Accidental placement of central venous catheter in lung parenchyma causing hydrothorax.

Central venous catheterization is associated with its share of complications. Most of these complications can be avoided and treated by appropriate patient selection, careful insertion technique and vigilance following catheter insertion. We report a patient presenting with unilateral hydrothorax due malposition of central venous catheter in lung parenchyma. Prompt recognition of complication and its treatment remedied the situation.

INTRODUCTION

Here, we report a case of unilateral hydrothorax as an early complication following central venous cannulation subclavian vein.

CASE REPORT

A 62-year-old male patient was referred to our hospital from a private hospital with the complaints of respiratory distress, altered mentation, and hypotension. Patient's history revealed that he had a fainting episode in his home, he regained consciousness within few minutes and was oriented to time, place, and person. Patient went to a local hospital where on examination; he was found to be hypotensive and dehydrated. His recorded blood pressure was 80/50 mm Hg and pulse 96/min and saturation was 98%. Patient was admitted and 7 Fr triple lumen Central line (arrow Int) was inserted in the right subclavian vein and ringer lactate infusion was started, at a brisk pace. Within approximately 20 min patient complained of breathlessness, chest discomfort, which progressively increased, along with fall in blood pressure and oxygen saturation. Patient was subsequently started on dopamine infusion and given oxygen through face mask and referred to our hospital.

Our examination revealed patient was dyspneic with SpO2 of 92% with 10 L oxygen/min through face mask, pulse rate 130/min and blood pressure of 96/60 mm Hg on dopamine. On auscultation, there were decreased breath sounds on right side of chest in all areas along with dullness on percussion on right side. There was a negative aspiration from all three ports of central line. Immediately, all fluids from central line were stopped and a peripheral iv cannula was inserted. Bed side chest X-ray [Figure 1] revealed homogenous opacification on the right side of chest with trachea and mediastinum shifted to left side, tip of the central line could not be visualized. Pleural tap was positive and intercostal drain was placed in right fifth intercoastal space to drain the hydrothorax, and 2.75 L of light straw colored fluid was drained. To detect the pathophysiology of pleural fluid computed tomography (CT) thorax was done and pleural fluid was sent for chemical analysis. Axial image of upper thorax CT [Figure 2] revealed surgical emphysema in Right upper chest wall with Central venous catheter lying in Right lung parenchyma.

Figure 1

X-ray chest: Opacified right hemithorax. Tip of central venous catheter cannot be visualized. Mediastinum is shifted toward left

Figure 2

Non contrast computed tomography thorax-axial image of upper thorax showing surgical emphysema in Right upper chest wall. Central venous catheter lying in Right lung parenchyma and traversing medially. Tip of central venous catheter cannot be visualized

Routine blood investigations, electrocardiogram, echocardiogram, and CT were within normal limits. Patients condition improved remarkably in few hours and he recovered uneventfully.

DISCUSSION

Central venous catheterization, though a safe procedure in experienced hands, still causes complications in significant number of patients. Studies report a incidence of more than 15%, out of which mechanical complications are reported to occur in 5-19% patients.[1] Rare but serious complications are cardiac tamponade[2] and hydrothorax.[3] Factors associated with higher complication rates in subclavian vein catheterization are operator inexperience,[4] multiple attempts at venipuncture[5] and high body mass index.[5]

Thus, it is imperative to scrupulously follow the proper guidelines regarding indications and method of any invasive procedure, to have a sound knowledge regarding its complications and to have a reasonable degree of suspicion towards complications, no matter how improbable they might seem.