SESSION TYPE: Critical Care Cases II
PRESENTED ON: Wednesday, October 24, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: Hydrothorax is a rare complication that occurs minutes, to days after Central Venous Catheter (CVC) placement. The incidence ranges from 0.4% to 1%(1). Most cases are reported after left sided CVC placement. We report a case of right-sided tension hydrothorax following a right internal jugular (IJ) vein CVC placement.
CASE PRESENTATION: A 49-year-old woman was admitted to the ICU with seizure and change in mental status. She was intubation and a right IJ CVC was placed. The position was confirmed by chest film (CXR) fig (1). Seven hours later, she became hypotensive. After 2 liters of fluid boluses, the patient became more hypotensive, hypoxic and cyanotic. Repeat CXR showed right-sided tension hydrothorax fig (2). Emergent thoracentesis was performed with drainage of four liters of sero-sanguinous fluid. This led to immediate improvement in the blood pressure as well as oxygenation. She was successfully extubated 24 hours later.
DISCUSSION: Delayed Hydrothorax is due to migration of the catheter tip through the superior vena cava (SVC) into the pleural cavity(2). This is contributed to anatomical factors, as the left subclavian or internal jugular vein is liable to abut the right wall of the SVC at a sharp angle. For this reason, right-sided line placement is preferable due to the larger caliber of the right-sided vessels and direct path to the SVC (2). The occurrence of hydrothorax after CVC placement is the result of a combination of different factors that leads to vein wall erosion. These factors include improper positioning of the catheter tip and insecure fixation of the catheter. The insecure fixation of the catheter combined with patient transportation, head and neck movement, and cardiopulmonary motion have been shown to result in the back and forth movement of the catheter tip that can lead to erosion through the vein wall. Clinical symptoms of CVC induced hydrothorax include chest pain and/or dyspnea. However, in intubated and sedated patients, it is difficult to rely on these clinical symptoms. In patients receiving intravenous infusions through a CVC, the unexpected onset of hypotension and hypoxia should alert physicians to a possible CVC induced hydrothorax. Prompt recognition of this complication is the major predictor of a favorable outcome.
CONCLUSIONS: Delayed hydrothorax is a serious complication of CVC placement. It can be fatal if not promptly recognized and appropriately treated. Acute hypoxemia and hypotension shortly after a CVC placement should raise suspicion for the diagnosis. Prompt recognition and treatment leads to favorable outcome.
1) P Duntley, J Siever, M Korwes, K Harpel. Vascular erosion by central venous catheters. Clinical features and outcome. Chest 1992;101;1633-1638
2) Iberti TJ, Katz LB, Reiner MA, Brownie T. Hydrothorax as a late complication of central venous indwelling catheters. Surgery 1983;94:842-6
DISCLOSURE: The following authors have nothing to disclose: Rabih Maroun, Kassem Harris, Michel Chalhoub
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