Case Report Bilateral Pleural and Pericardial Effusions Because of Mediastinal Placement of a Central Venous Catheter TIMOTHY C. From the West
SIMMONS, MD,
AND
DONALD R. HENDERSON, MD
Gastroenterology Group and Digestive Disease Center of Inglewood and Inglewood, California
ABSTRACT. Pneumothorax, hydrothorax, hydromediastinum, and cardiac tamponade are uncommon, although not unusual, complications of central venous catheter placement. We report a case of hydromediastinum with bilateral pleural
Los
Angeles; and Daniel Freeman Hospital of
and pericardial effusions, occurring in a patient after placement of a Silastic double-lumen central venous catheter for hyperalimentation. ( Journal of Parenteral and Enteral Nutrition
15:676-679, 1991)
Complications after central venous catheterization for edema of the vulva and labia. No distinct vaginal lacerparenteral nutrition are rare. Advances in the sur- ation or fistulous tract was identified. The initial laboratory tests disclosed the following gical technique of central venous catheterizationl-3 and improvement in catheter materials have decreased the abnormal values: hemoglobin, 9.8 g/dL; prothrombin incidence of catheter-related complications. A review of time, 13.5 seconds; total protein, 5.1 g/dL; albumin, 2.8 1987 to 1989 surgical statistics at Daniel Freeman Hos- g/dL. The white blood cell count, serum glucose, serum pital, Inglewood, CA, reveals an average of 48 central electrolytes, and serum transaminases were normal. venous catheter insertions per year for total parenteral Colonoscopy revealed an anal stricture and large ul-
total
nutrition. This case report represents the first serious technical complication of central venous catheterization for hyperalimentation recorded during the above 3-year retrospective review.
associated with A fistulous tract from the rectum to contiguous structures was demonstrated at colonoscopy. She subsequently underwent insertion of a doublelumen, 11 French, central venous catheter (HEMED CASE REPORT Central Venous Access Catheter, Gish Biomedical, Inc., &dquo; Ana, CA) via the right subclavian vein according A 22-year-old black woman with a 7-year history of ’Santa 1 the methods previously described.l-3 The surgeon was Crohn’s colitis, complicated by rectovesical, rectovaginal, to and vesicovaginal fistulae, was admitted to Daniel Free- ’Iexperienced with the technique for percutaneous introduction of silicone elastomer catheters. Using a fluoroman Hospital, Inglewood, CA, November 12, 1987, for total parenteral nutrition (TPN). Multiple exacerbations scopic image intensifier and contrast media injected of acute Crohn’s colitis were successfully managed with through the catheter, the surgeon verified the catheter’s prednisone, sulfasalazine, and metronidazole. However, tip location at the superior vena cava and right atrium junction. Before closing the skin, the surgeon reconon two prior occasions, episodes of acute Crohn’s colitis firmed accurate catheter location with a second injection bowel rest and TPN At required complete management. the current admission, she had complaints of intractable of contrast media. Although the surgeon aspirated blood diarrhea (8 to 12 watery stools per day), hematochezia, through a needle from the right subclavian vein before pneumaturia, fecaluria, and fecal discharge from her inserting the guidewire and catheter, at the end of the vagina. In addition, during the preceding 2 months, procedure he did not withdraw blood from the catheter with a syringe or allow blood to freely flow back through weight loss of 10 kg was noted. On physical examination the vital signs were normal, the catheter with gravity. The TPN infusion was started during the immediate total body weight was 48.2 kg, and emaciation was evident. At inspection, the abdomen was scaphoid; however, postoperative period. After receiving the first 1000 mL palpation did not disclose intra-abdominal abnormality. of TPN and 500 mL of emulsified lipid, the patient The rectal examination showed an anal stricture and a became anxious and restless. Two hours after the infuscarred rectal vault. The pelvic examination showed sion of the second L of TPN, she developed nausea, retching, dyspnea, and retrosternal chest pain. She was subsequently transferred to the medical intensive care unit. Reprint requests: T.C. Simmons, 633 Aerick Street, Inglewood, CA The admitting chest x-ray (Fig. 1) was normal. How90301. cerative
areas
of the left colon that
were
multiple colonic inflammatory pseudopolyps.
