal perforation on the 2nd day of admission with ensuing pyoperitoneum further threatens the hemodynamics and enhances the morbidity and mortality. This warrants an active and prompt action by multispecialty involvement. Emergency laparotomy to address the pyoperitoneum, closure of the duodenal perforation, reduction of the herniated abdominal visceras from the hemithorax, thorough saline lavage of the abdominal and involved chest cavity, placement of intrathoracic chest tube drain, repair of the lacerated diaphragm, placement of peritoneal cavity drains and closure of the abdomen settles the issue of damage control surgery in this case. Postoperative care in the ICU with ventilator support, higher antibiotics and supportive medications, repeated laboratory and radiological tests helps in overcoming the hemodynamic crisis in such critically ill patients. Our patient subsequently developed pneumonitis and had a postoperative protracted course in the ICU and finally shifted to the general ward on 7th day of his admission.

Enhanced Effective Fibrinolysis following the Neutralization of Heparin in Open Heart Surgery Increases the Risk of Post-Surgical Bleeding

SummaryThe tissue-type plasminogen activator related fibrinolytic system was studied in 24 patients undergoing cardiopulmonary bypass surgery. The degradation of fibrinogen and fibrin was followed during and after surgery by means of new sensitive and specific assays and the changes were related to the blood loss measured in the chest tube drain during the first 24 postoperative hours. Although tissue-type plasminogen activator was significantly released into the circulation during the period of extracor-poreal circulation (p <0.01), constantly low levels of fibrinogen degradation products indicated that a systemic generation of plasmin could be controlled by the naturally occurring inhibitors. Following extracorporeal circulation heparin was neutralized by protamine chloride, and in relation to the subsequent generation of fibrin, there was a short period with increased concentrations of fibrinogen degradation products (p <0.01) and a prolonged period of degradation of cross-linked fibrin, as detected by increased concentrations of D-Dimer until 24 h after surgery (p <0.01). Patients with a higher than the median blood loss (520 ml) in the chest tube drain had a significantly higher increase of D-Dimer than patients with a lower than the median blood loss (p <0.05).We conclude that the incorporation of tissue-type plasminogen activator into fibrin and the in situ activation of plasminogen enhance local fibrinolysis, thereby increasing the risk of bleeding in patients undergoing open heart surgery