INTRODUCTION:We present a case of an unusual complication of localized alveolar hemorrhage following the insertion of a central venous catheter (CVC) by the subclavian approach.
CASE PRESENTATION:A 78 year old man was transfered to our hospital with the diagnosis of acute myocardial infarction. He was treated conservatively. On the sixth day he developed acute respiratory failure requiring mechanical ventilation. A chest roentgenogram (CXR) following intubation revealed hyperinflation and flattening of the diaphragm.A CVC was inserted after several attempts in the left subclavian vein. This resulted in a small hematoma at the puncture site. A CXR obtained one hour after the procedure showed a new left upper lobe (LUL) alveolar infiltrate without pneumothorax or mediastinal widening. Within hours the patient developed hypotension and bloody secretions. His hematocrit decreased from 27 to 20. His PTT was 32 , INR 1.3 and platelet count 243,000. Clopidogrel was stopped and he received two units of packed red blood cells and six units of fresh frozen plasma. A chest CT scan showed alveolar densities in the LUL. An urgent bronchoscopy showed blood oozing from all LUL bronchial openings with serial bronchoalveolar lavages showed progressively increasing bloody return.The patient’s clinical condition worsened next day with decreasing hematocrit and hypoxemia requiring increased oxygenation and PEEP. A CXR showed progressive infiltrates in the left lung. Angiograms of the left pulmonary, left subclavian & left bronchial arteries failed to reveal the source of bleeding. The left bronchial artery was noted to be enlarged and irregular and was embolized . His hematocrit and pulmonary infiltrate stabilized. There after a pneumothorax developed on his left side and a chest tube was placed. The patient’s had a stormy course complicated by septic shock and he died. An autopsy showed localized pulmonary hemorrhage with infarction of all segments of the LUL.
DISCUSSIONS:It is estimated that five million CVC’s are placed in the USA each year. Of patients who receive CVC mechanical complications are reported to occur in 5% to 19%, infectious complications in 5% to 26% and thrombotic complications in 2% to 26 %.Arterial puncture, hematoma, line misplacement and pneumothorax are the most common mechanical complications during the insertion of CVC’s. Their incidence is higher after three attempts or with less experience. Arterial laceration, air embolism, hydrothorax, arrhythmia, & perforation of superior vena cava have all been reported as preventable lethal complication. The term “diffuse alveolar hemorrhage” is a distinct form of pulmonary hemorrhage that originates from the pulmonary circulation. Common causes of diffuse alveolar hemorrhage are vasculitis, coagulopathies, including the use of coplidogrel, connective tissue disorders, idiopathic and other rare disoroders. Localized alveolar hemorrhage may occur as the result of excessive bleeding from the bronchial circulation, which can rapidly flood the alveoli. In the present case, placement of a left subclavian vein line was temporally related to hemoptysis, decreases in hematocrit, and the development of a left upper lobe infiltrate. Neither a pneumothorax nor a hemothorax were noted immediately post line placement, although the patient developed a delayed hemothorax at higher PEEP levels. Significant alveolar bleeding was noted during bronchoscopy and massive localized pulmonary hemorrhage was confirmed on autopsy. Although significant bleeding was not was visualized on angiogram, we hypothesize that one or more perforations of the bronchial artery produced by repeated needle insertion in alveolar hemorrhage localized to the left upper lobe. Supporting this notion is the fact that bleeding stopped after bronchial artery embolization.
CONCLUSION:Localized alveolar hemorrhage may result from subclavian vein catheterization andone should be vigilant of this potentially fatal complication.
DISCLOSURE:Amandeep Bawa, None.