Disorders of the Pleura |

Thoracentesis Leading to Fatal Massive Hemoptysis FREE TO VIEW

Islam Ibrahim*, MD
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IMC, Jeddah, Saudi Arabia

Chest. 2012;142(4_MeetingAbstracts):504A. doi:10.1378/chest.1390858
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SESSION TYPE: Pleural Global Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Hemoptysis complicating paracentesis had been described with dry tap, we were able to find one case report of thoracentesis leading to fatal massive hemoptysis in the literature. The hemoptysis is usually caused by puncture of the lungs and puncture sites had been found on postmortem exam, it is unusual to get this complication with successful removal of pleural fluid when the lung is atelectatic.

CASE PRESENTATION: 79 YEAR OLD FEMALE WITH STAGE 4 LUNG CANCER NSCLCA WITH MALIGNANT PLEURAL EFFUSION, PRESENTED WITH DYSPNEA AND HYPOXEMIA AND ACCUMILATION OF RIGHT SIDED MASSIVE PLEURAL EFFUSION LEADING TO ATELECTASIS OF THE LEFT LUNG is 79-year-old female with stage IV non-small cell lung CA bronchogenic carcinoma with malignant pleural effusion, presented with dyspnea and hypoxemia, chest x-ray showed massive right-sided pleural effusion, with complete right lung atelectasis, the patient had mild episodes of hemoptysis which was attributed to the bronchogenic carcinoma, the patient was hemodynamically stable, nevertheless, her breathing was labored, and needed 60% oxygen supplement by Venturi mask, on a lateral decubitus chest x-ray film, the pleural fluid was freely floating in the pleural space, the patient underwent right thoracentesis with removal of 1000 cc of serous sanguinous pleural fluid, there was no blood through the needle upon entering the pleural space, the patient's dyspnea improved towards the end of the thoracentesis procedure, and the patient lied in bed comfortably, 5 minutes following the procedure the patient started coughing with large amounts of blood rushing through the airways, attempts to intubate the patient failed secondary to obscuring of the airways by the massive hemoptysis, the patient desaturated quickly, became bradycardic, and developed asystolic cardiac arrest, the family elected not to pursue CPR, patient expired.

DISCUSSION: THIS UNEXPECTED COMPLICATION LEAD TO THE THINKING THAT LARGE VOLUME THORACENTESIS FOR MASSIVE PLEURAL EFFUSION MAY LEAD TO COMPLICATIONS RELATED TO THE REEXPANSION OF THE ATELECTATIC LUNG, WHICH IS NOT LIMITED TO REEXPANSION PULMONARY EDEMA . The mechanism of hemoptysis in this patient was thought not to be secondary to needle puncture of the lungs, rather, relieving a tympanotomy and pressure exerted by the malignant massive pleural effusion on the bronchogenic carcinoma, once the tympanotomy and pressure was relieved by thoracentesis, hemoptysis occurred. There had been a description of one case in the literature where the patient developed massive fatal hemoptysis. 3 minutes following a dry pleural tap. The cause of hemoptysis was described as direct puncture of the lungs, and puncture sites were found on the posterior surface of the lungs on the postmortem examination, in our case, there was massive pleural effusion, which provided a good distance between the needle and the lungs making the lung. Posterior much less likely, and our tap was not dry, on the contrary, large volume of fluid was removed with improvement of the patient's sense of dyspnea, since the patient did not get the postmortem exam is very difficult to determine whether the mechanism postulated of the sudden release of tympanotomy and pressure exerted by me pleural effusion had led to the decompression of the Brooklyn genic carcinoma, leading to the massive hemoptysis

CONCLUSIONS: ALTHOUGH THIS IS AN UNUSUAL PRESENTATION AND COMPLICATION, ONME CAN LEARN TO BE CAREFUL WITH LARGE VOLUME THORACENTESIS IN A PATIENT WITH MALIGNANTPLEURAL EFFUSION AND HISTORY OF HEMOPTYSIS although this is an unusual presentation and complication of large-volume thoracentesis and malignant pleural effusions, one can learn to be more careful with the removal of pleural fluid and a patient with endobronchial extension of malignant neoplasms who had history of hemoptysis, insertion of the pigtail tube, and gradual removal of fluid may be preferred to large-volume thoracentesis in such patients, more research is needed to confirm this hypothesis.

1) Seneff MG, Corwin RW, Gold LH, Irwin RS: Complications associated with thoracocentesis. Chest 1986; 90:97-100

2) Virshup B, Coombs RH: Physicians' adjustment to retirement. West J Med 1993; 158: 142-144

3) Collins TR, Sahn SA: Thoracocentesis: Clinical value, complications, technical problems, and patient experience. Chest 1987; 91:817-822

DISCLOSURE: The following authors have nothing to disclose: Islam Ibrahim

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IMC, Jeddah, Saudi Arabia




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