’
676 Downloaded from pen.sagepub.com at Bobst Library, New York University on May 24, 2015
677
FIG. 1. The
patient had
a
normal chest x-ray when admitted to the
hospital. ever, a subsequent chest x-ray (Fig. 2), onset of chest pain, revealed bilateral
obtained after the
pleural effusions,
mediastinal widening, and enlargement of the cardiac silhouette. The TPN and emulsified lipid infusions were immediately terminated. Right thoracentesis yielded 1800 mL of milky opaque material. Twenty-four hours later, left thoracentesis produced 1700 mL of milky fluid. The pleural fluid glucose was 2048 mg/dL. A simultaneous serum glucose level was 156 mg/dL. The pleural fluid also contained a high lipid content. These findings were consistent with intrapleural infusion of TPN and emulsified lipid solutions. A 2-D echocardiogram revealed a large pericardial effusion. Pericardiocentesis was not performed because clinical evidence of cardiac tamponade was not observed. A small volume of water soluble contrast, injected through the central venous catheter, disclosed mediastinal placement of the catheter tip (Fig. 3). The central venous catheter was subsequently removed. A follow-up chest x-ray 5 days later (Fig. 4) showed complete resolution of the bilateral pleural effusions, and a follow-up 2-D echocardiogram revealed near complete absorption of the pericardial effusion. An elemental oral diet (Vivonex-T.E.N., Norwich Eaton, Norwich, NY) was started. She was discharged from the hospital on the 14th hospital day. DISCUSSION
Hydromediastinum with and without cardiac tamponade, pneumothorax, hemothorax, hydrothorax, subcla-
FIG. 2. Chest x-ray obtained after infusion of 2 L of TPN and emulsified lipid through a central venous silicone rubber catheter (HEMED). This study shows the central venous catheter with its tip at the mediastinum, mediastinal widening, and bilateral pleural effusions. or superior vena caval vein injury, infections, and thrombophlebitis exemplify major complications of central venous catheterization.4-’ Catheter perforation of the myocardium accounts for the majority of cardiac tamponade cases because of polyethylene central venous catheter insertion.’ Although not uncommon for polyethylene catheter insertion, inadvertent free mediastinal placement of a central venous catheter, as occurred in the patient reported herein, is an unusual complication of silicone rubber catheter insertion for long-term intravenous therapy. Aberrant venous locations during central venous cath-
vian
eterization have been noted. Brandi et a18 described in a case report, inadvertent catheterization of the right internal thoracic (mammary) vein, occurring after right internal jugular venous cannulation for TPN. Aberrant central venous catheter placement for total parenteral nutrition was reported by Jacobsen and his associates.’ Oakes and Wilson 10 reported a case of left subclavian line malposition into the right internal mammary vein; TPN infusion in this patient resulted in bilateral pleural effusions, interstitial pulmonary edema, and chest wall abscess. Unlike the case reported above, our patient had free mediastinal placement of her central venous catheter ; this finding suggested venous perforation central to the site of venous access. The contrast study via the central venous catheter confirmed free mediastinal
Downloaded from pen.sagepub.com at Bobst Library, New York University on May 24, 2015
678
FIG. 4. Chest x-ray 5 days postthoracentesis showing complete resolution of the bilateral pleural effusions. Enlargement of the cardiac silhouette is also noted as compared with the chest x-ray when admitted to the hospital. F~G. 3. Chest x-ray obtained after injection of contrast media through the central venous catheter showing free mediastinal placement of the catheter’s distal tip.
placement of the catheter’s tip but did not locate the site of vascular perforation. Possible causes of the vascular perforation included the following: right internal mammary vein catheter placement and subsequent catheter rupture into the mediastinum following TPN instillation; decreased vascular intimal integrity because of prior catheter insertions; and catheter guidewire-induced vascular injury or perforation. The development of acute dyspnea, tachypnea, and chest pain in our patient lead to the discovery of bilateral pleural and pericardial effusions. Instillation of TPN solution and emulsified lipids through a silicone rubber catheter, inadvertently placed in the mediastinum, was the primary cause of the symptoms and physical findings in the patient reported herein. So and Sutherlandll reported that the ability to freely aspirate blood through a central venous catheter is a good predictor of catheter function and central venous catheter placement. The surgeon used fluoroscopic guidance during catheter insertion in our patient; however, at the end of the procedure, he did not aspirate blood from the catheter with a syringe or allow blood to flashback through the catheter with gravity. This simple
maneuver, potentially would prevent inadvertent extravascular catheter placement such as occurred in the patient reported herein. When extravascular placement of a central venous catheter for TPN is suspected, immediate discontinuation of TPN infusion and catheter removal are critical initial steps in management.
