Broken-hearted chest drain

Cardiovascular Curveball 001

This 86 year-old male presented with shortness of breath. He developed a complication after insertion of a left chest drain. Here is his CT:

Cardiovascular curveball

Questions

Q1. What is the complication?

The chest drain is in the left ventricle.


Q2. Outline your management.

This complication was identified at the time by the presence ofpulsatile bright red blood coming from the drain.

  • Clamping the drain to prevent exsanguination is a good first step!
  • Not taking the drain out is a good second step.
  • The next step is to prepare the patient for cardiac surgery to remove the drain and repair the heart.  In this patient, removing the drain and repairing the heart was achieved via a mini thoractomy.

In addition to the issues of patient care, this is a sentinel event and appropriate reporting and follow-up needs to be undertaken. The CT below demonstrates how this complication arose…not everything that looks like a left pleural effusion on a plain chest X-ray is one!

image_1


Q3. How could this complication have been prevented?

Put your finger in the hole!

  • One of the most important steps in the insertion of an intercostal catheter is to insert a finger through the hole you have just made. Do this before inserting the intercostal catheter.
  • Using your finger you can detect any adhesions that may lead to penetration of the lung on insertion of the intercostal catheter, as well as the presence of underlying organs such as a beating heart!
  • In this case, the intercostal catheter is a one from a Seldinger kit. If you are going to use one of these kits, you should do an ultrasound to make sure that there really is a pleural effusion that can be safely drained.

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Comments

  1. Pete says

    Amazing that even in 2009 people are practicing medicine in the dark ages. Has ultrasound been around long enough for you to have heard about it? Putting “fingers in” is what surgeons do to give all their patients MRSA.

    • says

      Hi Pete,
      Even with ultrasound I’d recommend putting a finger in, otherwise there might still be adhesions that can cause problems. Also it helps ensure that the tract actually passes into the pleural cavity.
      I should imagine the infection risk from a surgically prepped hand inside 2 layers of sterile gloves is much less that simply having a tube sticking in your chest.
      Chris

      • Duncan says

        A course of IV cephalothin for the duration of the drain is also worth considering to avoid the infection concern (echoing Chris, the finger in is a safety feature). Particularly hurried ED trauma ICCs -- even with the best intent and care, our infection rates will be higher.

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        I’m sure there is additional evidence supporting the duration of the ICC rather than just 24h as well.

Comments