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Therapeutic application of intrapericardial tissue plasminogen activator in a 4-month-old child with complex fibropurulent pericarditis

Bigham, Michael T. MD; Brady, Patrick W. MD; Manning, Peter B. MD, FACS, FAAP; Jacobs, Brian R. MD; Kimball, Thomas R. MD, FAAP, FACC, FASE; Wong, Hector R. MD

Pediatric Critical Care Medicine: January 2008 - Volume 9 - Issue 1 - p e1-e4
doi: 10.1097/01.PCC.0000298765.02358.07
Online Case Reports: Case Reports

Objective: To describe a young child with complex fibropurulent pericarditis who was successfully treated with intrapericardial recombinant tissue plasminogen activator.

Design: Individual case report.

Setting: Pediatric intensive care unit of a tertiary children’s hospital.

Patient: A 4-month-old Asian girl with Staphylococcus aureus septic shock who later developed a loculated fibropurulent pericardial effusion that was refractory to management with a subxiphoid percutaneous pericardial drainage catheter.

Interventions: Three doses of intrapericardial tissue plasminogen activator were administered at 12-hr intervals, allowed to dwell for 2 hrs, and subsequently drained via low continuous suction.

Measurements and Main Results: Immediately after intrapericardial tissue plasminogen activator was administered via a percutaneous pericardial drainage catheter, the patient had an increase in pericardial fluid drainage and resolution of a complex fibropurulent pericardial effusion. Pericardial fluid drainage ceased and then increased to 122 mL, 270 mL, and 80 mL of fluid, respectively, after each of the three doses of intrapericardial tissue plasminogen activator. Serial echocardiography confirmed the initial presence of the effusion, the subsequent loculated nature of the effusion, and ultimate resolution of the effusion after tissue plasminogen activator. The patient survived to hospital discharge without cardiac dysfunction.

Conclusions: The fibrinolytic effect of tissue plasminogen activator therapy promotes the resolution of complex fibropurulent pericardial effusions refractory to traditional pericardial drainage via percutaneous catheter and suction. Use of intrapericardial tissue plasminogen activator may preclude the need for surgical intervention in fibropurulent pericarditis.

From the Department of Pediatrics, Divisions of Critical Care Medicine and Cardiology, and the Department of Surgery, Division of Cardiothoracic Surgery at Cincinnati Children’s Hospital Medical Center, Cincinnati, OH (MTB, PWB, PBM, TRK, HRW); and the Center for Pediatric Informatics, Children’s National Medical Center, Washington, DC (BRJ).

The authors have not disclosed any potential conflicts of interest.

Address requests for reprints to: Michael T. Bigham, MD, Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 2005, Cincinnati, OH 45229-3039. E-Mail: michael.bigham@cchmc.org

©2008The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies