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Emergent Median Sternotomy for Mediastinal Hematoma: A Rare Complication following Internal Jugular Vein Catheterization for Chemoport Insertion-A Case Report and Review of Relevant Literature.

Biswas S, Sidani M, Abrol S - Case Rep Anesthesiol (2014)

Bottom Line: Injury to the central venous system is the result of either penetrating trauma or iatrogenic causes as in our case.Meticulous surgical technique, knowledge of the possible complications, and close monitoring in the postprocedural period are of utmost importance.Chest X-ray showed to be routinely done to detect any complication early.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Brookdale University Hospital Medical Center, Brooklyn, NY 11212, USA.

ABSTRACT
Mediastinal hematoma is a rare complication following insertion of a central venous catheter with only few cases reported in the English literature. We report a case of a 71-year-old female who was admitted for elective chemoport placement. USG guided right internal jugular access was attempted using the Seldinger technique. Resistance was met while threading the guidewire. USG showed a chronic clot burden in the RIJ. A microvascular access was established under fluoroscopic guidance. Rest of the procedure was completed without any further issues. Following extubation, the patient complained of right-sided chest pain radiating to the back. Chest X-ray revealed a contained white out in the right upper lung field. She became hemodynamically unstable. Repeated X-ray showed progression of the hematoma. Median Sternotomy showed posterior mediastinal hematoma tracking into right pleural cavity. Active bleeding from the puncture site at RIJ-SCL junction was repaired. Patient had an uneventful recovery. Injury to the central venous system is the result of either penetrating trauma or iatrogenic causes as in our case. A possible explanation of our complication may be attributed to the forced manipulation of the dilator or guidewire against resistance. Clavicle and sternum offer bony protection to the underlying vital venous structures and injuries often need sternotomy with or without neck extension. Division of the clavicle and disarticulation of the sternoclavicular joint may be required for optimum exposure. Meticulous surgical technique, knowledge of the possible complications, and close monitoring in the postprocedural period are of utmost importance. Chest X-ray showed to be routinely done to detect any complication early.

No MeSH data available.


Related in: MedlinePlus

Preoperative chest X-ray: essentially normal.
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fig1: Preoperative chest X-ray: essentially normal.

Mentions: The patient was taken to operating room the following day for the placement of a chemoport. Her chest X-ray (Figure 1) was normal and she was asymptomatic. General anesthesia was induced with no complications. The patient was draped and positioned in Trendelenberg. Ultrasound guided insertion of a right internal jugular venous (IJV) access was attempted with a total of 4 trials using Seldinger's technique. Resistance was met while threading the guide wire. Ultrasound examination showed a chronic clot burden in the Right IJV. The vascular surgery team was consulted intra operatively. A right IJV access using a microset access under fluoroscopic guidance was obtained. The procedure was then completed without any further issues. Following extubation, and upon transfer of the patient to the stretcher, she started complaining of right-sided chest pain radiating to the back. She became tachycardic with a heart rate ranging between 105 and 110 beats per minute. CXR was immediately obtained and it revealed a contained white out in the right upper lung field (Figure 2).


Emergent Median Sternotomy for Mediastinal Hematoma: A Rare Complication following Internal Jugular Vein Catheterization for Chemoport Insertion-A Case Report and Review of Relevant Literature.

Biswas S, Sidani M, Abrol S - Case Rep Anesthesiol (2014)

Preoperative chest X-ray: essentially normal.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3926366&req=5

fig1: Preoperative chest X-ray: essentially normal.
Mentions: The patient was taken to operating room the following day for the placement of a chemoport. Her chest X-ray (Figure 1) was normal and she was asymptomatic. General anesthesia was induced with no complications. The patient was draped and positioned in Trendelenberg. Ultrasound guided insertion of a right internal jugular venous (IJV) access was attempted with a total of 4 trials using Seldinger's technique. Resistance was met while threading the guide wire. Ultrasound examination showed a chronic clot burden in the Right IJV. The vascular surgery team was consulted intra operatively. A right IJV access using a microset access under fluoroscopic guidance was obtained. The procedure was then completed without any further issues. Following extubation, and upon transfer of the patient to the stretcher, she started complaining of right-sided chest pain radiating to the back. She became tachycardic with a heart rate ranging between 105 and 110 beats per minute. CXR was immediately obtained and it revealed a contained white out in the right upper lung field (Figure 2).

Bottom Line: Injury to the central venous system is the result of either penetrating trauma or iatrogenic causes as in our case.Meticulous surgical technique, knowledge of the possible complications, and close monitoring in the postprocedural period are of utmost importance.Chest X-ray showed to be routinely done to detect any complication early.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Brookdale University Hospital Medical Center, Brooklyn, NY 11212, USA.

ABSTRACT
Mediastinal hematoma is a rare complication following insertion of a central venous catheter with only few cases reported in the English literature. We report a case of a 71-year-old female who was admitted for elective chemoport placement. USG guided right internal jugular access was attempted using the Seldinger technique. Resistance was met while threading the guidewire. USG showed a chronic clot burden in the RIJ. A microvascular access was established under fluoroscopic guidance. Rest of the procedure was completed without any further issues. Following extubation, the patient complained of right-sided chest pain radiating to the back. Chest X-ray revealed a contained white out in the right upper lung field. She became hemodynamically unstable. Repeated X-ray showed progression of the hematoma. Median Sternotomy showed posterior mediastinal hematoma tracking into right pleural cavity. Active bleeding from the puncture site at RIJ-SCL junction was repaired. Patient had an uneventful recovery. Injury to the central venous system is the result of either penetrating trauma or iatrogenic causes as in our case. A possible explanation of our complication may be attributed to the forced manipulation of the dilator or guidewire against resistance. Clavicle and sternum offer bony protection to the underlying vital venous structures and injuries often need sternotomy with or without neck extension. Division of the clavicle and disarticulation of the sternoclavicular joint may be required for optimum exposure. Meticulous surgical technique, knowledge of the possible complications, and close monitoring in the postprocedural period are of utmost importance. Chest X-ray showed to be routinely done to detect any complication early.

No MeSH data available.


Related in: MedlinePlus