Fatal pulmonary haemorrhage following repeated intercostal drain insertions: Think before you re-do.

Sir,

We present a case in whom re-insertion of intercostal drain (ICD) in intensive care unit (ICU) resulted in fatal pulmonary haemorrhage. A 70-year-old male underwent emergency coronary artery bypass grafting (CABG) due to unstable angina. The patient had triple vessel disease and three grafts, left internal mammary artery to left anterior descending, right internal mammary artery to posterior descending and reverse right great saphenous vein graft to the obtuse marginal artery, were performed. Following CABG, the patient stayed on mechanical ventilation due to lower lung collapse. The patient had ICD insertion thrice during the entire hospital course. First ICD was inserted on the right side of chest post-CABG due to pleura opening during the surgery. This was removed after three days in the post-operative period following extubation. The patient then developed right-sided pneumonia and pleural effusion with respiratory distress and was reintubated on post-operative day 5. The second ICD was inserted to drain the right-sided pleural effusion, which was later removed.

We were unable to wean the patient from ventilator due to right side consolidation and old age. For easy clearance of pulmonary secretions and ease of weaning from ventilation after two weeks of ventilation, a tracheostomy was planned. Percutaneous dilational tracheostomy was done, and size 8.0-mm tracheostomy tube was inserted. Following insertion of the tracheostomy tube, the patient had reduced air entry on the right side, increased airway pressure and reduction in oxygen saturation. FiO2was increased and immediate chest skiagram [Figure 1] was sought, which revealed right-sided pneumothorax. An ICD was inserted urgently. Following chest drain insertion, the patient had profuse bleeding from the ICD with sudden hypotension. Immediate fluid resuscitation was started, but hypotension was non-responsive. With ongoing hypotension, it was decided to clamp ICD. Instant transfer of the patient to the operative room for urgent thoracotomy was decided. With continuous fall in blood pressure, patient suffered cardiac arrest; immediately cardiopulmonary resuscitation was started but unfortunately, the patient could not be revived despite best possible efforts.

Figure 1

Pneumothorax on the right side of the lung following percutaneous dilatation tracheostomy

ICD insertion is a commonly done procedure in emergency and critical care settings. Pulmonary haemorrhage is known complication of ICD insertion.[123] Pneumothorax following tracheostomy is a known and documented complication and well documented in case reports.[4] The pathophysiology behind this complication could be a direct pleural injury, air dissection of the deep cervical fascial plane into the mediastinum, alveolar bleb rupture and inappropriate use of guide wire during the procedure.

In this case, we had attempted to insert the ICD from the same site as before. Previous ICD insertion may have caused the development of adhesions at the site of ICD insertion, which was not so evident on the chest skiagram, and reattempting ICD insertion may have caused pulmonary haemorrhage due to injury to the pulmonary vessel leading to massive bleeding. Bleeding during chest drain insertion is not an uncommon finding, but careful planning must be done in patients in which we reconsider reinsertion of ICDs, and we should take a different intercostal space or at least two space above the previous ICD insertion site. In the cases when there is a need for ICD insertion multiple times, ideally be done under ultrasound guidance or under fluoroscopy.[567]

We conclude that in patients who require multiple insertions of ICD, we must use real-time imaging in the form of either ultrasound or fluoroscopy to prevent any pulmonary vascular or pulmonary parenchymal injury.

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