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Ann Thorac Surg 2002;74:257-258
© 2002 The Society of Thoracic Surgeons
a The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
Accepted for publication October 20, 2001.
* Address reprint requests to Dr DiBardino, 6540 Bellows Lane, Apartment 603, Houston, TX 77030 USA
e-mail: ab9088{at}hotmail.com
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A 42-year-old man with a history of alcoholism was admitted to the Houston Veterans Affairs Medical Center with a diagnosis of rhabdomyolysis. A multiloculated right-sided empyema developed, and on hospital day 9, the patient underwent open right-sided thoracotomy and decortication. Two chest tubes were left in place, and a third chest tube was placed in the week that followed the operation for persistent air leak. Bedside pleurodesis with 100 mL of 50% dextrose was attempted on hospital day 35 but was ineffective.
On hospital day 44, bedside pleurodesis was attempted with 300 mg of doxycycline mixed in 125 mL of normal saline solution and 250 mL of 5% dextrose in water. Immediately after the introduction of this agent into the chest, the patient became severely hypoxic, tachycardiac, and diaphoretic with a heart rate of 137 beats per minute, a respiratory rate of 40 to 50 breaths/min, an arterial oxygen saturation of 25% to 32%, and palpable pulses. Although difficult to assess secondary to severe respiratory distress, the patient did not complain of pain. Major findings on examination included minimal airway movement in the bilateral lung fields at auscultation and severe cyanosis.
During emergent endotracheal intubation, a blood gas study revealed the following: pH 6.98; oxygen tension, 35 mm Hg; and carbon dioxide tension, 59 mm Hg. The patient was placed on a ventilator. Initial peak airway pressures were 50 to 65 mm Hg on the following ventilator settings: synchronized intermittent mandatory ventilation, 10 breaths/min; tidal volume, 600 mL; pressure support, 10 mm Hg; positive end-expiratory pressure, 5 mm Hg; and inspired oxygen fraction, 100%. The patient responded favorably to nebulizer treatments with albuterol and Atrovent (ipratropium bromide) (0.5 µm each), and vital signs revealed a heart rate of 141 beats per minute, a respiratory rate of 24 breaths/min, and a blood pressure of 178/98 mm Hg. Chest roentgenogram revealed no pneumothorax, infiltrate, or consolidation. Bronchoscopy was performed on arrival in the intensive care unit and revealed no abnormalities. The condition of the patient improved with a decrease in peak airway pressures to 25 mm Hg at 3 hours after intubation. The patient was extubated the following morning with no difficulty.
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A prospective, randomized trial [3] concluded that bleomycin is as effective as talc, but the agent is extremely costly and there is at least one report of adult respiratory distress syndrome and subsequent death after bleomycin pleurodesis [4]. Problems with tetracycline analogues include the requirement of multiple applications and the side effects of being well absorbed into the circulation, even achieving therapeutic serum levels after injection into the pleural space [5]. After pleurodesis with tetracycline, systemic absorption has led to acute renal failure at least once [5]. Reports of serious adverse effects after intrapleural doxycycline administration are absent from the literature. Fever after pleurodesis with doxycycline in humans and hepatotoxicity in the form of elevated transaminases has occurred in animal models [6].
Our patient appears to have had a severe anaphylactic reaction to the antibiotic used for pleurodesis. The acute onset of respiratory failure, the lack of airway movement on examination, the high initial mean airway pressures on the ventilator, and the response to nebulizers support this conclusion. The patient was noted to have a large air leak prior to the procedure, and even though it is possible that the doxycycline gained access to the bronchial mucosa, thereby increasing the severity of the reactive airway response, the patient did not cough up fluid and was considered to have normal mucosa on broncoscopy.
Bedside pleurodesis is an effective method for the control of malignant pleural effusions and persistent pneumothorax. Although the incidence appears to be low, this procedure can result in serious complications that vary according to the agent used. We suggest that bedside pleurodesis be performed in a monitored setting and under the direction of a surgeon so that rare but potentially serious complications can be addressed rapidly and effectively.
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This article has been cited by other articles:
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  Y. Aelony and R. Laniado-Laboren Talc Pleurodesis vs Iodopovidone Chest, April 1, 2003; 123(4): 1318 - 1319. [Full Text] [PDF]
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