日外科系連会誌 35 ( ４ ) ：555 -559 ，2010

Case Report

Iatrogenic and its Treatment ― Case Report

Siller Jiri, Havlicek K., Cerny M., Sakra L. and Cervinka V. Department of Surgery, Regional Hospital Pardubice

Abstract completed over 50 central vein cannulations exhibit Introduction Subclavian vein cannulation is associat- 50%-less risk of the occurrence of complications than ed with a number of complications. Hemothorax oc- those with less experienc e 2) . The most frequent me- curs in approximately 2% of cases. Immediate surgi- chanical complications related to catheter insertion cal revision of the chest cavity is indicated in case of or removal into/from the subclavian vein include, large loss or insufficient circulation. The man- apart from minor hemorrhage and local agement of hemorrhage in the pleural apex is ex- in the site of puncture, cannulation of the subclavian tremely demanding due to its bad accessibility and artery (19%), catheter malposition (6.5%) (most often conventional surgical procedures are often insuffi- into the vena jugularis interna), (6%), cient. In such situations the local application of topi- damage to the plexus brachialis, pulmonary embo- cal hemostats can be used instead. lism, etc .3) . Hemothorax occurs in about 2% of pa- Case report The report presents a 36-year-old pa- tients. A survey of early and late complication is tient with a massive, left hemothorax developing af- provided in Table 1 4) . The risk of hemorrhage dur- ter subclavian vein catheterization. Surgical review ing central venous catheter insertion is substantially detected a source of in the superior thoracic increased by . Careful choice of the aperture area that could not be stopped with con- site of puncture and of an appropriate method can ventional surgical procedures. As a result, TachoSil reduce hemorrhagic complications to a minimum. and Arista preparations were applied with good ef- Because the subclavian artery and the subclavian fects. vein cannot be accessed for direct compression, the subclavian approach is least suitable in patients Key words: central venous catheter, hemothorax, with the risk of hemorrhage 5,6) . topical hemostats Depending on the amount of blood, a hemotho- rax can be classified as small (less than 350 ml of Introduction blood), moderate and large (more than 1,000 - 1,500 Subclavian vein cannulation is associated with a ml of blood). The selection of the optimum treat- number of the complications and generally ment does not consider only the size of a hemotho- presents a greater risk than internal jugular vein rax but also the rapidity of its occurrence. Single- cannulation 1) . The incidence of the lung complica- time puncture and aspiration usually suffice to tions associated with subclavian vein cannulation manage smaller hemorrhage. Large hemorrhage, ranges from 0 to 21%. The relevance of these com- however, has to be secured with a chest drain. If plications depends on the surgeon’s practical experi- the pleural cavity absorbs more than half of circulat- ence and on the level of difficulty inserting a cathe- ing blood, lethal hypovolemia with the irreversible ter in a specific patient. The surgeons who stage of hemorrhagic shock is imminent. Review of the thoracic cavity by thoracotomy is indicated when initial blood loss exceeds 1,000 - 1,500 ml and Received: August 26, 2008/Accepted: July 21, 2010 Correspondence to: Siller Jiri hemorrhage into a drain of more than 200 ml/hour Department of Surgery, Regional Hospital Pardubice persists or increases or when insufficient circulation

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Table 1 Complications of subclavian vein catheterization

Early complications Late complications

1 Catheter malposition 1 2 Wrong catheter insertion in artery 2 Thrombophlebitis 3 Hemothorax 3 Thromboembolism 4 Pneumothorax 4 Hydrothorax

5 Nerve/nerves damage 5 Air embolism 6 Embolization of catheter or its part 6 Local (site of insertion) 7 Cardiac dysrhythmia 7 Catheter sepsis 8 Air embolism

