Management of Chest Catheter After Intrapleural Fibrinolysis
After administering intrapleural fibrinolytic therapy (alteplase, urokinase, or streptokinase), the chest catheter should be clamped for a dwell time of 1-2 hours, then opened to suction drainage—not left continuously open during the treatment period. 1, 2
Standard Post-Fibrinolysis Protocol
The evidence-based approach involves:
Clamp the catheter for 60-120 minutes after fibrinolytic instillation to allow the agent adequate contact time with fibrinous septations and loculations 3, 2
After the dwell period, open the catheter to suction drainage to evacuate lysed material and fluid 2
Repeat this cycle daily for the standard 3-day treatment course recommended by the British Thoracic Society 1
Specific Dosing and Timing Details
The British Thoracic Society protocol specifies:
Streptokinase: 250,000 IU in 100 mL normal saline, instilled twice daily, clamped for 6-12 hours between doses 1, 2
Urokinase: 100,000 IU in 100 mL normal saline, instilled once daily, clamped for 6-12 hours 1, 2
Alteplase: 2-5 mg instilled, clamped for 60-120 minutes (shorter dwell time than other agents) 3
Critical Management Points
Monitor catheter patency before attributing poor drainage to loculations:
If the catheter appears blocked, flush with 20-50 mL normal saline before assuming treatment failure 1, 4
A blocked catheter should be flushed, not left with fibrinolytic dwelling indefinitely 5
Assess treatment response at 5-8 days after initiating chest tube drainage and fibrinolytic therapy 1, 4
Resolution of fever and sepsis indicates successful therapy 1
Persistent sepsis despite adequate drainage position (confirmed by CT) indicates treatment failure requiring surgical consultation 4
Common Pitfalls to Avoid
Do not leave the catheter continuously open during fibrinolytic instillation - this defeats the purpose of allowing adequate dwell time for the agent to lyse fibrinous material 2
Do not continue fibrinolytic therapy beyond 3 days without clinical reassessment - the standard course should prompt evaluation for surgical intervention if drainage remains inadequate 1, 4
Do not delay surgical consultation beyond 5-8 days if effective pleural drainage has not been achieved despite fibrinolytic therapy 1, 4
Ensure proper catheter positioning - if CT shows malpositioned tube or undrained loculations, reposition the existing catheter or place additional tubes under image guidance rather than continuing ineffective fibrinolytic therapy 4
Safety Considerations
Fever is common, particularly with streptokinase, and does not necessarily indicate treatment failure 1
Rare bleeding complications (pleural hemorrhage, epistaxis) can occur, with alteplase showing higher bleeding rates than urokinase in comparative studies 1, 6
Patients receiving streptokinase must be given an exposure card and should receive alternative agents (urokinase or alteplase) for any future systemic indications 1