IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 17, Issue 4 Ver. 4 (April. 2018), PP 77-81 www.iosrjournals.org DOI: 10.9790/0853-1704047781 www.iosrjournals.org 77 | Page Radiologically Guided Chest Tube Insertion with Fibrinolytic Instillation for Loculated Pleural Effusion/Empyema Dr. Ab. Bari Shah 1 , Dr. Mohammad Akbar Bhat 2 , Dr. Farooq Andrabi, Dr. Shoaib Amin Banday, Dr. Tariq Hassan, Dr. Mudassir Sidiq 1 Registrar Surgery, SKIMS J&K India. 2 Professor, CVTS SKIMS J&K India. Abstract: Tittle; Radiologically guided chest tube insertion with fibrinolytic instillation for loculated pleural effusion/empyema Background; The management of loculated pleural effusion and empyema by chest tube drainage usually fails because of thick viscous fluid and multiple pleural space loculations. The use of radiographic assisted chest tube drainage with intrapleural fibrinolytic agents facilitates pleural drainage and can obviate the need for more invasive surgical interventions in these types of effusions. Objectives; to evaluate the role of radiographic chest tube drainage with intrapleural fibrinolytic therapy with streptokinase as an adjunctive therapy in the management of loculative pleural effusion and empyema Material and methods; 40 patients of CPE and empyema were considered for radiographic assisted cchest tube drain with adjunctive intrapleural fibrinolytic therapy. Intrapleural, STK was adminstered 12-24 hourly in the dosage of 2,50000 IU in 100 ml of saline. The end points were volume of fluid drained and radiological resolution. Results; Statistical analysis showed a success of 65% in study group and in thoracotomy group 97.5% with minimal complications in both the groups. Conclusion; Patients of loculative pleural effusion/ empyema should be first subjected to radiographic assisted chest tube drainage as we have seen from results and then add fibrinolytic if loculations present. --------------------------------------------------------------------------------------------------------------------------------------- Date of Submission: 26-03-2018 Date of acceptance: 11-04-2018 -------------------------------------------------------------------------------------------------------------------------------------- I. Introduction: Empyema thoracis is defined as pleural space suppurative fluid collection and is a disease entity that has been recognized throughout recorded medical history. The incidence of empyema has fallen since the introduction of antibiotics for the treatment of pulmonary infections. Early diagnosis and effective therapy are essential. The late complications of untreated empyema with a fixed fibrotic chest cavity should only remain in the history books. Pulmonary infections due to iatrogenic causes remain the most important etiology of the loculated pleural effusion/empyema because people now live so long with cardiac failure, rheumatic disorder and breast cancer1,2. Dry pleurisy may be the first indication of pleural Inflammation although this is quickly followed by the outpouring of fluid rich in protein and polymorphs. Although frank purulence should develop before an effusion is referred to as an empyema, a ph<7 is the best marker for the need for operative intervention, and therefore is probably the discriminator for empyema. Continued accumulation of pus compresses the lung with shift of mediastinum to the opposite side. Fibrin is continually deposited on pleural surfaces producing a thickened rind, the deeper layers of which become fibrotic and avascular. The established empyema is walled off and the space is fixed. This allows for open drainage or easy stripping of the empyema membrane (thickened rind) during surgical decortications. Such decortications at this stage will produce full re-expansion of the lung with gradual resolution of the pleural inflammation and no functional impairment. It is this fibrin deposition which limits the diffusion of oxygen that leads to anaerobic respirations and the fall in ph within the empyema. If the pus is not drained effectively or the empyema cavity excised, the continual formation and fibrosis of the pleural rind progressively restricts chest wall and diaphragmatic movement, eventually producing a shrunken, flattened, immobile hemi-thorax with overlapping ribs and scoliosis to the affected side. Sometimes empyema may push through the chest wall at one of the perforating pathways of the neurovascular bundle, forming a collar -stud abscess which may break down giving a discharging fistula in continuity with the empyema cavity (empyema necessitans)3.