REFERENCES
JW, Cole JJ, Schribner BHA: Silicone rubber atrial cathprolonged parenteral alimentation. Surg Gynecol Obstet 136:602-606, 1973 Tatooles CJ: A simplified technique for the percutaneous introduction of silicone elastomer catheters. Surg Gynecol Obstet 133:105-
1. Broviac eter for 2.
106, 1971 3. Cohen term
AM, Wood WC: Simplified technique for placement of longcentral venous silicone catheters. Surg Gynecol Obset
154:721-724, 1982 R, Mozes M: Fatal complications of cental venous catheters. Br Med J 3:746-747, 1971 Bone DK, Maddrey WC, Eagan J, et al: Cardiac tamponade: A
4. Adar 5.
fatal
complication
of central
venous
catheterization. Arch
Surg
106:868-870, 1973 6. Greenall MJ, Blewitt RW, McMahon MJ: Cardiac tamponade and central venous catheters. Br Med J 2:595-597, 1975 7. Thomas JH, MacArthur RI, Pierce GE, et al: Hickman-Broviac
Downloaded from pen.sagepub.com at Bobst Library, New York University on May 24, 2015
679 catheters: Indications and results. Am J Surg 140:791-796, 1980 8. Brandi LS, Oleggini M, Frediani M, et al: Inadvertent catheterization of the internal thoracic vein mimicking pulmonary embolism: A case report. JPEN 12:221-222, 1988 9. Jacobsen WK, Smith DC, Briggs BA, et al: Aberrant catheter placement for total parenteral nutrition. Anesthesiology 50:152-
154, 1979
10. Oakes
11.
DD, Wilson RE: Malposition of a subclavian line: Resultant pleural effusions, interstitial pulmonary edema, and chest wall abscess during total parenteral nutrition. JAMA 233:532-533, 1975 So SKS, Sutherland DER: Vascular access procedures: Vascular access for total parenteral nutrition: In Advances in Vascular Surgery, Najarian JS, Delaney JP (ed). Year Book Medical Publishers Inc., Chicago, 1983, pp 445-461
Downloaded from pen.sagepub.com at Bobst Library, New York University on May 24, 2015
SIMMONS, MD,
AND
DONALD R. HENDERSON, MD
Gastroenterology Group and Digestive Disease Center of Inglewood and Inglewood, California
ABSTRACT. Pneumothorax, hydrothorax, hydromediastinum, and cardiac tamponade are uncommon, although not unusual, complications of central venous catheter placement. We report a case of hydromediastinum with bilateral pleural
Los
Angeles; and Daniel Freeman Hospital of
and pericardial effusions, occurring in a patient after placement of a Silastic double-lumen central venous catheter for hyperalimentation. ( Journal of Parenteral and Enteral Nutrition
15:676-679, 1991)
Complications after central venous catheterization for edema of the vulva and labia. No distinct vaginal lacerparenteral nutrition are rare. Advances in the sur- ation or fistulous tract was identified. The initial laboratory tests disclosed the following gical technique of central venous catheterizationl-3 and improvement in catheter materials have decreased the abnormal values: hemoglobin, 9.8 g/dL; prothrombin incidence of catheter-related complications. A review of time, 13.5 seconds; total protein, 5.1 g/dL; albumin, 2.8 1987 to 1989 surgical statistics at Daniel Freeman Hos- g/dL. The white blood cell count, serum glucose, serum pital, Inglewood, CA, reveals an average of 48 central electrolytes, and serum transaminases were normal. venous catheter insertions per year for total parenteral Colonoscopy revealed an anal stricture and large ul-
total
nutrition. This case report represents the first serious technical complication of central venous catheterization for hyperalimentation recorded during the above 3-year retrospective review.