9 Vein wall/ damage or perforation

Fig. 2 Thorax CT scan on admission. Fig. 1 Chest X-ray on admission. ing of chest pain. The patient was sent for chest X- signs are observe d7,8) . Smaller hemorrhage can be ray which did not show, at that time, any signs of clarified and possibly also managed by videothoras- pneumothorax or any other pathology. On the fol- cop y9) . lowing day the patient reported continuing chest pain and difficulty breathing. He was sent for a Case Report check-up chest X-ray which detected a non-homoge- This is a presentation of a 36-year-old man with ex- neous opacity of the left lower lung field that exhib- tensive hemothorax. The man was transferred from ited expansive behavior and pushed the cardiac the cardiologic department to the surgical clinic of shadow to the right ( Fig. 1 ). A thorax CT scan was the Pardubice Regional Hospital with the diagnosis indicated for suspected left-sided hemothorax and of an acute left-sided hemothorax. the patient was transferred to the ICU of the surgi- The patient had been treated for hypertension cal clinic, Pardubice. from 2003. He received low molecular weight hepa- During his admission to the surgical ICU the pa- rin for atrial flutter. He was admitted to the cardio- tient was fully conscious, pale, with spontaneous logic department to undergo an electro-physiological ventilation, and without obvious dyspnea at rest. examination and radiofrequency ablation (RFA) of Breath sounds heard on auscultation were attenuat- the myocard for persistent symptomatic atrial flut- ed or even non-audible over the whole left hemitho- ter. During the procedure the left subclavian vein rax. BP 130/80, P 110-130/min. Blood count : RBC and the right femoralis vein were cannulized. In the 3.68 1 0 12 /l, Hb 11.6g/100 ml, Ht 33%. Irregular cardi- evening the same day the patient began complain- ac activity. O2 saturation measured with a pulse ox-

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whole area under the left clavicle was filled with TachoSil (collagen sponge). The defect created by the resection of the pleura was applied with the Arista tissue adhesive. After the treatment, the he- mostasis in this area was sufficient. Another chest drain was inserted into the left pleural cavity. During the procedure that took nearly 2 hours, 1,000 ml of crystalloids, 1,000 ml of colloids, 4 eryth- rocyte mass units and 4 plasma units were adminis- tered. The patient’s blood pressure and circulation were compensated and catecholamine support was not required. After the procedure the patient remained in the care of ICU. His blood pressure and circulation Fig. 3 Chest X-ray after surgical treat- were stable and ventilation was spontaneous. ment. Breath sounds were audible on both sides and were accompanied with additional acoustic phenomena on imeter : 98%. Other physical examination were nor- the left. The chest drain removed 300 ml of hemor- mal. The patient complained of persistent breathing rhagic liquid during the first 8 hours following the difficulties. The CT scan ( Fig. 2 ) proved the pres- procedure and another 350 ml of the same liquid ence of massive left-sided hemothorax (fluid density during the subsequent 9 hours. The drain removed about 42 HU - blood). Blood filled most of the left a total of 1500 ml of the liquid and was extracted af- hemithorax and compressed the left lung. The re- ter 53 hours. A control chest X-ray image taken af- sidual air-filled area of the left lung was imaged me- ter drain removal displayed an unfolded left lung dially. The mediastinal structures were moved to with insignificant residual fluidothorax at the left the right. Neither pneumothorax nor the signs of costophrenic angle ( Fig. 3 ). A control red blood were detected. Right-sided fluido- count continued to exhibit markedly decreased val- thorax was not present. ues as late as the 3 rd post-operative day (RBC A marked decrease in hematological values and 2.52.1 012 /l, Hb 8.0g/100 ml, and Ht 22%). However, clinical signs of circulatory instability appeared as no blood preparations were administered after the early as during the first hour after transfer to IUC. procedure. During hospitalization the patient con- Originally intended chest drainage was abandoned tinued to receive one subcutaneous application of an and urgent surgical revision of the left hemithorax LWMH prophylactic dose a day. He was also ad- was indicated instead. ministered analgesics, mucolytics, and breathing re- With the patient lying on his right side and being habilitation. On the 3 rd post-operative day the pa- under general anesthesia, the left pleural cavity was tient’s general condition was satisfactory, his opened by posterolateral thoracotomy in 5 th intercos- cardiopulmonary function was compensated, and the tal space. 4,000 ml of liquid blood and blood coagu- patient was transferred back to the cardiologic de- lates was removed at once from the left hemithorax. partment in good status. There was performed he- Review of the pleural cavity detected the presence matology examination. There was not confirmed of blood in the tissue in the site of the left brachio- disorder. During hospitalisation there cephalic vein and of the left subclavian vein. Bright was seen sinus rhythm, RFA was successful. On red blood was running out of a small hole in the postoperative day 11 there was seen minimal pleura. After resecting the parietal pleura in the amount of fluid in left hemithorax. Patient was dis- pleural apex and after isolating major veins and the missed home. artery in the superior thoracic aperture area the bleeding nearly stopped. Apart from the above-de- Discussion scribed small bleeding opening there was no other A supraclavicular approach or transclavicular ap- proven source of bleeding in the pleural cavity. The proach with clavicle resection or luxation can be

