Intrapleural instillation of tranexamic acid to control pleural hemorrhage complicating tissue plasminogen activator administration: case report

Intrapleural enzyme therapy consisting of tissue plasminogen activator and DNase has become a standard approach to the medical management of pleural space infection. The primary risk of such a strategy is pleural hemorrhage, which is rare but well-described, and this complication normally requires surgical intervention since tissue bleeding cannot be treated with vascular embolization. In this report, we describe the novel and successful use of intrapleural tranexamic acid administered at the bedside through a chest tube to control hemothorax caused by tissue plasminogen activator instillation into the pleural space. The index patient, a 60-year-old man with coagulopathy due to liver cirrhosis, had developed a nosocomial empyema following complex spine surgery. His empyema was being managed medically with intrapleural enzyme therapy when the second instillation of this regimen produced a hemothorax. A single dose of 500 mg of tranexamic acid led to the cessation of bleeding without surgery and enabled the patient to ultimately leave the hospital without experiencing recurrent pleural hemorrhage. Although the administration of tranexamic acid via tube thoracostomy is not unprecedented, our report is the first to document its use in this manner to address hemothorax resulting from intrapleural enzyme therapy, introducing a non-invasive option for this challenging clinical scenario.