SESSION TITLE: Critical Care Case Report Posters I
SESSION TYPE: Affiliate Case Report Poster
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Chest tube placement to drain pleural effusions is a commonly performed procedure. Complications associated with thoracostomy include bleeding, organ puncture, vasovagal events, and adverse reactions to anesthetics or topical antiseptics (1). We report a case of tube thoracostomy, complicated by perforation of the liver and introduction of catheter into the inferior vena cava (IVC) associated with severe mediastinal hemorrhage and cardiac tamponade that required major surgical correction.
CASE PRESENTATION: A 79 year old man with history of infectious endocarditis presented with a recurrence necessitating mitral valve replacement and tricuspid valve repair. Postoperatively, he developed a right sided pleural effusion that was drained with a percutaneous tube thoracostomy. After the initial aspiration of cloudy fluid with syringe, a 14 French pigtail catheter was advanced. There was immediate blood return and the catheter was clamped. CT of the chest revealed that the catheter traversed the liver parenchyma and terminated in the IVC just below the heart. It was associated with a large mediastinal hematoma causing cardiac tamponade. Interventional radiology removed the catheter under fluoroscopic guidance and embolized the transhepatic tract with gelfoam. A sternotomy was performed with evacuation of the mediastinal hematoma relieving the tamponade. After a prolonged postoperative period the patient was discharged to a rehabilitation facility.
DISCUSSION: This is the first reported case, to our knowledge, of a tube thoracostomy perforating the inferior vena cava causing mediastinal hematoma and cardiac tamponade. After perforating the liver, a chest tube can traverse the hepatic veins and perforate the inferior vena cava. In our case, due to close proximity of the point of insertion of catheter in IVC to the right atrium a mediastinal hematoma caused significant pericardial tamponade necessitating a sternotomy. Sonographic guidance during the placement of a chest tube might have reduced the complications associated with this procedure.
CONCLUSIONS: Perforation of the inferior vena cava, mediastinal hematoma and cardiac tamponade are rare complications of chest tube insertion. Catheter in such position should be removed under fluoroscopic guidance to watch for major extravasation in pleural or peritoneal cavity. Using sonography to help guide the insertion of a chest tube reduces the likelihood of complications (2).
Reference #1: Collins TR, Sahn SA ; Thoracocentesis. Clinical value, complications, technical problems, and patient experience; Chest. 1987 Jun;91(6):817-222.
Reference #2: Mercaldi CJ, Lanes SF.; Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis; Chest. 2013 Feb 1;143(2):532-8
DISCLOSURE: The following authors have nothing to disclose: Nidhi Aggarwal, Israel Jacobowitz, Yizhak Kupfer, Sidney Tessler
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