| Objective:The aim of this study was to compare and analyze the therapeutic effect,medication and adverse reactions of urokinase dissolution and drainage between central dissolving method and multi-point dissolving method under the guidance of contrast-enhanced ultrasound,and to seek a treatment plan for fibrinolytic therapy of multiloculated pleural effusion with lower dose,short time,more accurate,safe and effective,standardized and easy to popularize;and to further analyze the differences in the dosage and time required for different etiologies,effusion volume,and septation density treated by central dissolving method,which helps to improve the treatment experience of this method and provides more detailed guidance for the clinical application of this method.Method:According to the inclusion and exclusion criteria,116 patients with multiloculated pleural effusion who visited the First Affiliated Hospital of Guangzhou Medical University from February 2021 to February 2023 were selected.84 patients underwent contrast-enhanced ultrasound guided injection of urokinase center to gradually expand the dissolution,that is,ultrasound-guided catheterization was placed in the maximum liquid cavity in the center of the effusion.After evaluation by contrast-enhanced ultrasound of the drainage tube,the effusion in this area was fully evacuated,followed by injection of the initial dose of 20,000 U urokinase.After indwelling for 20 minutes,intrathoracic contrast-enhanced ultrasound was performed again to open and fully drain.Repeated(injection-indwelling-angiography-drainage)2-4 times until the node of effective dissolution effect was achieved,and the open drainage of injection was ended.32 patients underwent contrast-enhanced ultrasound guided fine-needle multi-point injection of urokinase for overall dissolution,that is,ultrasound-guided 22G fine-needle intrathoracic contrast-enhanced ultrasound,followed by multi-point injection of urokinase through fine-needle,at a dose of20,000～50,000 U.Contrast-enhanced ultrasound dynamically observed septation dissolution and contrast agent distribution every 30 minutes to achieve effective dissolution effect nodes that were catheterization drainage.The clinical symptoms,percentage of diffusion area of contrast-enhanced ultrasound,cellulose separation score and ultrasound imaging indexes of effusion depth before and after treatment were statistically analyzed and compared between the two methods,as well as the differences in the therapeutic effect,injection times,total dose,total indwelling time and adverse reactions between the two groups,and the application value of the two methods was comprehensively compared.Then 84 patients were divided into subgroups according to different grouping methods,and whether there were differences in treatment effect,injection times,total dose and total indwelling time within each subgroup of different etiologies,effusion volume and septation density treated with central dissolution method were further analyzed and compared,in order to help improve the treatment experience of this method.Results:1.A total of 116 patients were included in this study,including 65 cases of parapneumonic pleural effusion,14 cases of tuberculous pleurisy,22 cases of malignant pleural effusion,and 15 cases after thoracic surgery.Contrast-enhanced ultrasound guided urokinase septum lysis treatment overall response rate was 80.2%(93/116).In terms of medication,the mean total dose was 4(2,5.8)×10~4 U and the mean total indwelling time was 52.5(30,90)min.2.The percentage of diffusion area of ultrasound contrast agent increased after urokinase treatment,ultrasound showed that the intrathoracic septa were significantly reduced,the depth of effusion was significantly reduced after drainage,and the clinical symptoms were significantly improved,compared with those before treatment,the difference was statistically significant(P<0.05),indicating that the two groups were effective.3.There was no significant difference in the treatment response rate between the central lysing group and the multi-point lysing group[78.6%(66/84)VS 84.4%(27/32)](P=0.483).There was no significant difference in adequate drainage volume[350(220,500)ml VS 270(175,400)ml]between the two groups(P=0.138).In terms of medication,t the central lysing group injected 2(1,3)times,with a total dose of 3(2,5)×10~4U and a total indwelling time of 50(30,78.6)min,and the multi-point lysing group injected 1(1,2)times,with a total dose of 5(3,8)×10~4 U and a total indwelling time of 60(30,150)min.The central dissolving group had more injections and less total doses than the fine needle group,and the difference between the two groups was statistically significant(P=0.003,P=0.033).Although the total indwelling time was not significantly different between the two groups(P=0.087),the indwelling time was shorter in the central dissolving group on the overall trend.In terms of adverse reactions,there were no serious adverse reactions in the central lysing group and the multi-point lysing group;the risk of minor bleeding was lower in the central lysing group,and there was a significant difference in the incidence of minor gross bloody pleural effusion[17.9%(15/84)VS 37.5%(12/32)]between the two groups(P=0.025).Mild chest pain occurred in 1 patient in each group,and mild bleeding and mild chest pain could be relieved spontaneously without treatment.No other adverse reactions such as fever,anaphylaxis,and pneumothorax were found.4.The effective rates of parapneumonic effusion,tuberculous pleural effusion,malignant pleural effusion and pleural surgery were similar(P>0.05).The total dose of urokinase used in the thoracic surgery group was lower than that in the inflammatory,tuberculous and malignant groups,and the total indwelling time used in the thoracic surgery group was shorter than that in the inflammatory and tuberculous groups(P<0.05).The total dose of urokinase used in the treatment with central lysis generally increased with the increase of effusion volume,and the total dose of urokinase used in the small effusion group was significantly different from that in the medium and large effusion groups(P<0.05).The total dose of urokinase used in the treatment using the central dissolving method generally increased with the increase of cellulose compartmentalization density,with a significant difference between the total dose of urokinase used in the high compartmentalization density group and the low and medium compartmentalization densities(P<0.05).Conclusion:1.The effect of urokinase injection under the guidance of contrast-enhanced ultrasound is good.The dynamic monitoring of contrast-enhanced ultrasound can more accurately determine the node of action effect,which has the advantages of controlling the dose of urokinase,shortening the duration and reducing the occurrence of serious adverse reactions.2.Contrast-enhanced ultrasound guided central gradual expansion lysis method is as effective as contrast-enhanced ultrasound guided fine needle multi-point integral lysis method in the treatment of multiloculated pleural effusion,but compared with multi-point integration method,the urokinase dose used by central lysis method is smaller,the indwelling time is shorter,and the risk of minor bleeding is lower.And contrast-enhanced ultrasound guided central dissolving method on urokinase dose,indwelling time and treatment process standardized treatment,more conducive to promotion and application.3.Contrast-enhanced ultrasound-guided central dissolving method can be suitable for patients with higher risk of bleeding such as patients after thoracic surgery.The total dose and indwelling time of urokinase used in patients after thoracic surgery were less than other causes.Multiloculated pleural effusions with larger effusion volumes and higher septal densities may require higher total urokinase doses. |
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