PULMONARY ARTERY CATHETERIZATION: AN UNUSUAL COMPLICATION OF CHEST TUBE INSERTION
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Aust. N.Z. J. Surg. (1994) 64,513-514 513 CASE REPORTS PULMONARY ARTERY CATHETERIZATION: AN UNUSUAL COMPLICATION OF CHEST TUBE INSERTION K. J. SINGH AND M. A. J. NEWMAN Department of Cardiothoracic Surgery, Royal Perth Hospital, Perth, Western Australia, Australia This article reports the diagnosis and management of transpulmonary catheterization of the pulmonary artery by a chest tube. Key words: chest tube, pulmonary artery injury. INTRODUCTION Many complications of chest tube insertion have been described. Most of them are due to inappropriate position- ing of the tube or to the use of a trocar-containingtube in the setting of pleural adhesions. This is the first report of transpulmonary catheterization of the pulmonary artery with a chest tube. CASE REPORT A 62 year old woman underwent emergency coronary artery bypass grafting after failed percutaneous trans- luminal coronary angioplasty. She received five grafts including the left internal mammary artery to the left anterior descending coronary artery. Postoperative bleed- ing due to a generalized coagulopathy necessitated re- opening. Her early postoperative course was slow and on the third day she developed bilateral pleural effusions and poor respiratory function. Bilateral chest drains were inserted by a senior intensivist,using size 20 Fr Mallinck- rodt trocar tubes (Fig. 1). The technique of tube insertion involved blunt dissection through the chest wall at a site in the anterior axillary line at about the third intercostal space (Fig. 2). A finger was inserted into the pleural cavity and the chest tube advanced without pressure on the trocar. The left sided tube drained 600mL of blood- stained effusion. There was a little resistance to advance- ment of the right sided tube and then rapid drainage of dark red blood. After 800mL had drained, the patient became hypotensive and the central venous pressure dropped. It was suspected that a major vessel injury had occurred. The tube was clamped and the patient resusci- tated with Haemaccel and blood. The haemoglobin level of the fluid in the chest tube was found to be the same as the blood haemoglobin level. A chest X-ray (Fig. 3) showed the tube entering the chest in the right mid-zone and crossing the mid-line, with the tip overlying the cardiac silhouette. Simulta- Correspondence: M. Newman. 9 Lapsley Road, Claremont. Perth. Western Australia 6010, Australia. Accepted for publication 3 February 1993. neous pressure recordings were taken from the clamped chest tube via a needle and the Swan-Ganz catheter in the pulmonary artery. These revealed almost identical tracings and pressures (Fig. 4). A diagnosis was made of transpulmonary catheteriza- tion of the right pulmonary artery with passage of the tube across to the left pulmonary artery. The patient was returned to the operating theatre, anaesthetized, and a double lumen endobronchialtube inserted. The chest was opened via a right posterolateral thoracotomy incision entering the pleural cavity above the fifth rib. Pleural adhesions were found at the site of insertion of the Fig. 1. Tip of the 20 Fr chest tube. Fig. 2. Insertion site of chest tube.
Transcript of PULMONARY ARTERY CATHETERIZATION: AN UNUSUAL COMPLICATION OF CHEST TUBE INSERTION
Aust. N.Z. J . Surg. (1994) 64,513-514 513
CASE REPORTS
PULMONARY ARTERY CATHETERIZATION: AN UNUSUAL COMPLICATION OF CHEST TUBE INSERTION
K. J. SINGH AND M. A. J. NEWMAN Department of Cardiothoracic Surgery, Royal Perth Hospital, Perth, Western Australia, Australia
This article reports the diagnosis and management of transpulmonary catheterization of the pulmonary artery by a chest tube.
Key words: chest tube, pulmonary artery injury.
INTRODUCTION Many complications of chest tube insertion have been described. Most of them are due to inappropriate position- ing of the tube or to the use of a trocar-containing tube in the setting of pleural adhesions. This is the first report of transpulmonary catheterization of the pulmonary artery with a chest tube.
CASE REPORT A 62 year old woman underwent emergency coronary artery bypass grafting after failed percutaneous trans- luminal coronary angioplasty. She received five grafts including the left internal mammary artery to the left anterior descending coronary artery. Postoperative bleed- ing due to a generalized coagulopathy necessitated re- opening. Her early postoperative course was slow and on the third day she developed bilateral pleural effusions and poor respiratory function. Bilateral chest drains were inserted by a senior intensivist, using size 20 Fr Mallinck- rodt trocar tubes (Fig. 1). The technique of tube insertion involved blunt dissection through the chest wall at a site in the anterior axillary line at about the third intercostal space (Fig. 2). A finger was inserted into the pleural cavity and the chest tube advanced without pressure on the trocar. The left sided tube drained 600mL of blood- stained effusion. There was a little resistance to advance- ment of the right sided tube and then rapid drainage of dark red blood. After 800mL had drained, the patient became hypotensive and the central venous pressure dropped. It was suspected that a major vessel injury had occurred. The tube was clamped and the patient resusci- tated with Haemaccel and blood. The haemoglobin level of the fluid in the chest tube was found to be the same as the blood haemoglobin level.
A chest X-ray (Fig. 3) showed the tube entering the chest in the right mid-zone and crossing the mid-line, with the tip overlying the cardiac silhouette. Simulta-
Correspondence: M. Newman. 9 Lapsley Road, Claremont. Perth. Western Australia 6010, Australia.
Accepted for publication 3 February 1993.
neous pressure recordings were taken from the clamped chest tube via a needle and the Swan-Ganz catheter in the pulmonary artery. These revealed almost identical tracings and pressures (Fig. 4).
A diagnosis was made of transpulmonary catheteriza- tion of the right pulmonary artery with passage of the tube across to the left pulmonary artery. The patient was returned to the operating theatre, anaesthetized, and a double lumen endobronchial tube inserted. The chest was opened via a right posterolateral thoracotomy incision entering the pleural cavity above the fifth rib. Pleural adhesions were found at the site of insertion of the
Fig. 1. Tip of the 20 Fr chest tube.
Fig. 2. Insertion site of chest tube.
514 SINGH AND NEWMAN
Fig.3. Chest X-ray showing the tip of the right-sided chest tube lying to the left of the midline.
Fig. 4. Simultaneous pressure tracings from Swan-Ganz cath- eter (PA), chest tube (P3a) and arterial pressure (AP).
intercostal chest tube. The tube was seen to be entering the superior part of the right lower lobe. The interlobar fissure was dissected and the pulmonary artery located. The entry site of the chest tube into the pulmonary artery was found to be at a bifurcation. Haemorrhage from the side holes of the tube was controlled by clamping of the hilum of the lung. Further dissection allowed clamping of the pulmonary artery just proximal to the tube entry site. The clamps were released momentarily to allow the tube to be withdrawn. The hole in the pulmonary artery was sutured with 4.0 prolene. The chest was then closed in the routine way .
Postoperatively the patient made a slow but steady recovery. An air leak from the lung persisted for some 10 days, She was eventually discharged after 20 days in hospital.
DISCUSSION Insertion of chest tubes for the drainage of fluid or air from the pleural cavity is considered a safe routine procedure. However, there is a reported incidence of serious complications of between 1-2.4%.’
It is well known that the internal mammary artery or major mediastinal structures may be injured if the tube is placed too medial. Also well recorded are injuries of intra-abdominal organs if the tube is placed too low.
Bleeding from an intercostal artery injury can occur. Other rarer complications have been reported including injury to the subclavian vein,2 Homer’s syndrome due to injury of the sympathetic chain3 and traumatic intercostal- to-pulmonary artery f i~tula .~ Acute pulmonary oedema can result from rapid drainage of a large pleural e f f~s ion .~ Injury to the lung has been well-recognized and this is usually associated with pleural adhesions and the use of a trocar method of insertion.6
This case report is the first description of transpulmon- ary catheterization of the pulmonary artery with a chest tube. This occurred, despite a blunt dissection technique of insertion in a ‘safe’ area of the chest, when the relatively sharp end of the chest tube was able to penetrate the lung at the site of a pleural adhesion and to enter the intrapulmonary part of the right pulmonary artery and pass intravascularly across to the left pulmonary artery.
Diagnosis of the tube’s intravascular position was made by measuring the drainage haemoglobin level and by measuring the pressure wave in the tube. Knowing that the tube was in the pulmonary artery helped in planning the route of surgical approach for removal and repair.
This case emphasizes the need for care in defining the pleural cavity before insertion of a chest tube and points out the potentially dangerous design of this chest tube.
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management and complications. Chest 1987; 91: 258-64. 2. Tecchio T. Salcuni P, Azzarone M, Soliani P. A subclavian
vein lesion due to positioning of a chest tube via thoracos- tomy. G. Chir. 1991; 12: 435-7.
3. Fleishman JA, Bullock UD, Rosset JS, Beck RW. Iatrogenic Homer’s syndrome secondary to chest tube thoracostomy . J. Clin. Ophthalmol. 1983; 3: 205-10.
4. Cox PA, Keshishian JM, Blades BB. Traumatic arterio- venous fistula of the chest wall and lung. J . Thorac. Cardiovasc. Surg. 1967; 54: 109-12.
5 . Traphnell DH, Thurston JGB. Unilateral pulmonary oedema after pleural aspiration. Lancet 1970 1: 1367.
6. Fraser RS. Lung perforation complicating tube thoracos- tomy: Pathologic description of three cases. Hum. Parhol. 1988; 19 518-23.
