So we had an interesting case this week of an alcoholic cirrhotic fellow in his 60’s who was admitted with SBP, septic and in respiratory failure. A pigtail had been inserted (RLQ) a few days ago successfully draining 3 litres of cloudy ascites which grew morganella and e.coli. Obviously he was treated with antibiotics.
When I took him over on a monday morning he was hemodynamically stable but with a distended and tense abdomen. A quick look with bedside ultrasound revealed significant but highly septated ascites, and the pigtail had been draining little in the last 24 hours.
We decided to insert a second pigtail in this area, which immediately drained only 30-40 cc, and decided to use TPA to loosen things up a bit (we used 2mg TPA in each pigtail). In the following 12 hours, the original pigtail drained 700 cloudy cc’s and the new one, 1,000 cc’s. We repeated the TPA for two more doses but little more came out. No bleeding, and he was on prophylactic anticoagulation.
Just thought I’d put the case out there to add to the intra-abdominal thrombolysis data, which is substantially less than the pleural, and, as usual, to show how routine use of bedside ultrasound reveals things you’d either never otherwise see (loculations on CT??? Naaaah.), be guessing about, or have to wait and move your patient to CT.
Here is a nice little review on lysis: sir04264