Disorders of the Pleura: Student/Resident Case Report Poster - Disorders of the Pleura |

Chylous Appearing Effusion as a Complication of Total Parenteral Nutrition FREE TO VIEW

Vikas Koppurapu, MD; Kshitij Chatterjee, MD; Vibhor Wadhwa, MD; Aditya Chada, MD; Tarun Pandey, MD; Raghu Reddy, MD
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University of Arkansas for Medical Sciences, Little Rock, AR

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):593A. doi:10.1016/j.chest.2016.08.682
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SESSION TITLE: Student/Resident Case Report Poster - Disorders of the Pleura

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Vascular erosion is a well-known but infrequent complication of central venous catheters and peripherally inserted central catheters (PICC). We present a case of a patient receiving total parenteral nutrition (TPN) through a PICC that caused vascular erosion resulting in chylous appearing pleural effusions.

CASE PRESENTATION: A 93-year-old woman developed small bowel obstruction two days after undergoing an elective repair of right inguinal hernia. Exploratory laparotomy revealed adhesions posterior to the mesh repair of hernia, which were lysed. The patient's medical history included Hypertension, Coronary Artery Disease, Hypothyroidism, and GERD. TPN was initiated peri-operatively through PICC in the left arm. The patient developed shortness of breath gradually after two days. She was afebrile with stable vital signs. Chest examination showed decreased breath sounds bilaterally at the bases posteriorly. Abdominal exam showed diffuse mild tenderness to palpation without peritoneal signs, and diminished bowel sounds. Laboratory studies were normal except for an elevated WBC count of 14 K/mL. Chest X ray showed large bilateral pleural effusions [Fig.1]. Left sided thoracentesis was performed which showed chylous fluid chemically similar to TPN preparation, with normal pathology and microbiology studies. 1.8 liter of fluid was removed with resolution of symptoms. Computed tomography (CT) with injection of contrast through the PICC line showed obvious extravasation of TPN fluid and contrast into the pericardial and pleural space [Fig.2]. The PICC was removed and there was no recurrence of pleural effusions.

DISCUSSION: The incidence of vascular erosion by CVC for TPN administration is reported to be extremely low (0.17%), however, mortality is high.1 Left-sided lines are associated with more vascular erosions. Development of a new milky-white pleural effusion with a pleural fluid/serum glucose ratio more than 1 is suggestive of vascular erosion in patients receiving TPN.2 The catheter should be immediately removed if vascular erosion is diagnosed.

CONCLUSIONS: Vascular erosion by CVC or PICC should be considered as an important differential for a new or worsening pleural effusion in patients receiving fluids or TPN through the catheter. High suspicion should be maintained to ensure early diagnosis of this rare complication, which contributes significantly to morbidity and mortality of patients who often have underlying critical illness.

Reference #1: Walshe C, Phelan D, Bourke J, Buggy D. Vascular erosion by central venous catheters used for total parenteral nutrition. Intensive Care Med 2007;33(3):534-7.

Reference #2: Duntley P, Siever J, Korwes ML, Harpel K, Heffner JE. Vascular erosion by central venous catheters. Clinical features and outcome. Chest 1992;101(6):1633-8.

DISCLOSURE: The following authors have nothing to disclose: Vikas Koppurapu, Kshitij Chatterjee, Vibhor Wadhwa, Aditya Chada, Tarun Pandey, Raghu Reddy

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