Treatment of Complicated Parapneumonic Effusion With Fibrinolytic Therapy Versus VATs Decortication

Inclusion Criteria: * 18 years old and older * Admitted with pleural effusion that undergoes thoracentesis by medical/pulmonary service * Pleural fluid pH \<7.3 * SICU placed chest tube * Subsequent transfer to SICU Exclusion Criteria: * Existing malignancy * Malignant cells from initial pleural fluid sample * End stage liver disease (Child's B or greater) * Coagulopathy * Unable to tolerate surgical procedure * Frank purulent drainage (needs OR regardless) * Recent surgery of abdomen or thorax precluding the use of tPA * Baseline neurologic impairment requiring a proxy for consent