A standard procedure that by all standards went well: Easy cannulation of vein on first attempt. Good, non-pulsating backflow in the syringe. No problems on inserting the guide wire, and dilation of the vessel and insertion of the big dialysis catheter went easy – although more pain than usual was noted from the patient. Good, non-pulsatile backflow and easy injection was noted in both lumen. This was the subsequent CXR:
Anything out of the ordinary? Maybe, in retrospect, I would’ve liked to see the tip of the catheter inside the shadow of the heart – but it points in the right direction and follows the normal direction of the vessels. “There is no pneumothorax noted and the lung fields are clear, apart from a slight interstitial opaqueness in the lower right hemithorax. The catheter is well placed”, was the report from the radiologist.
But something’s wrong
The patient keeps complaining of pain that increased with respiration. She hadn’t received dialysis yet. The next day a new CXR including a lateral picture are taken:
Now, it’s easy to see the misplacement of the catheter. There is also sign of pleural fluid on the right lung. No pneumothorax. The pleural fluid could be blood, but by any standard a small amount. So, still nothing dramatic, the patient is stable and it’s almost 20 hours after catheter placement.
She’s taken down to the catheter insertion room and and the catheter is checked by attaching a bag of RL, showing a free running drip, and backflow on the line when the bag is lowered below patient level. After discussing the issue, it is first attempted to reposition the catheter. When this doesn’t work, it is decided to remove the catheter – and as a side effect they reveal the underlying problem.
Things just got real
The patient crashes. The patient quickly becomes tachycardic and BP is measured to 40/25. High flow clear fluid infusions are started until blood arrives and blood transfusions started. As the patient is slim, the right pleura is cannulated as a temporary measure. They get blood.
A small drain is placed and they get 750 ml of blood. After these initial clear fluid boluses and 2 PRBCs, the patient is again fairly stable. She’s taken to the perioperative ward, a thoracic surgeon is called and an OR made ready. She crashes again, is intubated on ketamine and sux and at the same time gets a proper chest drain which drains about a litre of blood. The patient gets somewhat stabilised again and is taken directly to a thoracic OR. During the resusitation effort, another CXR was taken:
In the OR the patient got a sternal split to get proper access to the pleural cavity and the vessels going up towards the head and arm on the right side. A lateral thoracotomy wouldn’t have given proper access in this case.
They find the dialysis catheter has speared through the brachiocephalic trunk and had been sitting there as a plug. When the catheter was removed, the patient got a massive arterial bleed into her right pleural space, leading to hypovolemia as well as creating a sort of tension hemothorax pressing on the caval veins and the right heart – which were already volume depleted. This would explain the patient stabilising after draining the right pleural space. The blood that was aspirated from the catheter tip during the insertion procedure, could have been blood sitting in the pleural space.
This is a very special case where the holes in the cheese line up nicely to create a scary scenario.
It reveals the need for vigilance and listening to patient symptoms. It also shows how a bleeding chest needs a big tube – not a small catheter. In pre-hospital medicine we’re usually better at improvising. In-hospital, the big system often gets us thinking inside the box – like here, waiting for a chest tube to be avialable, when you have an endotracheal tube at hand that would do the job a lot better than a tiny drain catheter.
Still, quick and decisive resuscitation and operation saved the day. And to finish the case, here’s the post-OP CXR: