From Pam Owens, Centennial Medical Center, Nashville, TN. Recently a pediatric group approached us asking if we would do a fibrinogen level on pleural fluids before and during administration of tissue plasminogen activator (TPA, Alteplase) for resolution of the effusion. I found the previous reference to this treatment in a post from August 2012, but no mention of a fluid fibrinogen level. So my question is threefold:
1 What is the utilization for this?
2 Does anyone else have experience with this request?
3 Would you put a potentially viscous sample on an instrument or would the test have to be performed some other way?
We are scheduled to meet with the pediatricians when they all return from the holidays, but would like some perspective.
Hello, Pam. I vividly recall the August, 2012 post as the idea of treating a mucinous pleural effusion with TPA seemed radical. Since 2012 I’ve found a few case studies and the review attached below that describe the procedure as safe and effective in children. I also found one instance of intrapleural hemorrhage following administration of a fibrinolytic in a 6 YO, also attached. Regrettably, I’ve not found anything in the literature that supports measuring effusion fibrinogen levels, so I don’t have an answer, nor do I know how you could accurately assay a viscous specimen, though you may be able to get a semiquantitative answer from a manual clot-based Clauss assay. Once treated with TPA, the resultant fluid fibrinogen level would no longer be representative. It may be a stretch, but could your pediatricians mean they want a plasma fibrinogen level as a measure of inflammation that parallels C-reactive protein? In that case, serial CRPs may be a better choice.
Meanwhile, I’ve sent your message to the colleague who sent the August 2021 entry in case they have an insight, and hope that some of our regular contributors may have some experience to relate. Here are the two articles: