Mishra Sandeep Kumar, Paulose Deepak, Kundra Pankaj, Parida Satyen
Department of Anaesthesiology and Critical Care, JIPMER, Puducherry, India.
Department of Anaesthesiology and Critical Care, IGMCRI, Puducherry, India.
Anesth Essays Res. 2015 Sep-Dec;9(3):433-6. doi: 10.4103/0259-1162.161815.
We present an unusual case of life-threatening hemothorax in a 15-year-old boy following subclavian vein tear during internal jugular vein (IJV) cannulation prior to initiation of surgery (mitral valve replacement). Successful IJV cannulation was done in the third attempt. However, we missed the subclavian tear which occurred during the first two initial attempts as there was no clinical evidence suggestive of it at that point of time. This undiagnosed hemothorax led to hemodynamic decompensation requiring high volume and inotropic support to wean the patient off cardiopulmonary bypass. This unusually high requirement of fluid and inotropes required the surgeon to look for noncardiac causes for the hemodynamic disturbance and he noticed a bulge in the right pleura, which on exploration had approximately 1.5 L of collected blood. It was then retrospectively analyzed that the cause of this hemothorax could have been the undue lateral orientation of the needle during IJV cannulation and the advancement of the dilator to its entire length could have injured the subclavian vein. Here, we also would like to discuss the safety precautions to be taken during the cannulation, like the needle orientation and the length to which the dilator must be advanced for safe central venous cannulation.
我们报告了一例不同寻常的病例，一名15岁男孩在二尖瓣置换手术前进行颈内静脉（IJV）置管时发生锁骨下静脉撕裂，导致危及生命的血胸。第三次尝试成功完成了IJV置管。然而，我们漏诊了在前两次初始尝试过程中发生的锁骨下静脉撕裂，因为当时没有临床证据提示这一情况。这种未被诊断出的血胸导致血流动力学失代偿，需要大量补液和使用血管活性药物支持，以使患者脱离体外循环。这种对液体和血管活性药物异常高的需求促使外科医生寻找血流动力学紊乱的非心脏原因，他注意到右胸膜有一个隆起，探查发现有约1.5升积血。经回顾性分析，此次血胸的原因可能是IJV置管时针头过度向外侧倾斜，并且扩张器推进至全长可能损伤了锁骨下静脉。在此，我们还想讨论置管过程中应采取的安全措施，如针头方向以及为安全进行中心静脉置管扩张器必须推进的长度。
