title: Life-threatening pleural hemorrhage following intrapleural enzyme therapy and successful treatment with fibrin-thrombin sealant pleurodesis: a case report.
abstract: BACKGROUND
  Intrapleural fibrinolytic enzyme therapy is a potentially surgery-sparing treatment for poorly resolving parapneumonic effusion and empyema. It is safe in the majority of patients, however the most significant risk associated with this treatment is severe bleeding secondary to pleural hemorrhage. Contraindications for intrapleural enzyme therapy are not widely agreed upon and little is known about how to treat this difficult and potentially lethal hemorrhagic complication.
  
  
  METHODS
  An independent 82-year-old Caucasian man presented to hospital with an empyema complicating community-acquired pneumonia and coincidental pulmonary embolus. He was initially commenced on intravenous antibiotics, pleural drainage and anticoagulation, however failed to improve significantly and was commenced on intrapleural fibrinolytic enzyme therapy. Shortly after, he suffered severe pleural hemorrhage that was uncontrollable despite emergency thoracotomy and washout. Subsequent hemostasis was achieved after re-exploration and application of topical fibrin-thrombin sealant spray. The patient survived and was discharged home.
  
  
  CONCLUSIONS
  Intrapleural enzyme therapy can be effective in loculated parapneumonic effusion and empyema, but massive pleural hemorrhage can complicate its use. Pleural hemorrhage appears to be associated with anticoagulation or coagulopathy, and can be difficult to manage. This case adds to the body of data on bleeding complications following intrapleural enzyme therapy, and to the best of our knowledge is the first report of fibrin-thrombin sealant use in this setting.
authors.affiliation: Cardiac and Thoracic Surgical Unit, Flinders University, Sturt Road, Bedford Park, SA, 5042, Australia. Simon.Vun@sa.gov.au.|Cardiac and Thoracic Surgical Unit, Flinders Medical Centre, Flinders Drive, Bedford Park, SA, 5042, Australia. Simon.Vun@sa.gov.au.
authors.forename: Simon V
authors.initials: SV
authors.lastname: Vun
authors.affiliation: Cardiac and Thoracic Surgical Unit, Flinders University, Sturt Road, Bedford Park, SA, 5042, Australia. David.Lance@sa.gov.au.|Cardiac and Thoracic Surgical Unit, Flinders Medical Centre, Flinders Drive, Bedford Park, SA, 5042, Australia. David.Lance@sa.gov.au.
authors.forename: David G
authors.initials: DG
authors.lastname: Lance
mesh_terms: D000369:Aged, 80 and over; D016724:Empyema, Pleural / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D057487:Enzyme Therapy / Q000009:adverse effects*; D015718:Fibrin Tissue Adhesive; D006801:Humans; D008297:Male; D010996:Pleural Effusion / Q000188:drug therapy; D018700:Pleurodesis / Q000379:methods*; D011014:Pneumonia / Q000150:complications / Q000503:physiopathology*; D015912:Thrombolytic Therapy / Q000379:methods*; D016896:Treatment Outcome
chemical_list: D015718:Fibrin Tissue Adhesive