Massive hemothorax following administration of intrapleural streptokinase

The administration of intrapleural streptokinase [IPSK] is widely practiced in the management of loculated empyema thoracis. To our knowledge, there have been only 4 cases of hemorrhagic complications attributed to the administration of IPSK reported in the literature. In this article, we report a case of a 17-year-old girl who received IPSK and developed shock, anemia, coagulopathy and massive hemothorax. Our discussion focuses on the hemorrhagic complication of chest tube insertion and the role of IPSK in blood clot lysis and inhibition of local hemostasis

Dolor lumbar por estreptoquinasa recombinante: presentación de un caso / Lumbar pain caused by recombinant streptokinase: a case presentation

La Heberkinasa® (estreptoquinasa recombinante), es un trombolítico utilizado en el tratamiento del infarto agudo del miocardio, presentada en forma de liofilizado en bulbos estériles, de conocidos y probados efectos de reperfusión coronaria y reducción del tamaño del infarto, además de otras aplicaciones como en la trombosis venosa profunda, trombosis de acceso vascular permanente de pacientes con insuficiencia renal crónica terminal tratados por hemodiálisis periódicas, disfunción de prótesis valvulares cardíacas por trombos y en el tromboembolismo pulmonar; se asocian reacciones adversas durante el tratamiento, frecuentes y menos frecuentes, dentro de las que se encuentra el dolor lumbar. Se presenta a una paciente con el diagnóstico de un infarto agudo del miocardio, de cara diafragmática, a quien se le aplicó la trombolisis con Heberkinasa y durante esta presentó dolor lumbar agudo, intenso, que cedió con la reducción de goteo de la infusión y esta se pudo continuar sin más problemas.

The Heberkinase® (recombinant streptokinase) is a thrombolytic agent used in treatment of acute myocardial infarction, presented as sterile bulbs, of known and proved effects of coronary reperfusion and reduction of infarction dimension, besides of other applications e.g. the deep venous thrombosis, permanent vascular access thrombosis in patients presenting with terminal chronic renal insufficiency treated by periodical hemodialysis, dysfunction of cardiac vascular prostheses by thrombi, and in case of pulmonary thromboembolism; there are adverse reactions associated during treatment, frequent and less frequent including those of lumbar pain. Authors present a case of a woman diagnosed with acute myocardial infarction of diaphragmatic side undergoing thrombolysis with Heberkinase, and during it she had intense and acute lumbar pain improving with reduction of dripping infusion without subsequent problems.

Production of mutant streptokinase recombinant protein

Streptokinase [SK] is most widely used for treatment of myocardial infarction, however, it is the most expensive thrombolytic agent. A major drawback to SK use is the widespread presence of anti-streptokinase antibodies [Abs]. These Abs cause allergic reactions and neutralize streptokinase therapeutic effects. To produce an engineered variant of streptokinase being functional and less antigenic than the native molecule, we cloned and expressed streptokinase mutant gene lacking the C - terminal 42 amino acids. Recombinant protein was confirmed by western blot analysis with anti T7 monoclonal antibodies. pGEMEX-1 expression vector contains T7 gene 10 protein as fusion protein immediately down stream of T7 promoter and before multiple cloning site, streptokinase mutant gene was cloned after fusion protein. We cloned and expressed mutant streptokinase gene, lacking the C-terminal 42 amino acids. If mut-C42 activity was less affected by neutralizing antibodies compared with native streptokinase, this engineered variant could be a preferred alternative to native streptokinase for thrombolytic therapy

Utilidad de la terapia trombolítica con estreptokinasa a dosis baja en infarto agudo del miocardio / Usefulness of thrombolytic therapy with low doses of streptokinase in acute myocardial infarction

