Case Presentation: A 63-year-old male with severe COPD (on 3L NC at baseline), coronary artery disease, obesity, and history of tobacco abuse initially presented to the emergency room with chest pain after a fall. A chest x-ray revealed multiple rib fractures. He had worsening hypoxia over the next few days, and a CT chest revealed an evolving empyema. A thoracentesis was significant for MSSA. Cardiothoracic surgery was consulted and placed a chest tube. The patient was started on the MIST II protocol for intrapleural administration of alteplase (TPA) and dornase alfa. After the third dose of TPA and dornase, the patient developed worsening hypoxia and a sharp drop in hemoglobin. The surgeons adjusted the chest tube with subsequent frank blood drainage. The patient was transferred to the medical ICU for hemothorax. After a discussion with the staff involved, the team determined that no staff member had turned the stopcock for the chest tube to allow for drainage of the intrapleural medications. The patient inadvertently had the medication instilled in the chest for 12 hours, leading to the development of a hemothorax. This was a sentinel event leading to the creation of a hospital-wide policy for these medications.
Discussion: The Multicenter Intrapleural Sepsis Trial 2 was a study designed to examine the effect of intrapleural TPA and dornase. This trial demonstrated that using these medications together increased pleural opacity change from day 1 to 7, reduced the need for surgical referral, and reduced hospital length of stay. The protocol of this study led to the widely used MIST II treatment for loculated effusions or empyema in nonsurgical candidates. However, these are high-risk medications with potential adverse complications as demonstrated by this case. In the trial, there were 2 out of 210 patients with intrapleural hemorrhages. A more recent observational study demonstrated 76 or 1,833 patients with pleural bleeding.
Conclusions: The administration of these medications includes injecting them into the chest tube, allowing them to act for 1-2 hours. After that time, a staff member should turn the stopcock to allow the medications to drain. In this case, no staff member turned the stopcock back. An interdisciplinary root cause analysis demonstrated a lack of proper communication, systems in the electronic medical record, and a lack of formal policy. A standard operating procedure was implemented at our medical center. This consisted of an order set including a required review of the standard operating procedure, nursing instructions requiring documentation of medication administration, and documented completed steps. The policy designated specific roles involved in medication administration. This adverse event calls hospitals to action to set defined roles and procedures for safely administering these intrapleural medications.