Iatrogenic Hemothorax and Its Treatment ― Case Report
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日外科系連会誌 35 ( ４ ) ：555 -559 ，2010 Case Report Iatrogenic Hemothorax 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 blood loss or insufficient circulation. The man- apart from minor hemorrhage and local hematoma 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), pneumothorax (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 bleeding in the superior thoracic increased by coagulopathy. 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 hemorrhag e 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 lung 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- cannulatio n 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 ― 555 ― 日本外科系連合学会誌 第 35 巻 ４ 号 Table 1 Complications of subclavian vein catheterization Early complications Late complications 1 Catheter malposition 1 Thrombosis 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 infection (site of insertion) 7 Cardiac dysrhythmia 7 Catheter sepsis 8 Air embolism 9 Vein wall/heart 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 y 9) . 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 12 and the right femoralis vein were cannulized. In the 3.68 1 0 /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- ― 556 ― Iatrogenic hemothorax and its treatment ― case report 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 hemopericardium 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 0 12 /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- coagulation 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.