What are the recommended intrapleural and intrapericardial streptokinase doses for breaking fibrinous strands or loculations?

Streptokinase Dosing for Intrapleural and Intrapericardial Fibrinolysis

For pleural cavity loculations, administer streptokinase 250,000 IU twice daily for 3 days (or alternatively urokinase 100,000 IU once daily for 3 days), and for pericardial cavity loculations, use streptokinase 500,000 IU every 12 hours for three doses (total 1,500,000 IU over 24 hours). 1, 2

Intrapleural Dosing (Pleural Cavity)

Standard Regimen

• Streptokinase 250,000 IU twice daily for 3 days is the guideline-recommended dose for breaking fibrinous strands and loculations in pleural infections 1
• Dissolve each dose in 100 mL normal saline and instill through the chest tube 3
• Clamp the chest tube for 3 hours after instillation to allow drug contact with loculations 3
• This regimen improves radiological outcomes and is recommended by the British Thoracic Society guidelines 1

Alternative Pleural Dosing

• Urokinase 100,000 IU once daily for 3 days is an equally effective alternative with potentially fewer immunological side effects 1, 4
• Urokinase may be preferred due to its non-antigenic properties and once-daily dosing convenience 4
• Both agents achieve similar clinical response rates (approximately 80%) and radiologic improvement (40-45%) 4

Administration Technique for Pleural Space

• Instill fibrinolytic through existing chest tube or pigtail catheter 3, 4
• Administer over 10-15 minutes 3
• Keep tube clamped for 3 hours post-instillation 3
• Resume drainage after clamping period 3
• Typically requires 2-8 instillations per patient (mean 3.7) for complete resolution 3

Intrapericardial Dosing (Pericardial Cavity)

Standard Regimen

• Streptokinase 500,000 IU dissolved in 50 mL normal saline administered intrapericardially 2
• Repeat dosing at 12 and 24 hours (three total doses) 2
• Total cumulative dose: 1,500,000 IU over 24 hours 2
• This regimen effectively dissolves fibrin layers and removes loculations in purulent pericarditis 2, 5

Administration Technique for Pericardial Space

• Requires prior subxiphoid pericardiotomy with drainage catheter placement 2, 5
• Instill through the pericardial drainage catheter over 10 minutes 2
• No clamping period specified for pericardial administration 2
• Clinical effect typically evident within several days, with cessation of purulent drainage 2

Critical Safety Considerations

Immunological Concerns

• Patients receiving intrapleural streptokinase must be given a streptokinase exposure card 1
• Streptokinase creates persistent neutralizing antibodies and cannot be re-administered within 6 months 6, 7
• For any subsequent thrombolytic needs (MI, PE), use urokinase or tissue plasminogen activator instead of streptokinase 1, 6
• This 6-month restriction is an absolute contraindication due to risk of serious allergic reactions and drug ineffectiveness 6, 7

Common Adverse Effects

• Fever occurs more frequently with streptokinase (14%) compared to urokinase (0%) 4
• Chest pain is the most common adverse event with both agents 4
• Isolated reports of pleural hemorrhage, nasal bleeding, and transient disorientation 1
• No systemic fibrinolysis occurs at cumulative doses up to 1.5 million IU 1

Pericardial-Specific Safety

• Intrapericardial streptokinase at the 1,500,000 IU total dose has shown excellent safety profile 2, 5
• No complications, arrhythmias, systemic bleeding, or anaphylactic reactions reported in clinical series 2, 5
• Follow-up echocardiography shows no pericardial constriction after treatment 2

Clinical Outcomes

Pleural Success Rates

• Overall success rate of 72-92% with streptokinase, avoiding surgical intervention 3, 8
• Clinical response achieved in approximately 80% of patients 4
• Radiologic improvement (>75% resolution) in 40-45% of cases 4
• Mean drainage volume post-fibrinolysis: 1,100-1,400 mL 4

Pericardial Success Rates

• Complete resolution of purulent pericarditis in all reported cases 2, 5
• Drainage cessation within several days of treatment 2
• No development of constrictive pericarditis on long-term follow-up 2, 5

Important Caveats

• These doses apply specifically to breaking loculations and fibrinous strands, not for primary thrombolysis of vascular occlusions 1, 2
• Surgical consultation should occur if drainage remains inadequate 5-8 days after starting fibrinolytic therapy 1
• The cumulative dose limit of 1.5 million IU for pleural use should not be exceeded to avoid systemic effects 1
• Pericardial dosing uses higher individual doses (500,000 IU) but fewer total administrations compared to pleural dosing 2