Pleural infection guidelines (2019)


Rationale

PLEURAL INFECTION

• Mortality 10 - 20 %, incidence rising, associated with prolonged hospital stay

• Standard therapy (antibiotics and pleural drainage) fails in up to a 1/3; often due to the thickness of the fluid

and division of fluid into pockets; surgical referral may be necessary, but some patients are not fit for thisI

INTRAPLEURAL tPA AND DNase

tPA (Alteplase) - fibrinolytic agent - divides pleural septations

DNase (Pulmozyme) - decreases viscosity of pleural fluid

• Intrapleural tPA and DNase therapy in combination have been shown to improve fluid drainage and decrease

frequency of surgical referral and duration of hospital stay

Use

‘As rescue therapy in patients with empyema for whom conventional therapy (antibiotics and pleural drainage) has failed

and who are not fit enough for surgical intervention’

• Consultant Respiratory Physician decision to initiate

• Appropriate antibiotic therapy should continue

• Intercostal drain should be adequately sited, clearly patent and ideally have 3 way tap

• Usually allow 24-48 hour initial drainage before decide to use tPA and DNase

• Consider relative contraindications (including anticoagulation*, underlying lung/pleural disease, recent stroke,

recent trauma, recent surgery)

• Never give single agent therapy if one drug is unavailable

Procedure

1. PRESCRIPTION

NHS GRAMPIAN RESPIRATORY MEDICINE

Prescribe on Kardex: -

• tPA 5mg and DNase 5mg intrapleural twice daily, for 3 days – six doses.

• Record as note “Medical staff to administer”

• Fixed times – 0900 and 1600 to ensure junior medical staff available to administer

2. DRUG PREPARATION – for each dose:

tPA (Alteplase, Actilyse) – 5 mg

• Use 10mg vial of Actilyse (tPA)

• Mix drug ampoule with provided 10mls of water for injection (for reconstitution of vial see drug information

leaflet)

• Draw up 5ml into syringe** – thus containing 5mg tPA (don’t shake it)

• Further dilute with water for injection to total volume of 10ml

• ** Store remaining in fridge for use later; must be labelled with patient label, date and time

DNase (Pulmozyme) – 5mg

• In a separate syringe, draw up 5ml from two 2.5mg (2.5ml) vials of Pulmozyme

3. DRUG ADMINISTRATION

• Full aseptic technique throughout

• Ensure drain is functioning – consider flush first if not swinging

• Sequentially instil prepared 5mg tPA and then 5mg DNase via 3 way tap into pleural cavity

• Flush with further 20ml sterile water for injection

• Clamp drain/turn off at 3 way tap for 1 hour after each dose, then open between doses

4. REPEAT PROCEDURE TWICE DAILY FOR 3 DAYS (TOTAL 6 DOSES)

*Note: - if abnormal coagulation, thrombocytopenia, or on anticoagulant please discuss with consultant. A tPA dose of 2.5mg can be given at consultant discretion

Authors: K Douglas, M Chetty, A Copland Date of Approval: Dec 2018 Review Date: Dec 2019