A49-10 Nowhere to Go

Introduction Empyema is an infection of the pleural space characterized by accumulation of purulent fluid in the thoracic cavity. Due to significant morbidity and mortality, early management with antibiotics and drainage is recommended and loculated effusions refractory to drainage are treated with intrapleural fibrinolytic therapy (IPFT). Prior investigations of intrapleural bleeding after IPFT demonstrate low rates of intrapleural bleeding (3.8-4.1%) or up to 9.6% in patients on systemic anticoagulation. Serious complications are uncommon with 2% requiring transfusion and a smaller minority requiring surgical intervention. Here we describe a case of intrapleural hemorrhage resulting in hemorrhagic shock following initiation of IPFT. Case description A 75 year old woman with a history notable for end stage renal disease and peripheral arterial disease on clopidogrel presented endorsing one day of shortness of breath and generalized aches. Imaging revealed a large left sided effusion with complete collapse of the lung. A12-French chest tube was placed with immediate return of purulent drainage. She was admitted to the ICU for vasopressor support. Pleural fluid and blood cultures grew methicillin resistant staph aureus and she was treated with vancomycin. On hospital day three, her chest tube drainage ceased and her imaging demonstrated a persistent fluid collection. Concomitantly, she developed large volume hematochezia secondary to ischemic ulcers necessitating transfusion of two units of red blood cells and endoscopic clipping. No coagulopathy was identified. Intrapleural alteplase and dornase alfa therapy was initiated on hospital day six after her hematochezia resolved. Four hours after her second IPFT dose she developed large volume bloody output from her chest tube, acute anemia and hypotension requiring eleven units of red blood cells, further vasopressor support, and intubation. After further thoracic surgery consultation, the family decided to forgo urgent thoracotomy and the patient expired. Discussion Although multiple cases have documented intrapleural hemorrhage following IPFT, our group found no reported cases resulting in death. There is a gap in the current literature regarding the incidence of complications in patients on P2Y12 inhibitors receiving IPFT. Prior investigations have demonstrated the antiplatelet effects of clopidogrel last for seven to ten days. In this case, our patient had discontinued clopidogrel six days prior to the administration of IPFT without any evidence of thrombocytopenia, coagulopathy, or elevated blood urea nitrogen at the time of hemorrhage. Future evaluation of patients on antiplatelet therapies to better understand their bleeding risk with IPFT is needed.