Background: The optimal dose of Streptokinase in the treatment of acute myocardial infarction is not well established. Apparently, the thrombolytic efficacy would not increase with doses over 750.000 units. Aim: To compare the effectiveness and safety of treatment with low doses of Streptokinase, ranging from 500.000 to 750.000 units, in patients with ST elevation acute myocardial infarction. Patients and methods: From September 1993 to September 1998, the GEMI register of patients with acute myocardial infarction, was carried out in 37 hospitals, incorporating 4,938 patients. Of these, 1,631 patients received streptokinase. According to the administered dose of Streptokinase, patients were divided in two groups: 1,465 patients who received 1.5 millions U in 60 minutes (classical therapy group), and 166 patients with ischemic chest discomfort and either ST-segment elevation or left bundle-branch block on the electrocardiogram, who received 500.000 to 750.000 U streptokinase administered in no more than 30 minutes, with heparin, within 0 to 6 hours of symptom onset. Successful reperfusion, mortality, complications, and hospital outcome was evaluated in both groups. Results: The low dose group of patients had a better reperfusion criteria profile. No differences between groups were observed in patient evolution, mortality, maximum Killip classification, post myocardial infarction heart failure, ischemic complications, arrhythmias or mechanical complications. Conclusions: These results suggest that streptokinase in low doses is at least as effective as classical therapy, in the treatment of ST elevation acute myocardial infarction.

Complications of streptokinase during infusion in acute myocardial infarction

Myocardial infarction is one of the most common causes of death worldwide. The cornerstone of therapy is thrombolytic therapy. Coronary thrombolysis helps restore coronary patency, preserves left ventricular function and improves survival. The most common thrombolytic agent used is streptokinase. But thrombolytic therapy is at times associated with some complications. This comparative study was aimed to find out the complications occurring during streptokinase infusion in patients presenting with acute myocardial infarction in Mayo Hospital, Lahore. Two hundred patients with definite diagnosis of acute myocardial infraction, who presented to East Medical Ward, Mayo Hospital, Lahore, were included in this study. All patients presenting with AMI were considered for SK therapy. Those who were actually given SK constituted the SK group and those who were not fit for SK, but otherwise SK was indicated, constituted the control group. In SK group 100 patients were given standard t reatment of acute myocardial infarction including streptokinase. In control group 100 patients were given standard treatment of acute myocardial infarction except streptokinase due to non-eligibility. Patients with typical chest pain of at least 30 minutes duration, serial ECG changes and serial cardiac enzyme changes were entered in the study. Comparative / interventional Post SK changes in blood pressure were significant [p= 0.011]. There was post SK hypotension in 48 [24%] and post SK hypertension in 20 [10%] patients. Allergic reaction was present in 4 [2%] only [p=0.044]. Arrhythmias were significantly less prominent in SK group [p=0.000]. Post SK bleeding occurred in 3 [1.5%] only [p=0.082]. 37 patients died [18.5%] in total, out of which 5 [2.55] patients died in SK group and 32 in control group [p=0.000]. CVA occurred in 1 SK group patient only, which was found to be hemorrhagic on CT scan [p= 0.31]. Early administration of SK lowers in-hospital mortality [p= 0.00 0]. Major complications during SK therapy are Hypotension [p= 0.011], Arrhythmias [p= 0.000], Allergic reactions [p= 0.044]

Angioedema relacionado ao uso de estreptoquinase / Angioedema related to the use of streptokinase

O angioedema é uma reacão rara, aguda e potencialmente fatal, à estreptoquinase, devendo ser diagnosticada prontamente e tratada para garantir melhor prognóstico ao paciente. Descrevemos aqui o caso de um homem de 65 anos, que apresentou reacão anafilática após o início de trombólise com estreptoquinase, sendo rapidamente tratado, permaneceu uma semana internado em Unidade de Terapia Intensiva.

Successful outcome after evacuation of intracranial hematoma following thrombolysis in acute myocardial infarction

Thrombolytic therapy is the modality of choice for the treatment of life threatening thrombosis in various vascular territories and nowadays, is used extensively in setting of acute myocardial infarction. There is, however, the omnipresent danger of serious bleeding inherently associated with the use of all thrombolytics which if it occurs in the brain, can lead to potentially serious neurological impairment and even death. In our report, we describe the successful surgical management of a streptokinase-induced intracranial hemorrhage. Timely neurosurgical intervention is advocated as the optimal approach for this particular side effect of thrombolytic agents

Utility of intrapleural streptokinase in management of chronic empyemas.

BACKGROUND: The nonsurgical medical approach with use of fibrinolytic agent is an alternative modality in management of chronic empyemas. With the introduction of purer forms of streptokinase, there has been renewed interest generated in the use of intrapleural thrombolytics with documented successful drainage of difficult to drain chronic empyemas. To evaluate the utility of streptokinase in the management of chronic difficult to drain empyemas in a single blind randomized case control study. MATERIAL AND METHODS: Twenty four cases of chronic/multiloculated empyema were included which had cases preferred having loculations or multiloculations and failure of drainage via thoracostomies for less than 100 ml during last 24 hours. Cases were randomized into two groups as 12 cases of streptokinases group and 12 cases of placebo group. Streptokinase given as 2.5 lac units in 100 ml of normal saline instilled intrapleurally for 6 consecutive days. In control group, 100 ml of normal saline without streptokinase was instilled intrapleurally through intercostal drain for 6 days. They were assessed by amount of drainage through intercostal drain for six days after instillation of streptokinase/placebo, duration of intercostal drainage in situ, and radiological improvement by standard x-ray chest. RESULTS: The study revealed increased drainage through intercostal drain in streptokinase group compared to control group. The mean duration of intercostal drainage in situ was shorter in streptokinase group compared to control group. Radiologically, streptokinase group revealed score 3 improvement in eight out of twelve cases and score 2 improvement in rest of the four cases. In control group, score 1 improvement was seen in two out of twelve cases and no improvement was seen in rest of the 10 cases. The observation difference is found to be highly significant statistically (p <0.001). No major adverse effects were noted in the streptokinase group. CONCLUSION: The study concludes the safety, efficacy, reduced hospital stay and decreased morbidity in patients treated with intrapleural streptokinase as compared to control group.

Efficacy, safety and tolerability of streptokinase in multiloculated empyema

Empyema thoracis is a common illness with significant morbidity and mortality. Standard treatment of Empyema includes tube drainage and antibiotics. But the tube drainage often fails if the fluid is loculated. Intrapleural Streptokinase has been used in multiloculated empyemas with good success rate. We evaluated the efficacy and safety of intra-pleural Streptokinase in loculated empyemas. A total of 15 patients admitted in Pulmonology unit with multiloculated empyemas whose drainage via drainage tube was less than 100 ml during the last 24 hours were included in the study. Aliquots of 250,000 units of Streptokinase in 100 ml of normal saline were instilled into the pleural cavity and the tube clamped for 3 hours. Response was assessed by clinical outcome, measurement of drain output after unclamping and subsequent chest radiography and serial chest ultrasounds. Streptokinase enhanced drainage in all patients with complete resolution of Empyema in 13 patients. Two patients with thickened visceral pleura following empyema drainage were referred to thoracic surgeon for decortication. The number of instillations of Streptokinase per patient ranged from 1 to 3 and the volume of drained empyema fluid ranged from 60 ml to 600 ml per patient. Streptokinase was well tolerated in all patients. Intrapleural Streptokinase is a safe and effective means of increasing the tube drainage in multiloculated Empyema without causing systemic fibrinolysis

Oxidative stress after acute myocardial infarction: effect of thrombolytic treatment.

OBJECTIVE: Treatment with thrombolysis plays a crucial role in salvaging the myocardium in myocardial infarction (MI) patients, but reperfusion of ischaemic areas may itself be associated with reperfusion injury mediated by free radical induced oxidation. Hence the present study was planned to evaluate oxidative stress in patients receiving thrombolytic therapy during MI and to compare them with those not receiving thrombolysis. METHODS: Thiobarbituric acid reactive substance (TBARS) was used as a marker of lipid peroxidation in 30 patients after acute MI. Thirteen were treated by intravenous thrombolysis and 17 served as control. Also, vitamin E levels were estimated in these patients. RESULTS: Patients treated with thrombolysis showed a fall in vitamin E and increase in TBARS within first hours. The decrease in vitamin E was independent of a change in cholesterol. However, the levels were similar at 72 hours. CONCLUSION: The results indicate increased free radical production after MI and reperfusion also increases in free radical production and antioxidants may have a part in improving thrombolytic reperfusion of ischaemic myocardium.