― 557 ― 日本外科系連合学会誌 第 35 巻 ４ 号 employed to manage hemorrhage in case of subcla- ments form a gel matrix that decelerates blood flow vian vein injury. Hemorrhage can also be managed in a certain area, thus contributing to its enhanced with thoracotomy whose application proves benefi- coagulation regardless of the patient’s hemocoagula- cial for the securing of present hemothorax. Alter- tion characteristics. It is absorbable. Because ab- natively, the site of the puncture can be treated sorption sets in immediately and is complete in 24 - from a sternotomy. A prerequisite for successful 48 hours, the risk of infection is not increased. hemostasis is the preparation of all major veins and However, in view of the risk of fatal thrombosis this clarification of their anatomic interrelations. We preparation must not be applied directly in vessels were not successful to identify exactly the site of and must not be used for massive hemorrhage treat- bleeding not only due to difficult approach but also ment 16) . because the bleeding stopped after preparation of Application of local hemostatics reduces the ne- main vesel truncks. This fact developed based on cessity to administer transfusion preparation both vasoconstriction of vessel wall. Based on this we as- prior to and after surgery. Hemostatics promote the sume that the vessel injury was small and the reduced occurrence of post-operative bleeding com- source of bleeding was on the back wall of the sub- plications. The use of local hemostyptics has be- clavicular vein developed during inducing the cath- come widespread in all fields of surgery, mainly in eter. If hemostasis cannot be achieved by a conven- the management of diffusion parenchyma-related tional surgical method (i.e. ligation or bleeding or in case of smaller bleeding in badly ac- electrocoagulation), a preparation from the range of cessible areas. Chest surgery often uses these prep- local hemostatics can be used as a reliable alterna- arations in case of visceral or parietal pleura inju- tive. The hemostasis affect blood coagulation at ries. The contribution of these preparations to the various levels and support the formation of blood reduced occurrence of adhesions was proven. Usage coagulate s10) . They are made from a synthetic or or- of the local hemostyptics expanded to all surgical ganic base material such as collagen (TachoSil, Tis- disciplines, especially to neurosurgery, thoracic, vas- sucol Kit), gelatin sponge (Spongostan) or oxidized cular and abdominal surgery. Their usage is advan- regenerated cellulose (Surgicel, Traumacel) 11-13) . tageous especially in bleeding control in difuse par- We use broad spectrum of hemostyptics to control enchymatous bleeding, in leakage from anastomosis bleeding on our department. Product TachoSil we of big vessels or in bleeding control from small used first time. TachoSil manufactured by Nycomed source but with difficult approach. Product Tacho- is based on collagen sponge derived from horse col- Sil can be used as a prevention of fistulas for exam- lagen. Sponge surface is coated with a layer of hu- ple after pancreatic resections, to occlude broncho- man fibrinogen and thrombin. On contact with pleural fistulas in lung abscesses. It can be also blood or other body fluids these coagulation factors used to stop air outflow from lung injury or after are activated thus creating a fibrin coagulate that elective lung procedures. It was shown also his in- firmly joins the basic matrix with adjacent tissues in fluence on development of postoperative adhesions. several minutes. It is used not only during the In neurosurgery is used to stop cerebrospinal fluid bleeding that cannot be stopped by other surgical leakage through dura 11,17,18) . methods but also in bleeding that is not possible to identify. Due to good adhesivity it enables to per- Conclusion form good wash of the wound even by big amount of Hemothorax does not belong to the most frequent water. This product is well tolerated by the human complications associated with the cannulation of the body and is fully absorbable in 12 weeks of a proce- subclavian vein yet its occurrence is not exactly dur e14,15) . rare and has to be considered whenever clinical Another preparation applied in a pulverized form signs of circulatory instability or respiratory insuffi- was Arista manufactured by Medafor. It is made of ciency appear. Treatment is based on immediate organic polysaccharide extracted from potato starch. surgery, revision of pleural cavity and consequent Its hemostatic function is that of a molecular filter bleeding control. In smaller lesions transthoracic that contains serum that makes its dry volume en- approach is possible, in more severe lesions, the large up to fifteen times. Concentrated blood ele- quick preparation of vein from of supra or transcla-

