Tension hydrothorax induced by central venous catheter migration in a patient with burns
Editor—We describe an unusual complication of tension hydrothorax, induced by migration of a central venous catheter in an ICU patient with burns. Correct clinical diagnosis resulted in an immediate intervention and insertion of pleural drainage.A 48-yr-old male was referred to our hospital with deep, third degree 30% total body surface area flame burns. He had attempted suicide by self-immolation. He was transferred to burn ICU. According to standard protocol, his trachea was intubated because of suspected inhalation injury, and fluid replacement therapy was administered according to the Parkland formula and a central venous catheter (CV-catheter) was inserted.
A CV-catheter (Arrow International, Reading, PA, USA, triple lumen 20 cm) was inserted uneventfully through unburned skin to the right internal jugular vein. The puncture site was 3 cm above the clavicle between the lateral and medial parts of the sternocleidomastoid muscle. The CV-catheter set contains two suture sites: one near the puncture site with distinct locking system and the other one proximally in the catheter itself.
The catheter was fixed at the puncture site using the suture supplied. The proximal end of the catheter was not fixed with sutures. Because of close proximity of the burned area, the puncture site was covered with wound dressings. The control chest X-ray showed the tip of the catheter locating optimally, in the superior part of the vena cava, with no signs of complications (Fig. 1). The central pressure was monitored through the distal lumen of the catheter. The waveform of the central pressure was optimal and was continuously monitored. Continuous infusion of Ringer's acetate was started at 200 ml h–1 to the proximal port of the CV-catheter.
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At the beginning of the second post-injury day, the patient started to develop ventilatory and haemodynamic problems. Tidal volumes showed a significant decreasing trend, which was compensated by a higher peak inspiratory pressure. Simultaneously, central venous pressure was increasing although diminishing urine output and tachycardia indicated inadequate perfusion. Routine chest X-ray was obtained before operation and the patient was transferred to the operating theatre for operation. At this time the chest X-ray was not reviewed, because it was not available. During the skin graft taking procedure the lung compliance decreased causing serious ventilatory problems. Skin graft taking was discontinued immediately and fascial excisions were performed to the burned areas of the thorax and abdomen to minimize the effect of the hard burn eschar on thoracal compliance. Fine-tuning of the mechanical ventilation improved the condition only temporarily. At the same time the patient became increasingly tachycardic with high central venous pressures.
During the operation the preoperative chest X-ray became available, showing a clear tension hydrothorax (Fig. 2) and the tip of the catheter was 2 cm higher than on the previous chest X-ray. After the diagnosis was made, pleural drainage was initiated by intercostal chest tube insertion in the midaxillary line in the fifth intercostal space. Four litres of clear fluid emerged under pressure from the interpleural space. The ventilatory and haemodynamic status of the patient improved immediately: central venous pressure decreased to acceptable levels, mean arterial pressure could be maintained with less vasoactive support and lung compliance was enhanced. A repeat chest X-ray showed resolution of the tension hydrothorax. The operation was completed uneventfully.
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Catheter tip migration is a documented event after central venous cannulation, occurring in up to 17% of percutaneously introduced catheters.1,2 The chest X-ray obtained in ICU (Fig. 2) after the patient showed signs of deteriorating ventilation and tissue perfusion, revealed migration of the CV-catheter because of poor fixation. The distal and medial lumens were inside the vessel, which was verified by testing the backflow of the blood. The proximal lumen of the catheter was located in the interpleural space. There was no backflow from the proximal lumen, indicating its extravascular location. The patient's clinical condition showing signs of elevated intrathoracal pressure, chest X-ray and lack of s.c. effusion all implied an interpleural location.
The usual cause for hypotension and tachycardia in burn patients is hypovolemia as a result of increased permeability and wound exudate. The clinical signs of escalating central venous pressure and falling lung compliance should alert the clinician to the possibility of catheter tip misplacement. The continuous monitoring of the central venous pressure through the proximal lumen may reveal the tip misplacement at early stage. It should be kept in mind that complications as a result of central venous catheterization can occur also at a later stage.
Helsinki, Finland
*E-mail: kreu.maisniemi{at}hus.fi
References
1 Paw HG. Bilateral pleural effusions: unexpected complication after left internal jugular venous catheterization for total parenteral nutrition. Br J Anaesth 2002; 89:647–50
2 Thomas CJ and Butler CS. Delayed pneumothorax and hydrothorax with central venous catheter migration. Anaesthesia 1999; 54:987–90[CrossRef][Web of Science][Medline]
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