Hemorragias intracraneanas secundarias a terapéutica trombolítica con estreptoquinasa en el infarto agudo de miocardio / Intracranial hemorrhages secondary to thrombolytic therapy with streptokinase in acute myocardial infarction

La trombolisis coronaria con Estreptoquinasa se emplea cada vez más frecuentemente en el tratamiento del Infarto Agudo de Miocardio, pero se puede complicar con hemorragias encefálicas hasta en un 3 por ciento de los casos. Hay una serie de factores que predisponen a su aparición, como ser: la edad avanzada, la hipertensión arterial, el uso previo de anticoagulantes orales, etc. La hemorragia encefálica secundaria al uso de Estreptoquinasa, es de pronóstico sumamente grave, con un porcentaje de mortalidad de aproximadamente el 70 por ciento. Los autores analizan una pequeña serie de 5 pacientes que durante el tratamiento con Estreptoquinasa por Infarto Agudo de Miocardio presentaron hematomas cerebrales y/o de cerebelo. La mortalidad de la serie fue del 60 por ciento. En todos los casos había claros factores predisponentes para la complicación. Tres fueron operados y de ellos, dos fallecieron

Hematoma retroesofágico com grave disfagia após estreptoquinase para tratamento da trombose venosa axilo-subclávia / Severe dysfagia due to retroesophageal hematoma after thrombolytic therapy for right axillosubclavian vein thrombosis

Homem de 72 anos, portador de neoplasia de próstata estágio IV, submetido à osteossíntese da coluna cervical para descompressäo metastática da raiz nervosa, responsável por dor intensa no membro superior direito. Após três meses da internaçäo, apresentou trombose total da veia axilo-subclávia direita, complicaçäo da cateterizaçäo prolongada da veia subclávia direita para controle de septicemia secundária a pneumonia hospitalar. Foi submetido a terapia trombolítica com estreptoquinase por via venosa, no membro superior contra-lateral, na dose de 250.000UI em 15 min, seguida de 100.000UI/h durante cinco dias, com total recanalizaçäo do trombo e reduçäo do edema. Após 24h so término da trombólise, apresentou disfagia a líquidos e o esofagograma mostrou extensa compressäo extrínseca do esôfago, por provável hematoma retroesofágico. Necessitou de nutriçäo enterlal durante três meses, quando ocorreu normalizaçäo da deglutiçäo, reabsorçäo do hematoma retroesofágico e passagem adequada do contraste pelo esôfago. No seguimente evolutivo näo apresentou sequelas da trombose venosa profunda, näo tem disfagia e permaneceu em uso profilático de meias elásticas e heparina de baixo peso molecular.

Is haemorrhagic myocardial infarction more common with streptokinase?

Autopsy reports and clinical data of 226 consecutive myocardial infarction deaths in whom postmortem studies could be carried out during the period 1980 to 1996 were analyzed retrospectively for the presence of haemorrhagic myocardial infarction (HMI). Of 53 autopsies done from 1980 to 1986 [prior to use of streptokinase (SK) therapy in our institution] none of the specimens showed haemorrhagic infarction. Of 173 autopsies done from 1987 to 1996 (intravenous SK therapy was utilised in this period), 20 specimens showed haemorrhagic infarctions. Sixteen of these 20 patients had received SK, while 66 of the remaining 153 non-haemorrhagic myocardial infarction patients received SK (statistically significant association of SK with HMI, p < 0.005). Acute mechanical complications [ventricular septal rupture (n = 10), papillary muscle rupture (n = 2), cardiac free wall rupture (n = 7)] were seen in 19 cases. Of these, 16 were HMIs and 14 of these patients had received streptokinase. These observations suggest a strong association of HMI with SK therapy and with acute mechanical complications.