― 558 ― Iatrogenic hemothorax and its treatment ― case report vicular approach is needed. Control of bleeding in 8) Motycka V, Siller J, Havlicek K. Urgentni chirurgic- apex is always extremely demanding and the visual- ka intervence u urazu hrudniku. VIII ostravske traumatologicke dny, rijen 2006, sbornik abstract, s. ization of all the structures in this area facilitates 29-30 the choice of a reasonable, safe treatment procedure. 9) Siller J, Havlicek K, Motycka V. Nase zkusenosti s From this casuistics is apparent that usage of local videothorakoskopii, 4. mezinarodni konference CM- CIE Miniinvaz Terap 2000 ; 5 : 43 (ISSN 1211-5177) hemostyptics in our case, TachoSil and Arista, can 10) Kondler R, Fuchs T. Clinical application of a hu- be simple but very effective treatment without fur- man-collagen fleece as haemostatic agent. Arz- ther trauma of vessel wall. neimittelforschung 1989 Mar ; 39(3) : 401-3 11) Haas S. The use of a surgical patch coated with hu- References man coagulation factors in surgical routine : a multi- center postauthorization surveillance. Clin Appl 1) Drabkova J. Centralni zilni katetry ― funkce, zakla- Thromb Hemost 2006 ; 12(4) : 445-50 (ISSN : 1076- dy zavadeni a osetrovani MSM 2004 0296) 2) Taylor RW, MD, Palagiri, AV, MD. Central Venous 12) Havlicek K, Tecl F, Siller J. Fibrin sealant in pulmo- Catheterization : Concise Definitive, Review Posted nary and thoracic surgery. Scr Med 1994 ; 67 : 15- 05/16/2007 19 (ISSN 0036-9721) 3) Larsen R, Anestezie, Grada 2004, str. 672-675 13) Nordentoft T, Romer J, Sorensen M. Sealing of gas- 4) Sevcik P., Cerny V, Vitovec J. Intenzivni medicina. trointestinal anastomoses with a fibrin glue-coated Praha, Galen-Karolinum, 2000. Kap. 3., odst. 3.3.3 collagen patch : a safety study. J Invest Surg 2007 Pristupy do centralniho zilniho reciste, s. 14-15 Nov-Dec ; 20(6) : 363-9 5) Nakamura V, Allaouchiche B, Mathon L, Lansiaux S, 14) Meisner H, Struck E, Schmidt-Habelmann P, Seben- Chasard D. : unusual compli- ing F. Fibrin seal application. Clinical experience. cation of central catheterization, Ann Fr Anesth Re- Thorac Cardiovasc Surg 1982 Aug ; 30(4) : 232-3 anim 2000 Nob ; 19(9) : 678-81 15) Silverstein ME, Chvapil M. Experimental and clini- 6) Ueki R, Okutani R, Fukushima A, Kurehara H, Sasa- cal experiences with collagen fleece as a hemostatic ki K, Tashiro C. Iatrogenic extrapleural hematoma, agent., J Trauma 1981 May ; 21(5) : 388-93 Masui 2000 Jan ; 49(1) : 37-9 16) Medscape Medical News FDA Approvals : Aptima, 7) Siller J, Havlicek K, Motycka V. Tupa poraneni Harmony Bionic Ear, Arista AH hrudniku, patofyziologicke aspekty a lecba (Ⅳ. slov- 17) Izbicki JR, Kreusser T, Trupka A, et al., Fibrin-coat- ensky chirurgicky kongres s medzinarodnou ucast’ou ed collagen fleece in thoracic surgery. Initial clinical a XXXV. spolocny kongres slovenskych a ceskych experience, Chirurg 1991 Jun ; 62(6) : 479-81 chirurgov, 6.-8. 9. 06, Nitra. Zbornik abstraktov, s. 56) 18) Getman V, Devyatko E, Wolner E et al., Fleece (ISNB 80-969120-5-4) bound sealing prevents pleural adhesions Interact Cardio Vasc Thorac Surg 2006 ; 5 : 243-246

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