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LETTERS TO EDITOR
Year : 2019  |  Volume : 63  |  Issue : 11  |  Page : 959-960  

Fatal pulmonary haemorrhage following repeated intercostal drain insertions: Think before you re-do


1 Department of Anaesthesiology, SGPGI, Lucknow, Uttar Pradesh, India
2 Department of Cardiovascular and Thoracic Surgery, SGPGI, Lucknow, Uttar Pradesh, India

Date of Submission13-Jun-2019
Date of Decision09-Jul-2019
Date of Acceptance27-Jul-2019
Date of Web Publication8-Nov-2019

Correspondence Address:
Dr. Amit Rastogi
Departments of Anaesthesiology, SGPGI, Lucknow - 226 014, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_473_19

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How to cite this article:
Rastogi A, Pandey S, Singh A, Tripathi S. Fatal pulmonary haemorrhage following repeated intercostal drain insertions: Think before you re-do. Indian J Anaesth 2019;63:959-60

How to cite this URL:
Rastogi A, Pandey S, Singh A, Tripathi S. Fatal pulmonary haemorrhage following repeated intercostal drain insertions: Think before you re-do. Indian J Anaesth [serial online] 2019 [cited 2019 Nov 19];63:959-60. Available from: http://www.ijaweb.org/text.asp?2019/63/11/959/270638



Sir,

We present a case in whom re-insertion of intercostal drain (ICD) in intensive care unit (ICU) resulted in fatal pulmonary haemorrhage. A 70-year-old male underwent emergency coronary artery bypass grafting (CABG) due to unstable angina. The patient had triple vessel disease and three grafts, left internal mammary artery to left anterior descending, right internal mammary artery to posterior descending and reverse right great saphenous vein graft to the obtuse marginal artery, were performed. Following CABG, the patient stayed on mechanical ventilation due to lower lung collapse. The patient had ICD insertion thrice during the entire hospital course. First ICD was inserted on the right side of chest post-CABG due to pleura opening during the surgery. This was removed after three days in the post-operative period following extubation. The patient then developed right-sided pneumonia and pleural effusion with respiratory distress and was reintubated on post-operative day 5. The second ICD was inserted to drain the right-sided pleural effusion, which was later removed.

We were unable to wean the patient from ventilator due to right side consolidation and old age. For easy clearance of pulmonary secretions and ease of weaning from ventilation after two weeks of ventilation, a tracheostomy was planned. Percutaneous dilational tracheostomy was done, and size 8.0-mm tracheostomy tube was inserted. Following insertion of the tracheostomy tube, the patient had reduced air entry on the right side, increased airway pressure and reduction in oxygen saturation. FiO2 was increased and immediate chest skiagram [Figure 1] was sought, which revealed right-sided pneumothorax. An ICD was inserted urgently. Following chest drain insertion, the patient had profuse bleeding from the ICD with sudden hypotension. Immediate fluid resuscitation was started, but hypotension was non-responsive. With ongoing hypotension, it was decided to clamp ICD. Instant transfer of the patient to the operative room for urgent thoracotomy was decided. With continuous fall in blood pressure, patient suffered cardiac arrest; immediately cardiopulmonary resuscitation was started but unfortunately, the patient could not be revived despite best possible efforts.
Figure 1: Pneumothorax on the right side of the lung following percutaneous dilatation tracheostomy

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ICD insertion is a commonly done procedure in emergency and critical care settings. Pulmonary haemorrhage is known complication of ICD insertion.[1],[2],[3] Pneumothorax following tracheostomy is a known and documented complication and well documented in case reports.[4] The pathophysiology behind this complication could be a direct pleural injury, air dissection of the deep cervical fascial plane into the mediastinum, alveolar bleb rupture and inappropriate use of guide wire during the procedure.

In this case, we had attempted to insert the ICD from the same site as before. Previous ICD insertion may have caused the development of adhesions at the site of ICD insertion, which was not so evident on the chest skiagram, and reattempting ICD insertion may have caused pulmonary haemorrhage due to injury to the pulmonary vessel leading to massive bleeding. Bleeding during chest drain insertion is not an uncommon finding, but careful planning must be done in patients in which we reconsider reinsertion of ICDs, and we should take a different intercostal space or at least two space above the previous ICD insertion site. In the cases when there is a need for ICD insertion multiple times, ideally be done under ultrasound guidance or under fluoroscopy.[5],[6],[7]

We conclude that in patients who require multiple insertions of ICD, we must use real-time imaging in the form of either ultrasound or fluoroscopy to prevent any pulmonary vascular or pulmonary parenchymal injury.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Takanami I. Pulmonary artery perforation by a tube thoracostomy. Interact Cardiovasc Thorac Surg 2005;4:473-4.  Back to cited text no. 1
    
2.
Rombola CA, Tomatis SB, Honguero Martinez AF, Atance PL. Parapneumonic pleural effusion. Accidental insertion of a chest tube into right pulmonary artery. Eur J Cardiothorac Surg 2008;34:903.  Back to cited text no. 2
    
3.
Bussieres JS. Iatrogenic pulmonary artery rupture. Curr Opin Anaesthesiol 2007;20:48-52.  Back to cited text no. 3
    
4.
Matsumura S, Kishimoto N, Iseki T, Momota Y. Tension pneumothorax after percutaneous tracheostomy. Anesth Prog 2017;64:85-87.  Back to cited text no. 4
    
5.
Klein JS, Schultz S, Heffner JE. Interventional radiology of the chest: Image-guided percutaneous drainage of pleural effusions, lung abscess, and pneumothorax. AJR Am J Roentgenol 1995;164:581-8.  Back to cited text no. 5
    
6.
Rosenberg ER. Ultrasound in the assessment of pleural densities. Chest 1983;84:283-5.  Back to cited text no. 6
    
7.
Harnsberger HR, Lee TG, Mukuno DH. Rapid, inexpensive real-time directed thoracocentesis. Radiology 1983;146:545-6.  Back to cited text no. 7
    


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