Complicaciones del tratamiento trombolítico en pacientes con infacto del miocardio / Complications of thrombolytic therapy in patients with myocardial infarction

Analizamos en forma retrospectiva las complicaciones del tratamiento trombolítico observadas en 221 pacientes (pts) conseutivos con infarto del miocardio (IAM) y que fueron tratados con estreptoquinasa por vía sistémica (STK) dentro de las primeras 6 horas de evolución. La edad promedio fue de 61,5 años, la distribución por sexo H/M fue de 77/23 por ciento, la localización del IAM fue anterior en 49,5 por ciento e inferior en 51,5 por ciento, el tiempo promedio de inicio de tratamiento en relación al inicio de síntomas fue de 3,4 horas. En 37 pts (18 por ciento) se administró STK 1.000.000 de UI, en 46 pts (22 por ciento) STK 1.250.000 UI y en 128 pts (60,7 por ciento) 1.500.000 UI en un plazo de 30 minutos asociado con aspirina vía oral y seguida de heparina endovenosa. Las complicaciones por tratamiento con STK se calificaron en mayores (hipotensión severa que requirió drogas vasoactivas, shock anafiláctico, arritmias con compromiso hemodinámico y hemorragia cerebral) y menores (reacciones alérgicas locales, sangramiento en sitios de punción, hemorragia gastrointestinal u otra que no necesitará de transfusión). Se observaron complicaciones en 90 de los 221 pts (41 por ciento) tratados con STK: a) Mayores: hipotensión 15 por ciento, arritmias 7,2 por ciento, BAVC complicado 2 por ciento, shock anafiláctico 0,4 por ciento y hemorragia cerebral 0,9 por ciento. Menores: alergias 8,1 por ciento, braquidiarritmias 9,0 por ciento, hemorragia gastrointestinal 3 por ciento, equinosis 0,4 por ciento. No se observaron diferencias en cuanto a la presencia o ausencia de complicaciones según tiempo de evolución, dosis de STK administrada y localización de IAM. La mortalidad a las 48 horas post procedimiento tuvo una incidencia del 7,7 por ciento del total de pacientes y fue significativamente mayor en mujeres (p< 0,001) y en pacientes mayores de 75 años (p< 0,0001). De todas las complicaciones observadas, la más frecuente fue la hipotensión severa, que obligó al empleo de drogas vasoactivas y fue independiente de la dosis de STK. La incidencia de complicaciones registradas por administración de STK en el IAM es semejante a la reportada en la literatura

Impaired hepatic function tests after streptokinase for acute myocardial infarction

Comparing the results of livers function tests for 50 patients with acute myocardial infarction, of which 25 patients received strepto- kinase and the other 25 patients matched in age, sex, and clinical presentation did not receive streptokinase, on admission and after one week. There was a significant increment in the serum total bilirubin, alkaline phosphotase and GGT in both groups after one week. While SGPT was no significantly elevated in the control group while it was very highly significantly elevated at one week in SK group. Both group had comparable results after one week with not significant difference. So the results of this study concluded that hepatic dysfunction was more marked after SK administration. The exact mechanism of these dysfunction are not yet fully elucidated

Intervención de enfermería en paciente con infarto sometido a trombolisis sistémica / Nursing intervention in patient with infarctation subjected to systemic thrombolysis

La trombolisis sistémica es una terapia de reperfusión miocárdica precoz utilizados en la década de los 80 en el manejo de los pacientes con infarto agudo al miocardio, ha sido posible gracias a los avances científicos tecnológicos alcanzados en el campo de la cardiología. Estos avances en el manejo de los pacientes que cursan infarto, ha permitido a su vez una participación más activa y permanente de enfermería en los servicios de cuidados intensivos donde se realiza con mayor frecuencia este tipo de atención. Este artículo tiene como objetivo principal analizar la intervención de enfermería en este tipo de pacientes, se utiliza el proceso de enfermería, profundizando principalmente las etapas de valoración, diagnóstico y planificación de la atención