associated with A fistulous tract from the rectum to contiguous structures was demonstrated at colonoscopy. She subsequently underwent insertion of a doublelumen, 11 French, central venous catheter (HEMED CASE REPORT Central Venous Access Catheter, Gish Biomedical, Inc., &dquo; Ana, CA) via the right subclavian vein according A 22-year-old black woman with a 7-year history of ’Santa 1 the methods previously described.l-3 The surgeon was Crohn’s colitis, complicated by rectovesical, rectovaginal, to and vesicovaginal fistulae, was admitted to Daniel Free- ’Iexperienced with the technique for percutaneous introduction of silicone elastomer catheters. Using a fluoroman Hospital, Inglewood, CA, November 12, 1987, for total parenteral nutrition (TPN). Multiple exacerbations scopic image intensifier and contrast media injected of acute Crohn’s colitis were successfully managed with through the catheter, the surgeon verified the catheter’s prednisone, sulfasalazine, and metronidazole. However, tip location at the superior vena cava and right atrium junction. Before closing the skin, the surgeon reconon two prior occasions, episodes of acute Crohn’s colitis firmed accurate catheter location with a second injection bowel rest and TPN At required complete management. the current admission, she had complaints of intractable of contrast media. Although the surgeon aspirated blood diarrhea (8 to 12 watery stools per day), hematochezia, through a needle from the right subclavian vein before pneumaturia, fecaluria, and fecal discharge from her inserting the guidewire and catheter, at the end of the vagina. In addition, during the preceding 2 months, procedure he did not withdraw blood from the catheter with a syringe or allow blood to freely flow back through weight loss of 10 kg was noted. On physical examination the vital signs were normal, the catheter with gravity. The TPN infusion was started during the immediate total body weight was 48.2 kg, and emaciation was evident. At inspection, the abdomen was scaphoid; however, postoperative period. After receiving the first 1000 mL palpation did not disclose intra-abdominal abnormality. of TPN and 500 mL of emulsified lipid, the patient The rectal examination showed an anal stricture and a became anxious and restless. Two hours after the infuscarred rectal vault. The pelvic examination showed sion of the second L of TPN, she developed nausea, retching, dyspnea, and retrosternal chest pain. She was subsequently transferred to the medical intensive care unit. Reprint requests: T.C. Simmons, 633 Aerick Street, Inglewood, CA The admitting chest x-ray (Fig. 1) was normal. How90301. cerative
areas
of the left colon that
were
multiple colonic inflammatory pseudopolyps.
’
676 Downloaded from pen.sagepub.com at Bobst Library, New York University on May 24, 2015
677
FIG. 1. The
patient had
a
normal chest x-ray when admitted to the
hospital. ever, a subsequent chest x-ray (Fig. 2), onset of chest pain, revealed bilateral
obtained after the
pleural effusions,
mediastinal widening, and enlargement of the cardiac silhouette. The TPN and emulsified lipid infusions were immediately terminated. Right thoracentesis yielded 1800 mL of milky opaque material. Twenty-four hours later, left thoracentesis produced 1700 mL of milky fluid. The pleural fluid glucose was 2048 mg/dL. A simultaneous serum glucose level was 156 mg/dL. The pleural fluid also contained a high lipid content. These findings were consistent with intrapleural infusion of TPN and emulsified lipid solutions. A 2-D echocardiogram revealed a large pericardial effusion. Pericardiocentesis was not performed because clinical evidence of cardiac tamponade was not observed. A small volume of water soluble contrast, injected through the central venous catheter, disclosed mediastinal placement of the catheter tip (Fig. 3). The central venous catheter was subsequently removed. A follow-up chest x-ray 5 days later (Fig. 4) showed complete resolution of the bilateral pleural effusions, and a follow-up 2-D echocardiogram revealed near complete absorption of the pericardial effusion. An elemental oral diet (Vivonex-T.E.N., Norwich Eaton, Norwich, NY) was started. She was discharged from the hospital on the 14th hospital day. DISCUSSION
Hydromediastinum with and without cardiac tamponade, pneumothorax, hemothorax, hydrothorax, subcla-
FIG. 2. Chest x-ray obtained after infusion of 2 L of TPN and emulsified lipid through a central venous silicone rubber catheter (HEMED). This study shows the central venous catheter with its tip at the mediastinum, mediastinal widening, and bilateral pleural effusions. or superior vena caval vein injury, infections, and thrombophlebitis exemplify major complications of central venous catheterization.4-’ Catheter perforation of the myocardium accounts for the majority of cardiac tamponade cases because of polyethylene central venous catheter insertion.’ Although not uncommon for polyethylene catheter insertion, inadvertent free mediastinal placement of a central venous catheter, as occurred in the patient reported herein, is an unusual complication of silicone rubber catheter insertion for long-term intravenous therapy. Aberrant venous locations during central venous cath-
vian
eterization have been noted. Brandi et a18 described in a case report, inadvertent catheterization of the right internal thoracic (mammary) vein, occurring after right internal jugular venous cannulation for TPN. Aberrant central venous catheter placement for total parenteral nutrition was reported by Jacobsen and his associates.’ Oakes and Wilson 10 reported a case of left subclavian line malposition into the right internal mammary vein; TPN infusion in this patient resulted in bilateral pleural effusions, interstitial pulmonary edema, and chest wall abscess. Unlike the case reported above, our patient had free mediastinal placement of her central venous catheter ; this finding suggested venous perforation central to the site of venous access. The contrast study via the central venous catheter confirmed free mediastinal
Downloaded from pen.sagepub.com at Bobst Library, New York University on May 24, 2015
678
FIG. 4. Chest x-ray 5 days postthoracentesis showing complete resolution of the bilateral pleural effusions. Enlargement of the cardiac silhouette is also noted as compared with the chest x-ray when admitted to the hospital. F~G. 3. Chest x-ray obtained after injection of contrast media through the central venous catheter showing free mediastinal placement of the catheter’s distal tip.
