What are the options and doses for irrigation fluid and medications used with the Modified Clagett procedure for empyema, specifically regarding inflow and outflow tubes?

From the Guidelines

The modified Claggett procedure for empyema involves irrigation of the pleural space using inflow and outflow tubes, with normal saline (0.9% NaCl) being the most commonly used irrigation solution, typically infused at rates of 100-250 mL/hour continuously for 7-14 days, as recommended by the British Thoracic Society guideline for pleural disease 1. The irrigation solution can be supplemented with antibiotic solutions, such as gentamicin (80-240 mg daily) and vancomycin (1-2 g daily), or mucolytic agents like N-acetylcysteine (10-20 mL of 10-20% solution diluted in 100-200 mL saline) for viscous collections. Some key points to consider when using the modified Claggett procedure include:

• The use of urokinase, which appears to reduce the need for thoracic surgery, hasten the time to resolution of fever, and reduce the length of hospital stay compared with placebo or standard care in adults with pleural infection 1.
• The use of TPA plus DNAse, which may reduce the length of hospital stay, reduce the likelihood of persistent fevers, and increase improvements in CXR opacification, but may also increase the risk of post-treatment complications 1.
• The temperature of the irrigation fluid should be close to body temperature (37°C) to prevent patient discomfort.
• The total daily volume of irrigation fluid can range from 2-6 liters, depending on the size of the empyema cavity and clinical response.
• The irrigation is typically continued until the effluent is clear and pleural fluid cultures are negative. It is also important to note that:
• Streptokinase appears to have no effect on mortality, length of hospital stay, the need for thoracic surgery, or radiographic resolution of effusion for the treatment of pleural infection, and may increase post-treatment complications 1.
• Single agent TPA or single agent DNAse do not appear to improve clinical outcomes when compared with placebo for treating pleural infection 1.
• Saline irrigation (250 mL saline three times a day) may reduce the need for thoracic surgery, but appears to have no impact on mortality, length of hospital stay, or time to resolution of fever when compared with saline flushes 1. In terms of specific dosing and administration, urokinase can be given twice daily for 3 days (6 doses in total) using 40,000 units in 40 ml 0.9% saline for children weighing 10 kg or above, and 10,000 units in 10 ml 0.9% saline for children weighing under 10 kg, as recommended by the BTS guidelines for the management of pleural infection in children 1.

From the Research

Options and Doses of Irrigation Fluid/Medications

• The modified Clagett procedure involves instillation of antibiotic solutions into the pleural space, with reported options including:
  • Kanamycin 500 mg and polymyxin sulfate 500,000 units dissolved in 10-100 ml saline 2
  • Gentamicin 80 mg/L, neomycin 500 mg/L, and polymyxin B 100 mg/L in 2 L of debridement antibiotic solution (DAB solution) 3
• Infusion rates are not explicitly stated in the provided studies, but the procedures involve filling the pleural space with the antibiotic solution and then removing the irrigation and drainage catheters 2, 3

Infusion Rates and Administration

• The studies do not provide detailed information on infusion rates, but rather focus on the overall procedure and outcomes
• Administration of the irrigation fluid/medications is typically performed via tube thoracostomy, with the chest tube clamped overnight and then removed 2
• In some cases, the procedure may involve repeated irrigation and drainage, followed by closure of the pleural space with an antibiotic solution 3

Reported Outcomes and Efficacy

• The modified Clagett procedure has been reported to be effective in treating empyema, with successful outcomes in various studies 2, 4, 5, 3
• The procedure has been shown to reduce morbidity and hospitalization time compared to traditional treatments 3
• However, the success rate of the procedure can be influenced by factors such as the presence of a bronchopleural fistula 6