Fax +41 61 306 12 34 E-Mail karger@karger.ch www.karger.com Novel Insights from Clinical Practice Respiration 2011;81:513–516 DOI: 10.1159/000321249 Intrapleural r-tPA in Association with Low-Molecular Heparin May Cause Massive Hemothorax Resulting in Hypovolemia Stavros Anevlavis Kostas Archontogeorgis Argyris Tzouvelekis George Kouliatsis Sofia Pozova Ioannis Bougioukas Demosthenes Bouros Marios E. Froudarakis Department of Pneumonology, and CardioThoracic Surgery Medical School, Democritus University of Thrace, Alexandroupolis, Greece lution. The use of r-tPA is generally well tolerated. Here we report 2 cases of massive pleural hemorrhage resulting in life-threatening hypovolemia, in 2 patients treated with in- trapleural r-tPA for a pleural infection, who were simultane- ously receiving systemic anticoagulation (1 therapeutic, the second prophylactic) with low-molecular weight heparin. It appears that the decision of treating pleural infection with r-tPA in patients receiving therapeutic or prophylactic sys- temic anticoagulation must be well balanced and in case of association of these compounds, close monitoring is neces- sary. Copyright © 2010 S. Karger AG, Basel Key Words Complicated parapneumonic effusion  Empyema  Fibrinolytics  Hemothorax  Hypovolemia  Low-molecular weight heparin  Pleural infection  Recombinant tissue plasminogen activator Abstract The use of intrapleural instillation of recombinant tissue plasminogen activator (r-tPA) in the treatment of pleural in- fection may increase pleural fluid drainage associated with a clinical and imaging improvement, leading to a faster reso- Received: June 28, 2010 Accepted after revision: September 9, 2010 Published online: November 9, 2010 Stavros Anevlavis, MD, PhD Department of Pneumonology University Hospital of Alexandroupolis GR–68100 Alexandroupolis (Greece) Tel./Fax +30 25 5107 5096, E-Mail anevlavis  @  yahoo.com © 2010 S. Karger AG, Basel 0025–7931/11/0816–0513$38.00/0 Accessible online at: www.karger.com/res Established Facts • r-tPA is under investigation as an intrapleural fibrinolytic in pleural infections. Novel Insights • r-tPA associated with either therapeutic or prophylactic low-molecular weight heparin may cause massive intrapleural hemorrage with hypovolemia.