placement of the catheter’s tip but did not locate the site of vascular perforation. Possible causes of the vascular perforation included the following: right internal mammary vein catheter placement and subsequent catheter rupture into the mediastinum following TPN instillation; decreased vascular intimal integrity because of prior catheter insertions; and catheter guidewire-induced vascular injury or perforation. The development of acute dyspnea, tachypnea, and chest pain in our patient lead to the discovery of bilateral pleural and pericardial effusions. Instillation of TPN solution and emulsified lipids through a silicone rubber catheter, inadvertently placed in the mediastinum, was the primary cause of the symptoms and physical findings in the patient reported herein. So and Sutherlandll reported that the ability to freely aspirate blood through a central venous catheter is a good predictor of catheter function and central venous catheter placement. The surgeon used fluoroscopic guidance during catheter insertion in our patient; however, at the end of the procedure, he did not aspirate blood from the catheter with a syringe or allow blood to flashback through the catheter with gravity. This simple
maneuver, potentially would prevent inadvertent extravascular catheter placement such as occurred in the patient reported herein. When extravascular placement of a central venous catheter for TPN is suspected, immediate discontinuation of TPN infusion and catheter removal are critical initial steps in management.
REFERENCES
JW, Cole JJ, Schribner BHA: Silicone rubber atrial cathprolonged parenteral alimentation. Surg Gynecol Obstet 136:602-606, 1973 Tatooles CJ: A simplified technique for the percutaneous introduction of silicone elastomer catheters. Surg Gynecol Obstet 133:105-
1. Broviac eter for 2.
106, 1971 3. Cohen term
AM, Wood WC: Simplified technique for placement of longcentral venous silicone catheters. Surg Gynecol Obset
154:721-724, 1982 R, Mozes M: Fatal complications of cental venous catheters. Br Med J 3:746-747, 1971 Bone DK, Maddrey WC, Eagan J, et al: Cardiac tamponade: A
4. Adar 5.
fatal
complication
of central
venous
catheterization. Arch
Surg
106:868-870, 1973 6. Greenall MJ, Blewitt RW, McMahon MJ: Cardiac tamponade and central venous catheters. Br Med J 2:595-597, 1975 7. Thomas JH, MacArthur RI, Pierce GE, et al: Hickman-Broviac
Downloaded from pen.sagepub.com at Bobst Library, New York University on May 24, 2015
679 catheters: Indications and results. Am J Surg 140:791-796, 1980 8. Brandi LS, Oleggini M, Frediani M, et al: Inadvertent catheterization of the internal thoracic vein mimicking pulmonary embolism: A case report. JPEN 12:221-222, 1988 9. Jacobsen WK, Smith DC, Briggs BA, et al: Aberrant catheter placement for total parenteral nutrition. Anesthesiology 50:152-
154, 1979
10. Oakes
11.
DD, Wilson RE: Malposition of a subclavian line: Resultant pleural effusions, interstitial pulmonary edema, and chest wall abscess during total parenteral nutrition. JAMA 233:532-533, 1975 So SKS, Sutherland DER: Vascular access procedures: Vascular access for total parenteral nutrition: In Advances in Vascular Surgery, Najarian JS, Delaney JP (ed). Year Book Medical Publishers Inc., Chicago, 1983, pp 445-461
Downloaded from pen.sagepub.com at Bobst Library, New York University on May 24, 2015
