Massive hemothorax immediately after removal of central venous catheter -A case report-
A 29-year-old woman with Marfan's syndrome was scheduled to undergo the elective Bentall's operation and thoracic aortic replacement with artificial graft. There were no abnormal findings or special histories on the preoperative evaluations.\nOn patient's arrival at the operating room, standard monitoring devices were applied including the left radial arterial cannulation. Anesthesia was induced and maintained according to institutional guidelines. After anesthetic induction, the right subclavian vein was cannulated with MAC™ Multi Access Catheter (ARROW international Inc., PA, USA) using the infraclavicular Seldinger technique. During this attempt to cannulate the subclavian vein, there was neither air aspiration nor arterial puncture. After ensuring the aspiration of dark and nonpulsatile blood, a guidewire was introduced without any resistance. This was followed by sliding the catheter over the guidewire, and the wire was withdrawn without apparent resistance. Thus, the catheter was placed without any difficulty during catheterization. After that, the patient received standardized management according to institutional guidelines including mechanical ventilation and cardiopulmonary bypass during intraoperative period.\nThe operation was performed uneventfully. The patient was transferred to the intensive care unit (ICU) and was very stable in vital signs and laboratory tests. On postoperative day 1, the patient was successfully weaned from mechanical ventilation. There was no evidence of hemorrhage including the volume of blood drained to chest bottles and follow-up chest X-ray (). On postoperative day 3, the patient was transferred to the general ward and the central venous catheter was removed. Ten minutes after the removal of the catheter, the patient complained of dyspnea and pleuritic pain on right side, at which time approximately 1,700 ml of blood was abruptly drained to chest bottles and the patient's chest X-ray confirmed a hemothorax on the same side as the cannulation. Although the blood pressure was stable with administration of intravenous fluid and norepinephrine, hematocrit values dropped from 32.0% to 22.6%.\nThe patient promptly underwent emergent thoracotomy and approximately 2,500 ml of clotted blood was evacuated during operation. The patient was maintained hemodynamically stable with infusion of 0.05 mcg/kg/min of norepinephrine, 3,500 ml of crystalloid and 4 units of packed red blood cell. There was an injury site by the central venous catheterization on the right side of superior vena cava, which was 3 cm distant from the junction of the right atrium and superior vena cava without any other injuries and reinforced by hemostatic materials. After transfer to the ICU, vital signs and other laboratory findings such as arterial blood gas analysis were stable without any pharmacologic supports. The patient was transferred to the general ward after a 4-day ICU stay and discharged on the 15th day after the thoracotomy without any complications.